The National Heart, Lung, and Blood Institute (NHLBI) has established its first cardiovascular disease (CVD) enhanced

dissemination and utilization centers

(EDUCs). These centers are part of a

nationwide strategy to develop a network of

partners to promote cardiovascular health in

high-risk populations at the community

level. The NHLBI created the EDUCs in

response to the Healthy People 2010 (HP

2010) call for action to increase the quality

and years of healthy life and eliminate

health disparities. The EDUCs are

designed specifically to implement

health promotion and disease

prevention activities to

achieve the heart disease and stroke objectives. The

NHLBI is supporting six

EDUCs initially and

plans to

expand the

number

over time. 

The

NHLBI is

developing

this national

strategy in

response to

serious challenges to cardiovascular health in

the United States.

Heart disease and stroke

are the first and third leading

causes of death for Americans.

Heart

Trends in CVD-associated risk factors

MEMO

Spring 2001

NATIONAL INSTITUTES OF HEALTH

NATIONAL HEART, LUNG, AND BLOOD INSTITUTE

NHLBI Funds Enhanced

Dissemination and Utilization

Centers To Improve

Cardiovascular Health

(continued on page 3)

show a tremendous geographic variation in

heart disease and stroke death rates, and

certain racial/ethnic minority groups are

disproportionately affected. The decline in

coronary heart disease (CHD) mortality

appears to be slowing, and the decline in

stroke mortality appears to be leveling off.

Other disturbing trends are less-than-optimal control of high blood pressure (particularly in older Americans), recent increases

in teenage smoking, and high levels of

physical inactivity coupled with high prevalence of overweight/obesity. 
SPRING 2001

2Letter From the Director

Contents

Letter From the Director

CARDIOVASCULAR

HEALTH FOR ALL

The year 2000 saw the launch of several NHLBI-sponsored communitybased efforts aimed at achieving

cardiovascular health for all Americans. These initiatives are part of

NHLBI’s new heart-health agenda—

whose aim is to meet the cardiovascular health goals in the Federal

Government’s Healthy People 2010

report, the blueprint for building a

healthier country and ending ethnic

and racial disparities in the burden of

disease. This issue of HeartMemo

highlights a few of these initiatives:

the EDUC initiative, which is highlighted in our cover story, the Jackson

Heart Study (JHS) (page 17), and the

ASPIRE for Healthy Hearts program

(page 18).

These efforts offer help where

the need is greatest—communities

where people suffer an inordinately

high burden of CVD. The EDUCs

will operate in rural counties in

Arkansas, North Carolina, Virginia,

and West Virginia as well as the city

of Fort Worth, Texas. The JHS,

being conducted in Jackson, Mississippi, will focus on learning why

African Americans are more likely

to die from CVD than other

racial/ethnic groups in the country.

Mississippi is the only state where

the number of people who die from

CVD is increasing. ASPIRE for

Healthy Hearts reaches out to Asian

Americans and Pacific Islanders

(AAPIs), a group in which CVD

continues to be the leading cause of

death. ASPIRE will disseminate

culturally appropriate heart-health

information to AAPI communities in

Worcester, Massachusetts; Houston,

Texas; and Long Beach, California.

With these and other projects,

NHLBI is proving its commitment

to its Cardiovascular Health for All

initiatives. We look forward to seeing the results of these intensive

efforts—lower rates of CVD in communities nationwide—as the century

progresses. 

Claude Lenfant, M.D.

Director, NHLBI

1 NHLBI FUNDS ENHANCED

DISSEMINATION AND UTILIZATION

CENTERS TO IMPROVE

CARDIOVASCULAR HEALTH

2 LETTER FROM THE DIRECTOR

4 THE NATIONAL HIGH BLOOD

PRESSURE EDUCATION PROGRAM

7 THE NATIONAL CHOLESTEROL

EDUCATION PROGRAM

9 THE NATIONAL HEART ATTACK

ALERT PROGRAM

11 THE NATIONAL CENTER ON SLEEP

DISORDERS RESEARCH

13 SPOTLIGHT ON PERFORMANCE

PROJECTS: NHLBI OBESITY

EDUCATION INITIATIVE

17 SPOTLIGHT ON MINORITY PROJECTS

19 SPOTLIGHT ON WOMEN

20 HEARTSCIENCE

21 NEW AT THE NHLBI HEALTH

INFORMATION CENTER

23 ORDER FORM
Cover Story HEARTMEMO

3

(continued from page 1)

T H E F IRST S I X EDUC S

Delta Health Education Center (DHEC), University of Arkansas for Medical Sciences 

This Center will bring a spectrum of health education and services to residents in Lee and St. Francis Counties in

eastern Arkansas, a low-income rural area where minority populations, primarily African American, comprise more

than half the population. This project will disseminate science-based information to community members through

local churches, disseminate information to community health care providers through onsite office programs and

interactive video continuing medical education programs, and enlist existing DHEC Community Advisory Boards for

guidance in implementing and expanding the project in their respective communities.

HEART (Helping Educators Attack CVD Risk Factors Together)

Operated by St. Mary’s Hospital in Huntington, West Virginia, this Center will work to prevent the development of

CVD risk factors and to detect and treat these risk factors among students in 45 public elementary schools. The

project will target Cabell, Wayne, and Lincoln Counties—rural, medically underserved areas with high rates of

poverty and CVD mortality. Along with partners including the West Virginia Department of Education, the West Virginia Bureau for Public Health, and the American Heart Association’s West Virginia Chapter, HEART will offer

school-based interventions for approximately 8,000 students in grades 3 to 5.

Wake Forest University School of Medicine Project

Based at Wake Forest University School of Medicine in Winston-Salem, North Carolina, this Center will mobilize a

collaboration of academic and community-based health care organizations to implement low-cost strategies to promote cardiovascular health. The project targets Robeson and Columbus Counties in southeastern North Carolina

that have large Native American and African American populations. Interventions are designed to reach out to

health care providers, train community volunteers to disseminate CVD prevention messages, conduct screenings,

and work with community organizations.

North Texas Salud Para Su Corazón Outreach Initiative

This Center, operated by the University of North Texas Health Science Center in Fort Worth and the newly created

Center for Cross-Cultural and Community Research, will develop state-of-the-art, culturally competent public health

education and training activities. This project targets low-income Hispanics living in Fort Worth and the metroplex

area of North Texas. The Center will partner with community-based organizations and other agencies to promote

culture- and language-appropriate CVD health and wellness activities, including outreach by lay health educators

and workers known as “promotoras.”

The Healthy Heart Project, West Virginia Health Right, Inc.

This project will track and compare three groups of patients in a free primary care clinic serving a medically underserved low-income population in south central West Virginia. All patients will be screened at entry for CVD, enroll

in an exercise and nutrition program, and attend AHA Basic Life Support classes. One group with hypertension will

receive intensive interventions in exercise therapy, dietary therapy, weight loss, and smoking cessation; they will

also attend behavior change classes and receive a risk factor management plan. Followup will determine which

interventions are most effective.

Dan River Regional Cardiovascular Health Initiative Program (DR CHIP)

DR CHIP provides community-based cardiovascular screening and education to low-income populations in southern Virginia that are served by the Danville Regional Medical Center. The program will expand its activities under

the coordination of case managers and community outreach workers. Proposed projects include additional screenings using trained volunteers; tracking of patient risk factors over time; followup of patients evaluated in the emergency room chest pain clinic; an expanded Healthy Lifestyles middle school curriculum; phone and online focus

groups; and a computer-based continuing medical education model.

(continued on page 22)
SPRING 2001

4HeartFile: NHBPEP

The National High Blood

Pressure Education Program

DASH-SODIUM STUDY:

SALT REDUCTION

BENEFITS ALL

The results of the second DASH

(Dietary Approaches to Stop Hypertension) trial—DASH-Sodium—

showed dramatic declines in blood

pressure for persons on “usual” diets

who reduced salt intake as well as

declines for persons on the DASH

diet. Dietary salt reduction led to

blood pressure declines in persons

with or without hypertension. The

results were published in the January

4 issue of the New England Journal

of Medicine (2001;344[1]:3–10).

The strong findings were initially

presented in May 2000 at the annual

meeting of the American Society of

Hypertension and were reported

rapidly and widely by the national

press. Dr. Eva Obarzanek, an

NHLBI nutritionist and project officer for the DASH-Sodium trial,

announced, “The study shows how

important it is to reduce sodium in

the diet. The findings suggest that

the current recommendation for how

much dietary sodium Americans

should consume may need to be lowered. By reducing their dietary sodium to 1,500 milligrams a day, all

Americans, and especially those at

high risk for hypertension, can

decrease their chances of developing

high blood pressure as they become

older.”

The DASH-Sodium trial was a

multicentered 14-week feeding study

involving 412 participants. The

DASH diet is one rich in vegetables,

fruits, and low-fat dairy foods, and

low in saturated fat, total fat, and

cholesterol. In the study, participants who followed the DASH diet

and a lower intake of sodium (1,500

milligrams per day) experienced an

average reduction in blood pressure

of 8.9 mmHg (systolic). For participants following a usual diet, similar

to the average diet of Americans,

reducing salt intake from a higher

(3,300 milligrams per day) to a

lower level produced an average

blood pressure reduction of 6.7

mmHg (systolic).

The DASH-Sodium trial reconfirmed the beneficial effects of

reducing sodium intake for persons

with hypertension. It also demonstrated that persons who do not have

high blood pressure can lower their

blood pressure significantly by lowering salt intake. About 57 percent

of the study participants were

African Americans. “African Americans have more hypertension than

other Americans,” said Dr. Frank

Sacks, chairman of the DASH-Sodium Steering Committee. “The findings suggest that more than sodium

may play a role in African Americans’ blood pressure, and they

would benefit from adopting an eating plan similar to that of a lower

sodium DASH diet.”

The NHLBI supported DASHSodium as well as an earlier DASH

study (see HeartMemo, winter 1999

and the Web site

http://dash.bwh.harvard.edu). Work

was conducted by investigators from

the Brigham and Women’s Hospital

B LOOD P RESSURE W E B S ITE

U P AND R UNNING

Internet users can now access the new National High Blood Pressure

Education Program (NHBPEP) Web pages through the NHLBI Healthy

People 2010 Gateway or at the following address:

http://hp2010.nhlbihin.net

The NHBPEP site contains the following items:

• A description of the NHBPEP

• A roster of the NHBPEP Coordinating Committee

• A Guide to Lowering High Blood Pressure—a special 

Web page for older Americans

• Slide shows based on The Sixth Report of the Joint

National Committee on Prevention, Detection,

Evaluation, and Treatment of High Blood

Pressure (JNC VI)

• Additional JNC VI materials

• NHLBI NHBPEP educational materials, which can be ordered online.

Look for these items and more to come.
HeartFile: NHBPEP HEARTMEMO

5

in Boston, Massachusetts; Duke

University Medical Center in

Durham, North Carolina; The Johns

Hopkins University in Baltimore,

Maryland; the Pennington Biomedical Research Center of Louisiana

State University, in Baton Rouge;

and the Kaiser Permanente Center

for Health Research in Portland,

Oregon.

The first DASH trial studied the

effects on blood pressure of whole

dietary patterns and not the effects

of single nutrients such as salt. It

measured significant drops in blood

pressure related to use of the DASH

diet. An NHLBI workshop on sodium and blood pressure, held in January 1999, studied a range of salt

issues and made recommendations

about salt intake. Please see the

summer 1999 issue of HeartMemo

for information about that 

workshop.

Additional information and recommendations for dietary salt reduction

can be found by searching the NHLBI

Web site at http://www.nhlbi.nih.gov.

HYPERTENSION: FROM

GENE TO COMMUNITY

On August 25, 2000, the NHLBI

hosted a satellite symposium in conjunction with the Society of Hypertension’s 18th Scientific Meeting,

“Hypertension: From Gene to Community.” The symposium was

broadcast live through the NHLBI

Web site and can still be viewed as a

Webcast-recorded conference. Webcast is a medium permitting broadcasting of events that can be viewed

by personal computer. 

NHLBI Director Dr. Claude

Lenfant presented a keynote

address at the symposium, and

nine speakers covered a spectrum

of issues in hypertension research

and its applications:

• Molecular Genetics of Hypertension and Its Complications

• Hypertension and Associated End

Organ Damage

• Peripheral and Central Regulation

of Cardiovascular Functions 

• The Renin-Angiotensin-Aldosterone System in Hypertension

and Target Organ Damage

• Medical Treatment: Evidence

from Randomized Trials

• Adherence to Medical Treatment

• Medical Research: Translation to

Clinical Practice

• Blood Pressure Levels in and

Across Populations 

• Psychological and Social Factors

in Etiology, Prevention, and 

Control

To view the Webcast version of the

conference, point your browser to

http://www.nhlbi.nih.gov/meetings/

ish/video.htm. 

PATIENT ADHERENCE TO

MEDICATION TREATMENT

FOR HYPERTENSION

Among patients with hypertension,

20 to 63 percent take less than 80

percent of their medication doses,

and 21 to 60 percent discontinue

their medication. This lack of adherence to medication is a major obstacle to good control of high blood

pressure. Patient adherence was the

topic of a presentation by Dr.

Jacqueline Dunbar-Jacob, director of

research at the University of 

Pittsburgh School of Nursing, at the 

symposium “Hypertension: From

Gene to Community.” (See previous

article for details about the 

symposium.)

Dr. Dunbar-Jacob explained that

traditional methods for identifying

poor adherers include patient selfreport, health professional clinical

judgment, and blood pressure control monitoring. However, patients

may not be aware of the extent of

their missed and extra medication

doses, and health care professionals

are unlikely to identify adherence

problems among their patients. 

A new measurement strategy uses

the electronic event monitor (EEM),

a medication bottle fitted with a

microprocessor chip that records the

dates and times the patient opens

and closes the bottle. One study

demonstrated that EEM may be a

more accurate measure of adherence

than 7-day recall or pill count 

methods.

Researchers have identified some

predictors of poor adherence among

hypertensive patients: the busy

lifestyles of middle-age people,

cognition problems exhibited in

very old people, smoking, and 

misconceptions about hypertension.

Other factors associated with poor

“The findings suggest that

the current recommendation

for how much dietary sodium

Americans should consume

may need to be lowered.”

(continued on page 6)
SPRING 2001

6HeartFile: NHBPEP

adherence are a complex medication

regimen, lack of motivation to follow a regimen, undesirable side

effects, and changes in the daily

routine. 

The development and application

of interventions aimed at improving

medication adherence require more

attention. However, research shows

that successful interventions involve

counseling and educating patients,

monitoring blood pressure, reducing

the complexity of medication therapy, and reducing medication side

effects. 

HYPERTENSION/

DIABETES CLINICAL

ADVISORY RELEASED

A clinical advisory issued by the

NHBPEP recommends that physicians pursue a more aggressive

treatment approach to lower the

blood pressure of patients who have

both hypertension and diabetes. The

clinical advisory, published in the

March-April 2000 issue of the Journal of Clinical Hypertension, indicates that the coexistence of the two

conditions imposes a need for a significantly lower goal blood pressure

(130/85 mmHg) than the goal blood

pressure for a patient with hypertension who does not have diabetes

(140/90 mmHg). Results from several studies show that efforts to

lower high blood pressure in

patients with type 2 diabetes produce dramatic results. The advisory

suggests that weight reduction,

• 2000 Working Group Report on

High Blood Pressure in Pregnancy Slide Show. A slide show featuring key recommendations of the

new report. This can be downloaded from the NHLBI Web site.

• 2000 Working Group Report 

on High Blood Pressure in 

Pregnancy. 

increased physical activity, and

moderation of salt and alcohol

intake are important therapies, and

four classes of drugs are effective

first-line therapy for these patients.

Most hypertensives will require

more than one class of drug to

achieve a therapeutic goal of 

130/85 mmHg. 

This advisory is an update to the

Sixth Report of the Joint National

Committee on Prevention, Detection, and Treatment of High Blood

Pressure (1997).

NEW NHBPEP

PUBLICATIONS

The following NHBPEP-related publications (and one slide set) are now

available:

• Statement from the NHBPEP:

Prevalence of Hypertension. 

A statement based on NHANES

III data, available as a reprint from

the American Journal of Hypertension (2000;13[1]:103–4).

• NHLBI Workshop on Sodium

and Blood Pressure: A Critical

Review of Current Scientific

Evidence. An article based on a

workshop that featured 55 expert

speakers. Available as a reprint

from Hypertension (2000;35[4]:

858–63).

• 1999 Clinical Advisory: Treatment of Hypertension and Diabetes. An article updating the

JNC VI, including a treatment

algorithm. Available as a reprint

from Journal of Clinical Hypertension (2000;13[2]:132–3).

• Importance of Systolic Blood

Pressure in Older Americans. A

clinical advisory statement updating the JNC VI. Available as a

reprint from Hypertension

(2000;35[5]:1021–4); also

available through the NHLBI

Web site.

(continued from page 5)

The new NHBPEP report updating

the 1990 report, for clinicians.

Clarifies how to monitor and treat

pregnant women who have hypertension prior to pregnancy and

those who develop hypertension

during gestation. Available as a

reprint from American Journal of

Obstetrics and Gynecology (July

2000;183[1]:S1–S22); also available through the NHLBI Web site

and can be ordered through the

NHLBI Health Information 

Center. 
HeartFile: NCEP HEARTMEMO

7

CHOLESTEROL COUNTS

FOR EVERYONE

Recent studies have reinforced the

idea that cholesterol lowering is

important for all Americans, regardless of age, sex, and whether or not

CHD has been diagnosed. Those

who have CHD and those who

would like to prevent it both benefit

significantly from cholesterol lowering. This message is so salient that

“Keep the Beat—Cholesterol Counts

for Everyone” was the theme for

Cholesterol Month in September

2000.

For Men and Women

Clinical trials addressing cholesterol

lowering and CHD in middle-age

men with and without CHD have

shown that men benefit greatly from

cholesterol lowering. Recent clinical trials have shown that women

benefit from cholesterol lowering as

much as men. The lifetime risk of

developing CHD is high for both

men and women, and it is important

to begin cholesterol lowering as

early as possible. One of every two

men age 40 and younger, and one of

every three women age 40 and

younger, will develop CHD sometime in their life. 

For Young Adults

It has been shown that atherosclerosis begins during the teen years and

early 20s. High cholesterol levels in

young adulthood significantly

increase the risk for developing

CHD later in life. The Framingham

Heart Study showed that young

adults with lower cholesterol levels

have greater longevity and lower

cardiovascular mortality. This has

recently been confirmed in a

very large pooled study by

Stamler et al.* that

showed a strong, continuous, independent relationship

between serum

cholesterol levels in young

men and their

long-term

risk of CHD

and CVD

death.

This

relationship was

stronger

for the

younger

men than

for middleage men

with similar

cholesterol

levels.

Younger men

with high cholesterol levels (≥

240 mg/dL) also

had an increased

risk of CHD and

CVD death in the short

term (i.e., young adulthood through middle age)

compared to those with favorable

(<200 mg/dL) cholesterol levels.

The Stamler study also showed that

younger men with favorable cholesterol levels did not experience

greater non-CVD mortality than

those with higher levels. A significant positive correlation

between rising cholesterol

levels and long-term,

all-cause mortality

was seen in this

study. In the

analysis by

Stamler et al., a

substantially

longer estimated life

expectancy

was

observed in

younger

men with

favorable

cholesterol

levels. 

In light

of the evidence from

these studies, it is

clear that

establishing a

healthy eating

pattern and

other positive

habits early in

life is an important

step in keeping CHD

risk low. It is important to measure cholesterol levels in young adults so

that life habit changes that decrease

the lifetime risk for CHD can be initiated early. Waiting until midlife to

measure and treat cholesterol can be

costly. Approximately one-third of

first CHD events are fatal, leaving

no second chance. Once CHD has

The National Cholesterol 

Education Program

* Stamler J, Daviglus ML, Garside DB, Dyer AR, Greenland P, Neaton JD. Relationship of baseline serum

cholesterol levels in 3 large cohorts of younger men to long-term coronary, cardiovascular, and all-cause

mortality and to longevity. JAMA 2000;284:311–18. (continued on page 8)
SPRING 2001

8HeartFile: NCEP

become manifest, there is usually a

lot of atherosclerosis to treat.

Although cholesterol lowering in

those with CHD has been shown to

be highly beneficial, once CHD is

present it is not possible to eliminate

all of the excess risk.

For Older Adults 

Among older Americans, cholesterol

lowering is beneficial for those with

CHD as well as those trying to prevent it. As a group, older Americans

(over 65 years) have the highest rate

of CHD. Up to three-quarters of

older individuals have either obvious

or subclinical disease. Even among

men who reach 70 years of age without obvious CHD, one out of every

three will still develop the disease in

his remaining years; among women

free of CHD at age 70, one out of

every four will go on to have the

disease. Furthermore, clinical trials

in people with CHD and in primary

prevention demonstrated that older

participants reduce their CHD risk

with cholesterol lowering as much

as middle-age ones. Of particular

interest is that cholesterol lowering

also reduced the occurrence of

strokes in older persons. In older

adults, life habit changes are the

foundation of treatment for primary

prevention, and a combination of

life habit changes and drug therapy

will often be needed in those with

CHD.

CHOLESTEROL CLINICAL

GUIDELINES TO BE

UPDATED

The National Cholesterol Education

Program (NCEP) has convened an

expert panel (Adult Treatment

Panel III, known as ATP III)

to update the existing clinical practice guidelines in

detecting and treating high

blood cholesterol in adults. The

ATP III report will provide up-todate guidance on clinical cholesterol management based on all of

the scientific evidence. The panel

is working diligently to complete its

work by the spring of 2001 when the

ATP III report is due to be released

at a major media briefing. Release

of the new guidelines will be followed by a joint national conference

cosponsored by the NHLBI and the

National Committee for Quality

Assurance (NCQA). The goal of

this conference is to speed the adoption and implementation of the

guidelines by practitioners and

health care organizations. This

interactive conference will offer

practitioners

the first indepth

look at the ATP III

guidelines, as well as expert

advice and tools to help implement the guidelines in actual practice. (See the box for conference

information.) Existing NCEP

patient education materials will be

updated to reflect the recommendations made in ATP III, and Webbased applications of the new

guidelines will be developed. The

NCEP is considering several possibilities, including applications for

personal digital assistants, a Webbased 10-year CHD risk calculator,

and a continuing medical education

module for the “Live Healthier, Live

Longer” Web page. 

NHLBI/NCQA

CONFERENCE

WHAT: “Advances in Cholesterol

Management: Putting the National

Cholesterol Education Program’s

New Clinical Guidelines Into Practice” is a joint national conference

designed to speed the adoption of

the ATP III, the new, updated cholesterol clinical guidelines.

WHEN: June 3–5, 2001

WHERE: Omni Shoreham Hotel,

Washington, DC

WHO SHOULD ATTEND?

Physicians, medical directors,

nurses, dietitians, pharmacists,

health educators.

For more information about the

conference, please go to

http://www.nhlbi.nih.gov. Under

highlights, click on NHLBI Healthy

People 2010 Gateway, select Cardiovascular, National Education

Programs and Initiatives, and

National Cholesterol Education

Program. 

Mark Your Calendar

(continued from page 7)

“One of every two men age 

40 and younger, and one of

every three women age 40 

and younger, will develop

CHD sometime in their life.”
HeartFile: NHAAP HEARTMEMO

9 The National Heart 

Attack Alert Program

NEW EDUCATIONAL

TOOLS FOR HEART

ATTACK RESPONSE

Lori Moore knows how difficult it

can be to get people to call for

emergency assistance in a timely

manner. As director of the Department of Emergency Medical Services for the International

Association of Fire Fighters (IAFF),

Ms. Moore sees emergency services

across the Nation deal with this and

other issues almost daily. Ms.

Moore, who is the IAFF’s representative on the National Heart Attack

Alert Program’s (NHAAP) Coordinating Committee, is convinced that

new materials and strategies to urge

people to call for assistance

would be welcome. 

“They would be a great improvement,” she said recently, adding the

following caution: “We know the

need exists, but local groups must

also recognize the need for such

materials.”

Such materials, or tools, are on

the way.

The NHAAP has been developing

new tools that are based on the

materials used in the Rapid Early

Action for Coronary Treatment

(REACT) study of delay times in

seeking care for heart attack warning signs (see the summer 1999

issue of HeartMemo). In the wake

of the REACT research program, the NHAAP is undertaking a new effort to

provide education to the

general public in addition

to its educational efforts

with health care

providers. Titled the

Heart Attack Awareness

Campaign, this new program will feature revised

and strengthened educational materials with new

messages and themes to

stimulate people to act

quickly in response to

potential heart-related

emergency situations.

The centerpiece of the

Heart Attack Awareness

Campaign will be a toolkit

containing items for educating community groups and

other public

groups about

heart attack

warning signs and

necessary action

steps. The new materials

will continue to address the

goal of reducing delay time when

individuals or someone in their presence experiences symptoms of a

heart attack—as they did for the

REACT study. The materials will

be tailored to address vulnerable

population groups and will feature

clear presentation of the issues. The

goal is to extend the reach of the

REACT messages based on lessons

learned in REACT.

Materials in the toolkit will

include the following:

• “Act in Time”—a powerful

videotaped presentation including

real people describing attitudes

and actions surrounding heart

attack symptom recognition and

response.

• Core brochure (in English and

Spanish)—a clear and comprehensive print presentation of key

messages about the main symptoms of a heart attack and appropriate action steps. 

• Low-literacy brochure—a pamphlet with key heart attack messages in simpler language (i.e.,

easy to read). 

• Instructor’s guide—a curriculum

for health care workers and others who can influence persons at

risk. 

• Brochure for high-risk patients—

especially targeting high-risk

persons with key messages.

• Wallet card—contains key messages in a format that is easy to

access.

These materials are being carefully revised or newly crafted to

crystallize key messages that are as

science-based as possible, based on

lessons learned from REACT. 

(continued on page 10)
SPRING 2001

10HeartFile: NHAAP

The messages target desired results

and specific groups. For example,

the messages will include clear, concise descriptions of the symptoms of

heart attack; they will describe specific differences in symptoms for

women and men; they will emphasize making a telephone call (911)

to get to the hospital immediately.

The primary audience for the program comprises older adults,

women, minority groups, and communities at risk. In addition, the

campaign targets persons who have

been released from emergency

departments after having been ruled

out for an acute myocardial infarction or discharged from the hospital

with a diagnosis of heart disease.

The 4-year REACT study tested

community education strategies to

reduce patient delay time in seeking

care for heart attack symptoms. At

the study’s completion, advisors to

the NHAAP recommended targeted

dissemination of the REACT messages, materials, and strategies to

persons who are likely to delay

seeking treatment. 

The materials will be distributed

through community partnerships

using strategies devised by partnership members. The NHAAP and

community partners will place special emphasis on bringing information to African Americans, who are

one of the targeted minority groups.

Organizers will develop strategies

and networks that are especially

appropriate for African American

audiences. The Heart Attack Awareness Campaign effort represents yet

another in NHLBI’s series of programs to translate health research

knowledge into usable information

through community-based performance projects.

For more information about the Heart

Attack Awareness Campaign, check

the NHLBI Web site at

http://www.nhlib.nih.gov. 

STUDY LAUNCHED TO

TEST PUBLIC ACCESS

DEFIBRILLATION

The NHLBI, in collaboration with

the American Heart Association

(AHA), has launched a large multicenter study to test the life-saving

potential and cost-effectiveness of

public access defibrillation (PAD).

PAD, which involves placing defibrillators in the community, is considered a promising means of

improving emergency treatment for

victims of sudden cardiac arrest who

collapse in public places. About

one-fourth of the 300,000 annual

deaths from sudden cardiac arrest

occur outside the home—in public

areas. Automatic external defibrillators (AEDs) are known to work

effectively to help victims of sudden

cardiac arrest when the devices are

used by highly trained emergency

medical services personnel and

other trained persons such as airline

flight attendants. This study is

designed to find out whether placing

AEDs in the community where

trained volunteers could access them

will prevent additional deaths. 

The 21⁄2 year study, which began

in the summer of 2000, will be conducted in 24 centers throughout the

United States and Canada. 

Volunteers in participating communities will be trained to recognize

cardiac arrest, to access the 911 system, and to perform cardiopulmonary resuscitation. Half of the

community units will have AEDs

placed in conspicuous locations in

community residential apartments,

shopping centers, senior centers,

gated communities, office buildings,

and sports venues. Volunteers in

those locations will be trained to use

the devices. 

(continued from page 9)

“The centerpiece of the Heart

Attack Awareness Campaign

will be a toolkit containing

items for educating community groups and other public

groups about heart attack

warning signs and necessary

action steps.”

J OIN THE NHLBI

H EALTH I NFORMATION

N ETWORK (HIN)

Imagine regularly receiving the

latest information on heart

health at no cost—right in your

e-mailbox. This—and much

more—is now available on the

new NHLBI HIN. It’s all part of

NHLBI’s commitment to getting

you our latest and best information as quickly and conveniently as possible.

Through the HIN, you receive

e-mail messages advising you

of available resources in your

areas of interest: news about

NHLBI publications, notifications of Webcast scientific conferences that you can access

through your computer, and

news about new NHLBI discoveries.

Joining the HIN is simple.

Just visit the NHLBI Healthy

People 2010 Gateway at

http://hin.nhlbi.nih.gov, and

click on “Join the Network” at

the bottom left. There is 

no cost.
HeartFile: NCSDR HEARTMEMO

11 The National Center on 

Sleep Disorders Research

SLEEP APNEA AND

SNORING LINKED TO

HYPERTENSION

Reports from three studies provide

new evidence that persons who

experience sleep apnea are at an

increased risk for hypertension.

Although further evidence is needed

to fully establish how much the risk

of hypertension varies with sleep

apnea severity, the results point to a

strong association. One of the studies also found a relationship

between snoring and hypertension.

Researchers in the large Sleep

Heart Health Study (SHHS), which

is ongoing, provided preliminary

results in the April 12 issue of the

Journal of the American Medical

Association (2000;283[14]:

1829–36). They found that middleaged and older adults with sleep

apnea had a 45 percent greater risk

of hypertension than persons who

did not experience sleep apnea. The

study involved more than 6,000

adults, ages 40 and over, during

1995–98, who were participating in

a number of NHLBI cohort studies

of cardiovascular and respiratory

diseases. The risk of hypertension

was found to increase with the

severity of the sleep apnea in all

participants, regardless of age, sex,

race, or weight. Even moderate levels of sleep apnea were associated

with increased risk.

NHLBI Director Dr. Claude

Lenfant said about the SHHS

results, “This is the first study large

enough to examine the relationship

between sleep apnea and hypertension, independent of other cardiovascular risk factors. Although

these results must be verified, they

offer hope that we may be able to

reduce cardiovascular mortality in

hypertensives by more aggressively

diagnosing the apnea.”

About 12 million Americans

experience sleep apnea, a condition

characterized by brief interruptions

in breathing during sleep. The

breathing pauses last at least 10 seconds, and there may be 20 to 30 or

more pauses per hour. For more

information about sleep apnea, go to

the NHLBI Web site at

www.nhlbi.nih.gov. Click on

National Center on Sleep Disorders

Research, and then click on Patient

Information, Publications and 

Materials.

The Wisconsin Sleep Cohort

Study (WSCS) further established

the association between sleep apnea

and hypertension. Researchers from

the University of Wisconsin Medical

School measured the presence of

Facts About Sleep Apnea

This 4-page brochure discusses

sleep apnea, its causes and

effects, and how it is diagnosed

and treated. Copies can be

ordered from the NHLBI Health

Information Center. The

brochure is available at

http://www.nih.gov/health/public/sleep/sleepapn.htm.

Sleep Apnea: Is Your Patient At

Risk?

This 10-page booklet gives

health care providers an

overview of sleep apnea, including its consequences and

comorbidity, how to identify atrisk patients, diagnosis, treatment options, and management

considerations. The booklet can

be accessed at

http://www.nhlbi.nih.gov/

health/prof/sleep/slpaprsk.htm.

(continued on page 12)

P UBLICATIONS ON S LEEP A PNEA
F EDERAL A GENCIES T EAM U P W ITH THE A MERICAN H EART

A SSOCIATION T O A D V ANCE W AR ON H EART D ISEASE AND S TROKE

On February 1, 2001, the NHLBI, several other Federal health

agencies, and the American Heart Association (AHA) signed a

Memorandum of Understanding (MOU) to speed progress

toward the heart disease and stroke goals set forth in Healthy

People 2010. “This historic MOU will create a working partnership that promises to greatly improve the Nation’s cardiovascular health by the year 2010,” said Surgeon General David

Satcher.

In addition to the NHLBI, Federal health agencies signing the

MOU include the National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP), Centers for Disease

Control and Prevention; the National Institute of Neurological

Disorders and Stroke (NINDS); and two entities within the Office

of Public Health and Science (OPHS), Department of Health

and Human Services—the Office of Disease Prevention and

Health Promotion (ODPHP) and the Office of the Surgeon General. The AHA and its division, the American Stroke Association,

also signed the MOU.

AHA President Dr. Rose Marie Robertson called the agreement a “milestone in public and private sector cooperation.” She said, “By coordinating with the Government’s Healthy People 2010 initiative and closely aligning our

mutual goals and efforts, we can make a major contribution to the Nation’s cardiovascular health.”

The Federal agencies and the AHA will work to accomplish four cooperative goals for CVD and stroke: prevent

the development of risk factors; detect and treat risk factors; achieve early identification and treatment, especially in

the diseases’ acute phases; and prevent recurrence and complications.

For more information, visit www.nhbli.nih.gov.

SPRING 2001

12HeartFile: NCSDR

sleep apnea in 700 participants, then

assessed their health, including

blood pressure, 4 or 8 years later.

They considered the range of 5 to 15

breathing pauses per hour to 

represent mild-to-moderate sleep

apnea. They reported in the May 11

New England Journal of Medicine

(2000;342[19]:1378–84) that sleep

apnea played a significant and independent role in risk for hypertension. Even persons with minimal

sleep apnea had an increased risk of

becoming hypertensive compared

with those without apnea. Persons

with moderate-to-severe sleep apnea

were three times as likely to become

hypertensive. 

“This study dramatically

enhances our understanding of the

role of sleep apnea in hypertension

and provides additional evidence

that it may be an independent risk

factor for hypertension,” said Dr.

Lenfant. “Once we have additional

followup data from the large NHLBI

Sleep Heart Health Study, we should

be able to make a more reliable

determination of the precise role of

sleep apnea as a risk factor for cardiovascular disease.”

In a third study, researchers at

Penn State’s College of Medicine

showed that patients with moderateto-severe sleep apnea are 7 times

more likely to develop hypertension

compared with patients with no

sleep problems, and that hypertension risk increases with the severity

of the sleep problem. The study

also showed that people, especially

the young, who snore with no other

sleep disorder problems have an

increased risk of hypertension. 

(continued from page 11)

“This study dramatically

enhances our understanding

of the role of sleep apnea in

hypertension and provides

additional evidence that it

may be an independent risk

factor for hypertension.”

(continued on page 22) Photo by Bill Petros

NHLBI Director Dr. Claude Lenfant, Surgeon General Dr. David Satcher, and AHA President Dr.

Rose Marie Robertson (sitting, left to right) sign

the MOU. Other signers included (left to right) Dr.

Darwin Labarth, Associate Director for Cardiovascular Health, NCCDPHP; Dr. Gerald D. Fischbach,

Director, NINDS; and Randolph F. Wykoff, Deputy

Assistant Secretary for Health, ODPHP, OPHS.
HeartFile: NHLBI OEI HEARTMEMO

13 Spotlight on Performance

Projects: NHLBI Obesity

Education Initiative

HEARTS N’ PARKS

NATIONAL LAUNCH

The Hearts N’ Parks program to

teach young people heart-healthy

behaviors took a big step forward on

July 18, 2000, as national figures

and local partners in Arlington, Virginia, launched the program’s

national phase. The Arlington

County Department of Parks, Recreation, and Community Resources,

site of the second Hearts N’ Parks

program, hosted daylong health-promoting events. U.S. Surgeon General Dr. David Satcher and others

spoke out for heart health.

NHLBI Director Dr. Claude

Lenfant moderated a press conference that included Dr. Satcher,

Olympic figure skating champion

Michael Weiss, government officials

from Arlington, and Alice Conkey,

president-elect of the National

Recreation and Park Association

(NRPA). Representatives of

NHLBI’s Obesity Education Initiative (OEI) helped coordinate the

event. The event was timed to occur

during Recreation and Parks Month.

The Arlington Hearts N’ Parks

program follows last year’s pilot

program in North Carolina in

attempting to translate scientific

knowledge about physical activity

and heart-healthy eating

to communities,

Arlington, Virginia: A

Hearts N’ Parks Community

The Arlington Parks and Recreation

Department was a fitting choice to

help initiate the national program.

Each year it offers a wide range of

services, focusing on youth, seniors,

immigrants, and people with special

needs. As an example of its youthfocused services, each year the

department sends some 3,000 

children through a summer camp

program. 

Arlington’s multifaceted summer

especially those that are at higher

risk for cardiovascular disease. Said

Dr. Lenfant at this year’s press conference, “Hearts N’ Parks is a fine

example of how we can apply what

research has shown to improve the

health of all Americans.” Dr. Satcher noted, “Hearts N’ Parks shows

what the Federal Government can

accomplish with community and private sector support to improve the

health of Americans from all ethnic

and socioeconomic backgrounds.”

Throughout the morning of the

18th, the Thomas Jefferson Community Center in Arlington was the

scene of a host of activities, including the following:

• Healthy cooking demonstration

and classes conducted by the

Fresh Fields grocery chain

• Tennis demonstration conducted

by the U.S. Tennis Association

• Volleyball demonstration led by

the George Washington University and Georgetown University

women’s volleyball coaches

• Jumping-rope demonstration

• Blood pressure screening by

Arlington Hospital

• Boxing demonstration by the

Arlington Boxing Club

• Gymnasium activities and

demonstrations, including

cycling, seated exercises, pickle

ball, volleyball,

and strength training

• Clinic on race-walking

• Sidewalk heart-art activity.

Dr. David Satcher and Dr. Claude Lenfant are

greeted by Arlington Wellness Coordinator 

Jennifer Blau Martin at the Hearts N’ Parks event.

Summer camp participants try out the “6-man

walker” team-building activity at the Hearts N’

Parks event.

(continued on page 14)
SPRING 2001

14HeartFile: NHLBI OEI

camps program integrated Hearts N’

Parks themes and programs in the

past year, with camp workers engaging in a Hearts N’ Parks training

program including how to conduct

pre- and posttests to evaluate performance. The department was pleased

to adopt the slogan, “Arlington Is a

Hearts N’ Parks Community.” Officials created message boards and

posted that motto in community centers throughout the region.

Jennifer Blau Martin, Arlington’s

Wellness Coordinator, recalled, “I

was reading an issue of HeartMemo

(referring to the summer 1999

issue). I wanted to create a trainthe-trainer program, and I saw the

article about Hearts N’ Parks.” Ms.

Blau Martin contacted OEI coordinator Karen Donato, who suggested

that the Arlington program could be

the next site for Hearts N’ Parks.

The Arlington community parks

program features a spectrum of

activities, such as its elementary

after-school and playground camp

programs, which employ trained

supervisors and accommodate

“high-risk” children. It also features a “Wellness Lending Library,”

from which members can borrow

books and other hands-on materials

relating to physical activity and

health. One focus of the Arlington

program includes the Thomas Jefferson Community Center and Barcroft

cards are designed to hang on the

scales where patients are weighed,

to remind health practitioners to

evaluate each patient’s BMI 

(see photo). 

The BMI tools are the first product of a community action project of

Leadership Spokane Class 1999, an

affiliate of the Spokane Area Chamber of Commerce. Each year, a new

leadership class selects a project to

help develop leadership skills to

build a better community. The 30

members of the 1999 class developed the BMI project to improve the

health of the people of Spokane by

educating health care providers,

employers, insurers, and the community about the significance of

BMI as a risk indicator.

According to campaign coordinators Kathy Cope, R.N., CNSN, a

critical care and certified nutrition

support nurse and quality improvement specialist, and Dr. Kelli Pearson, BMI is a key clinical indicator

of health status, which identifies

persons at risk. Said Ms. Cope,

“This project will encourage health

practitioners to incorporate BMI

measurements in their practices and

make other community leaders

aware as well. We are developing a

system, a plan, and a structure to

help institutionalize BMI measurement—to make it happen.”

Sport and Fitness Center, which now

are acting as flagship sites for the

Hearts N’ Parks program. 

An Ongoing Program

The Arlington program was the second Hearts N’ Parks program site,

following the North Carolina Hearts

N’ Parks activities of summer 1999

(see the spring 2000 issue of HeartMemo). The Hearts N’ Parks program aims to help impact the

growing trend in overweight and

obesity not only by encouraging

individuals of all ages to engage in

regular physical activity and hearthealthy eating but also by influencing the environment of parks and

recreation departments, which many

people frequent. 

Seventy-five percent of Americans live within a 2-mile walking

distance of a public park. Park

facilities are widely accessible to

individuals from culturally and

socioeconomically diverse populations and persons with disabilities.

Also, park and recreation professionals are trained to produce programs that are fun and affordable

and meet the needs of communities.

Hearts N’ Parks is about bringing

science-based information on health

promotion to the people in ways that

are friendly and fun; in so doing, it

adds value to what is already happening in communities. 

SPOKANE FOCUSES

ON BMI

In Spokane, Washington, organizers of a BMI (body mass index)

Awareness Campaign have extracted key information from NHLBI’s

obesity guidelines, placed the

information on laminated cards,

and distributed the cards to

every physician in the Spokane

area. With BMI measurement

tables on one side and a treatment algorithm on the other, the

(continued from page 13)

“Hearts N’ Parks shows what

the Federal Government can

accomplish with community

and private sector support to

improve the health of Americans from all ethnic and

socioeconomic backgrounds.”

Dr. Katherine Tuttle, The Heart Institute of

Spokane’s director of research, demonstrates the

use of the BMI chart classification and treatment

algorithm tool (hanging from scale).
HeartFile: NHLBI OEI HEARTMEMO

15

Many

local

organizations have

endorsed the BMI campaign, including the Spokane County Medical

Society, Spokane Regional Health

District, Heart Institute of Spokane,

Health Care Community (comprising four hospitals), Spokane Area

Chamber of Commerce, Spokane

city and county governments, the

educational community, and health

insurers.

George Schneider, M.D., served

as the project’s medical advisor and

now chairs the city’s steering committee that adopted the project.

Said Dr. Schneider, “This project is

a grassroots community effort that is

implementing good public health

policy. This is not just conversation; rather, it is action.”

With no grant funding to date,

the program produced the 2,500

laminated BMI cards using 

community resources. Sacred Heart

Medical Center printed them, the

Boeing Company laminated them,

and other local companies attached

grommets and chains to the cards.

Several companies sponsored a

booth at a senior wellness program

featuring an exhibit on BMI. Persons stopping by the booth took part

in a survey to measure their awareness of BMI—thereby providing

useful baseline data.

The NHLBI Web site includes a

BMI table, a BMI calculator, and

information on downloading the

BMI calculator for use on Palm OS®

hand-held devices. These tools can

be accessed at

http://www.nhlbi.nih.gov/health/

public/heart/obesity/lose_wt/

profmats.htm.

SURGEON GENERAL’S

EFFORT TO DEVELOP

NATIONAL ACTION PLAN

TO COMBAT

OVERWEIGHT AND

OBESITY

On January 8, 2001, Surgeon General

David Satcher announced a year-long

effort to develop a national action

plan for reducing the prevalence of

overweight and obesity in the United

States. This process intends to

include “listening sessions,” Federal

and non-Federal dialogue, periods for

public comment, interactive workshops, and the formation of working

groups to implement strategies. 

The effort’s inaugural event was a

listening session entitled “Toward a

National Action Plan on Overweight

and Obesity: The Surgeon General’s

Initiative,” which was held December

4–5, 2000, at the National Institutes

of Health (NIH). The NHLBI as well

as other NIH Institutes and Offices,

the Centers for Disease Control and

Prevention, the Health Resources and

Services Administration, the Indian

Health Service, and the President’s

Council on Physical Fitness and

Sports served on the steering committee for the event. During this event,

five panels of experts presented their

views on priorities for obesity prevention efforts. A Webcast of the listening session is accessible at

http://videocast.nih.gov (requires

Real Player). 

Future plans include distributing

information on BMI to worksite

wellness programs, convening a

group of physicians to write protocols for BMI measurement, and

launching a media campaign to

spread the word about BMI to

targeted audiences. Fourteen

members of Leadership Spokane

Class 1999 have committed to continuing their work on the campaign.

The campaign’s structure will

help ensure the project’s success.

The BMI Steering Committee coordinates implementation of a strategic plan that has identified four

goals. Four councils (for health

care providers, employers, insurers,

and community) have been charged

with identifying action steps and

developing strategies specific to

each group. In addition, a communications and marketing task force

promotes BMI awareness, and an

evaluation and grants task force

works with each council to develop

and implement methods and pursue

funding.

Karen Donato, coordinator of the

NHLBI OEI, stated, “The BMI

Awareness Campaign will no doubt

lead to lasting awareness of BMI

and obesity long after the Leadership Spokane Class 1999 program is

over. With its well-thought-out

strategic plan, it can serve as a

model for how communities can

come together to translate research

into practice.”

BMI TOOLS FOR

HEALTH

PROFESSIONALS

A reproducible BMI table can be

found on page 16. To use this table,

find the appropriate height in the

left-hand column. Move across to a

given weight. The number at the top

of the column is the BMI at the

height and weight. 
SPRING 2001

16HeartFile: NHLBI OEI
Spotlight on Minority Projects HEARTMEMO

17 Spotlight on Minority Projects

JACKSONHEARTSTUDY

TAKES TO THE

FIELD

Last fall in Jackson, Mississippi,

researchers launched an important

new investigation of the cardiovascular health risks of African Americans. The Jackson Heart Study

(JHS) is a long-term population

study that will build on knowledge

gained from the Atherosclerosis

Risk in Communities Study

(1987–1999) and will focus on the

cardiovascular risks of African

Americans living in the Jackson

metropolitan area. The JHS is

cosponsored by the NHLBI and the

Office of Research on Minority

Health (ORMH) of the National

Institutes of Health (NIH).

CVD death rates in Mississippi are the highest in the

Nation, especially for

African Americans.

Although rates of CVD in

the United States have

been declining in recent

years, the decline occurring

between 1980 and 1995 was slowest among African Americans. The

JHS will help correct for a lack of

population-based studies of CVD

risks among African Americans. In fact, the JHS will be the largest-ever

study of CVD in an African American population.

“This project is unprecedented in

its comprehensive and focused look

at cardiovascular disease in African

Americans, and the data we collect

will eventually be used to improve

the lives of all people,” said JHS

Director Dr. Herman Taylor.

“Simultaneous with the scientific

endeavor is a large effort to improve

the capacity for research among historically black institutions. This will

also provide unique and indepth experience for students who we hope

to inspire to careers in epidemiology, public health, or medicine.”

The primary objective of the JHS

is to investigate the causes of CVD

in African Americans to learn how

best to pre- vent

this group of 

diseases in the

future. More specific objectives include

the following: • Identifying factors that influence

the development and worsening

of CVD in African Americans,

emphasizing manifestations related to high blood pressure, such as

enlargement of the left ventricle

of the heart, coronary artery disease, heart failure, stroke, and

disorders affecting the blood vessels of the kidney.

• Building research capabilities in

minority institutions at the 

undergraduate and graduate levels

by developing partnerships

between minority and majority

institutions and boosting participation of minority investigators in

large-scale epidemiologic 

studies.

• Attracting minority students to

and preparing them for careers in

public health and epidemiology. 

The JHS will collect data on

6,500 African American men and women between the ages of 35 and

84. Last fall saw the start of an initial examination phase of the study,

which will last for 3 years. In a

series of questionnaires, participants

are being asked for information on

lifestyle habits, medical history,

medications, and cultural factors.

Researchers will perform physical

assessments of the participants and

measure physiological factors such

as cholesterol and glucose.

The study will collect information on conventional CVD risk factors (smoking, overweight, and so

forth) as well as additional factors,

such as early disease indicators,

genetics, sociocultural influences,

and socioeconomic status.

The JHS is a partnership of

NHLBI, ORMH, and three local

institutions: Jackson State University, the University of Mississippi

Medical Center, and Tougaloo College. At Jackson State University, a

coordinating center has been set up

to organize the activities and collect

and analyze the data. An exam center at the University of Mississippi is

responsible for recruiting and conducting examinations. A unique

aspect of the JHS is the Undergraduate Training Center at Tougaloo College, which will offer course work to

students in public health and epidemiology and provide practical experience in health research to prepare them for possible careers in

these fields.

(continued on page 18)
SPRING 2001

18Spotlight on Minority Projects

By incorporating state-of-the-art

methods in a population-based

cohort, providing research experience, and building research capabilities at minority institutions, the JHS

is uniquely positioned to answer key

questions about the excess burden of

CVD among African Americans and

to address a shortage of minority

investigators. In addition to the

undergraduate training center, a

series of workshop and seminar programs will educate community members about public health and CVD.

Along with the inclusion and education of the local investigators, these

field-based educational programs

will push beyond the scientific goals

of the JHS. As researchers uncover

key information about cardiovascular

risk among African Americans, local

minority participants will be trained

in CVD epidemiology and will

receive key information about CVD

risks and heart health. As a result,

knowledge gleaned from the JHS

will be translated quickly to the

local communities. 

Cheryl Nelson, a project officer at

the NHLBI, expressed the Institute’s

hopes for the JHS, saying “The hope

is that the JHS will enhance the

communities’ knowledge of CVD,

leaving a positive legacy of health

for future generations of African

Americans. We also hope to counter

the effects of other legacies that

have made African Americans hesitant to participate in medical

research that might lead to treatments for heart disease.”

For more information about the JHS,

please search the NHLBI Web site at

www.nhlbi.nih.gov.

ASPIRE FOR HEALTHY

HEARTS GATHERS

COMMUNITY SUPPORT

ASPIRE for Healthy Hearts, the

NHLBI cardiovascular community

outreach program for Asian Americans and Pacific Islanders (AAPIs),

has gained support and interest as a

result of national dissemination of

two reports focusing on the toll of

heart disease on AAPIs.

More than 1,000 AAPI community-based organizations, local and

state health departments, and community health centers received copies of

Addressing Cardiovascular Health in

Asian Americans and Pacific

Islanders: A Background Report and

Asian American and Pacific Islander

Workshops Summary Report on Cardiovascular Health. Since April

2000, more than a dozen community

coalitions, community-based organizations, associations, churches, and

health centers from different regions

of the country have joined the NHLBI

Health Information Network (HIN)

and expressed their support of

ASPIRE for Healthy Hearts and their

interest in disseminating heart-health

information to their local AAPI 

communities.

These organizations represent

diverse experiences, yet they share a

common commitment to providing

culturally and linguistically appropriate social and health services to

AAPIs. Through their unique 

programs, services, and local community networks, they are making significant contributions to improving

the quality of life of AAPIs. 

The Southeast Asian Health Program in Worcester, Massachusetts,

provides health promotion and outreach about chronic disease prevention, and education on accessing and

navigating the health care system.

The Asian American Health Coalition

in Houston, Texas, engages local

organizations and leaders in addressing health needs of AAPIs by gathering community support for the

establishment of an Asian Health

Center. The Cambodian Association

of America in Long Beach, California, provides multifaceted social services ranging from employment and

skills training to violence prevention.

Keiro Services in Los Angeles, California, offers a culturally tailored

continuum of care for older Asians. 

As the NHLBI continues its efforts

to develop heart-health messages,

tools, and resources for AAPIs, local

organizations will play a key role in

sharing life-saving heart-health information to AAPI families and 

communities. 

For information on how to become an

ASPIRE for Healthy Hearts supporter, call Matilde Alvarado at 301-

496-4236 or e-mail her at

alvaradm@nhlbi.nih.gov.

(continued from page 17)

2002 CVH

CONFERENCE

Make plans! On April 11–13, 2002,

the NHLBI will host the National

Cardiovascular Health Conference

in Washington, DC. It will build on

the success of the 1998 national

conference and focus on Healthy

People 2010. Watch the NHLBI

Web site for developing details. 

Mark Your Calendar
Spotlight on Women HEARTMEMO

19 Spotlight on Women

SEMINAR EXAMINES

DIABETES AS A RISK

FACTOR FOR CVD IN

WOMEN

“Women and Diabetes” was the title

of a recent seminar that focused on

the adverse effect of diabetes on

women’s health in general and, in

particular, on their risk of CVD.

The seminar was part of the 2000

seminar series sponsored by the

Women’s Health Seminar Committee of the National Institutes of

Health’s Office of Research on

Women’s Health (ORWH). 

Dr. Barbara Howard, president of

MedStar Research Institute, discussed type 2 diabetes as a significant independent risk factor for

CVD, especially among women, and

as a serious CVD comorbid condition that calls for more aggressive

treatment of both diabetes and CVD.

Women die from diabetes-related

heart disease at a much greater rate

than their male counterparts—across

all ethnic groups and ages.

Type 2 diabetes most often develops in women and men who are

overweight or obese, physically

inactive, older than age 35, and have

a family history of the disease. Diabetes that develops during pregnancy (gestational diabetes) typically

goes away after women give birth,

but these women often develop type

2 diabetes later in life. In addition,

women who have one or more

babies who weigh more than 

9 pounds at birth are at higher risk

of developing type 2 diabetes. 

While the national increase in

type 2 diabetes in the general population may be due, in part, to the

aging population, Dr. Howard

reported that diabetes rates also are

cardiovascular complications of type

2 diabetes. The Prevention of Cardiovascular Disease in Diabetes trial

is studying the benefits of intensified control of high blood

sugar, cholesterol,

and hypertension

in persons who

have diabetes but

not CVD.

The

Study of

Health

Outcomes of

Weight

Loss trial

will focus

on the benefits of weight

loss in obese individuals with diabetes as

a means to manage their diabetes

as well as to prevent development of

heart disease. These two major

studies will provide important information about the effectiveness of

several new medications and treatment regimens to reduce the complications of 

diabetes. 

ROLE OF HORMONE

REPLACEMENT THERAPY

AND LIFESTYLE

CHANGES IN CORONARY

HEART DISEASE IN

WOMEN

Two NHLBI-funded studies published in the August 24, 2000, issue

of The New England Journal of

Medicine indicate the need for further clinical trials to determine how

best to prevent CHD in women.

increasing dramatically in younger

people. The increase may be due to

the growing number of Americans of

all ages who are overweight or

obese, according to Dr.

James Hill, University of Colorado

Health Sciences 

Center.

Moreover,

the disease

begins

developing as

much as

12 years

before it is

diagnosed,

and so it can

begin causing

severe damage to blood

vessels long before treatment is

begun. 

Dr. Howard reported that women

with diabetes have higher blood

pressure than do men with diabetes,

which compounds their heart disease

risk. In addition, across all age

groups, African American women

and white women with diabetes have

a greater decrease in HDL (the

“good” cholesterol) and worse

triglyceride levels than their male

counterparts with diabetes. American Indian women with diabetes

have a 4.3-fold greater risk of heart

disease than their male counterparts,

and virtually all CVD in Native

Americans occurs in women with

diabetes. 

The NHLBI and the National

Institute on Diabetes and Digestive

and Kidney Diseases are supporting

two large clinical trials designed to

identify ways to reduce 

(continued on page 20)
SPRING 2001

20Spotlight on Women

Results of the “Effects of Estrogen

Replacement on the Progress of

Coronary-Artery Atherosclerosis”

study indicate that postmenopausal

hormone replacement therapy (HRT)

is not beneficial in the short term to

either prevent the progression of or

induce the regression of atherosclerosis in women with established

CHD. The 3-year study randomly

assigned 309 women with diagnosed

coronary artery disease to either

placebo, estrogen, or estrogen plus

progesterone. While both the single

and combination hormone therapies

had an impact on atherosclerosis

risk factors, neither affected the progression of coronary atherosclerosis.

The study’s limitations include its

short term and the fact that the

women studied were approximately

65 years old and initiated the therapy an average of 23 years after

menopause. More studies of postmenopausal women are needed to

determine whether the study results

apply to women of all ages and to

HRT started soon after menopause. 

The second study found that positive lifestyle patterns resulted in significant declines in the incidence of

CHD in women who had no previously diagnosed CVD. The study evaluated the effects of risk factors on the

incidence of CHD in nearly 85,000

women ages 34 to 59 who were participating in the Nurses’ Health

Study. Over a 14-year period, the

incidence of CHD declined by 31

percent after adjustment for age.

Smoking declined 41 percent; the rate

of HRT use among postmenopausal

women increased by 175 percent; and

diet improved considerably. However, during the same period, the proportion of women who were

overweight increased by 38 percent,

which may explain an 8 percent rise

in the incidence of CHD. 

(continued from page 19)

W ORKSHOP ON W OMEN ’ S H EART H EALTH

“Women’s Heart Health: Developing a National Health Education Action

Plan,” an NHLBI workshop held on March 26–27 in Bethesda, Maryland, 

is the first step in developing an ambitious new health education effort

aimed at reducing death and disability from CVD in women. The workshop brought together about 60 key researchers, public health leaders,

women’s and minority health advocates, health communicators, health

care delivery experts, and others who have a stake in improving women’s

cardiovascular health. Their goal was to develop a science-based blueprint for a comprehensive health education effort for patients, health professionals, and the public.

The workshop’s aim was to develop goals and objectives for the women’s

heart health education effort; identify the primary target audiences and

their cardiovascular health knowledge, skills, and behavior; identify the

needs of minority target audiences who are at greater risk for CVD; and

develop programmatic recommendations as well as methods for implementation and dissemination.

To view the workshop Webcast on the NHLBI Web site,

http://hin.nhlbi.nih.gov, click on Cardiovascular and then on Distance

Learning Opportunities.

HeartScience

Hispanic, and 10 percent Asian.

Researchers will collect information

on standard risk factors, as well as

sociodemographic, lifestyle, and psychosocial factors and newly emerging

factors such as calcium deposits in

the coronary artery. Each participant

will undergo four examinations over

the course of the study, using tests

including computed tomography, cardiac magnetic resonance imaging,

ultrasound, ankle-brachial blood

pressure index, electrocardiograms,

and measurement of pulse waves at

the artery. Blood samples will be

used to measure new risk factors such

as indicators of inflammation and

genetic markers. 

NEW 10-YEAR STUDY

ON EARLY DETECTION

OF HEART DISEASE

The NHLBI has launched a 10-year,

multicenter study to find new ways to

detect heart disease early, before

symptoms appear. The $68 million

Multi-Ethnic Study of Atherosclerosis (MESA) will involve six centers,

which will recruit approximately

6,500 participants ages 45 to 84—

none of whom will have known heart

disease at the time of their enrollment

in the study. Study participants will

include equal numbers of men and

women, with racial backgrounds 

representing 40 percent white, 30

percent African American, 20 percent
New at the NHLBI Health Information Center HEARTMEMO

21 New at the NHLBI Health

Information Center

The Practical Guide:

Identification, Evaluation, and

Treatment of Overweight and 

Obesity in Adults (2000) 

(#4084, $5 each; 25 copies, $106.25;

100 copies, $400). Based on The Clinical Guidelines on the Identification,

Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence Report (published in 1998), The

Practical Guide provides health care

practitioners with the tools they need

to effectively manage overweight and

obesity in adult patients. The Guide

was developed cooperatively by the

NHLBI and the North American 

Association for the Study of Obesity.

Asian American and Pacific

Islander Workshops Summary

Report on Cardiovascular Health

(#3793, $3.00). This report includes

summaries of and recommendations

from the 1998 Native Hawaiian

Heart Health Initiative Workshop

and the 1999 National AAPI Cardiovascular Strategy Workshop. The

report provides an overview of the

cardiovascular health profile of

these groups, background on

research and programs, and community recommendations on how to

improve heart health at the local,

state, and Federal levels. The report

also includes a bibliography and

appendixes on gathering community

input through key informant interviews and ethnographic interviews.

Facts About Mitral-Valve Prolapse

(#865, single copy free; 25 copies,

$12.50; 100 copies, $40.00). 

This 1-page fact sheet (front and

back) provides information for

patients on mitral-valve prolapse

(MVP), a condition that affects

about 2 percent of the adult population and is usually harmless. It discusses what causes MVP, how it is

diagnosed and treated, how complications can be prevented, and its

clinical significance.
SPRING 2001

22Cover Story

It is hoped that the EDUCs will

implement innovative strategies at the

local level that will contribute significantly to the reversal of these trends

by 2010. 

The NHLBI is also concerned that

lifesaving information is being lost in

the information glut of the 21st century and thus is taking aggressive

steps to enhance dissemination and

outreach activities to address this disturbing trend. Several sources of data

in the United States point to the need

for enhanced dissemination of science-based information. The EDUCs

will also serve as key partners to

stimulate and promote increased use

of proven therapies that can potentially save many lives. For example,

they will create interventions to reach

physicians in their practice setting,

which will enhance physicians’ utilization of clinical guidelines,

improve patient-provider interaction,

and improve patient 

outcomes. 

“Clearly, great numbers of Americans are not enjoying the improvements in health that application of

existing information has the potential

to offer,” says Dr. Gregory Morosco,

director of the NHLBI’s Office of

Prevention, Education, and Control

(OPEC). “Putting today’s best 

prevention strategies into practice in

high-risk communities will save more

lives and give more Americans a better quality of life. A greater focus on

enhancing the dissemination of science-based information and utilization and mobilization of partnerships

in local community settings will be

critical elements that must be implemented in order to successfully

achieve the U.S. HP 2010 goals in the

21st century.”

Characteristics of the

EDUCs 

Each EDUC had to demonstrate that

it had the capacity to develop, implement, and evaluate multifaceted

strategies; furthermore, they had to

show that they had experience working with other partners within highrisk communities. In addition, the

EDUCs had to be located within a

high-risk health service area—one

that serves at least 100,000 people

and has a high CHD or stroke mortality rate. The EDUCs are one element

of a larger heart-health agenda that

the NHLBI has launched as part of its

efforts to meet the cardiovascular

health goals and objectives in the

Federal Government’s Healthy People

2010 report. “The NHLBI intends for

the EDUCs to become the foundation

of a nationwide network of performance partners addressing CVD in

high-risk populations,” says NHLBI

Director Dr. Claude Lenfant. “These

first six centers will serve as models

for what can be achieved through a

targeted approach, and we hope that

many more such centers will be

established as the new century 

progresses.”

“Putting today’s best prevention strategies into practice in

high-risk communities will

save more lives and give more

Americans a better quality 

of life.”

(“Cover Story” continued from page 3) (“Sleep Apnea” continued from page 12)

People who snore and have mild

sleep apnea were 21⁄2 times as likely

to be affected by hypertension as

those with no sleep disordered

breathing. Those who snore without

evidence of sleep apnea were 11⁄2

times more likely to have hypertension. The 5-year study, involving

1,741 people ages 20 to 100, was

the largest sleep laboratory study of

its kind. This study was reported in

the August 14 issue of the journal

Archives of Internal Medicine

(2000;160[15]:2289–95). “This

study extends earlier findings with

evidence that even minimal sleep

disordered breathing may be a risk

factor for hypertension,” said 

Dr. Lenfant.

Unlike earlier studies, all three

studies weeded out other factors that

might play a role in developing

hypertension, including age, gender,

and weight. All three studies were

funded by the NHLBI. 
HEARTMEMO

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HM
HeartMemo is a National Heart, Lung, and

Blood Institute (NHLBI) publication for health

professionals working in disciplines and settings related to cardiovascular health. HeartMemo reports on the activities of the NHLBI’s

national education programs, projects, initiatives, and research advances and on other news

of interest to the field. Readers are urged to

submit information on current treatment and

prevention activities as well as research findings and activities.

HeartMemo is a publication of the U.S. Government published by the Office of Prevention,

Education, and Control of the NHLBI. Unless

otherwise specified, all materials appearing in

HeartMemo are in the public domain and may

be reproduced without permission from the

NHLBI or the authors. Citation of the source

is appreciated.

To subscribe to HeartMemo (at no charge),

order extra copies, or submit an address

change, contact the NHLBI Health Information

Center, P.O. Box 30105, Bethesda, MD 20824-

0105; phone 301-592-8573; fax 301-592-8563.

MANAGING EDITOR:

Judith Estrin

Prospect Associates, Ltd.

PRODUCTION EDITOR:

Laina Ransom

Office of Prevention, Education, and 

Control, NHLBI

COPY EDITOR:

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Prospect Associates, Ltd.

GRAPHIC DESIGNER:

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Prospect Associates, Ltd.

EDITORIAL BOARD:

National Heart, Lung, and Blood

Institute

Ann Taubenheim

Consumer Services Team Leader, Office of 

Prevention, Education, and Control

Terry Long

Senior Manager, Health Communications

and Information Science, Office of 

Prevention, Education, and Control

Laina Ransom

Writer/Editor, Office of Prevention,

Education, and Control

Edward J. Roccella

Coordinator, National High Blood 

Pressure Education Program, Office of 

Prevention, Education, and Control

Louise Williams

Senior Science Writer, Office of 

Prevention, Education, and Control

CONTRIBUTING WRITERS:

Whitney Cobey, Don 

Cunningham, Amy Danzig,

Joanne Karimbakas, Sue Shero,

Ann Taubenheim

This publication is produced by Prospect

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