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Physician Advice and Individual Behaviors About Cardiovascular Disease Risk Reduction - Seven States and Puerto Rico, 1997.

Cardiovascular disease (CVD) (e.g., heart disease and stroke) is the leading cause of death in the United States and accounted for 959,227 deaths in 1996 (1). Strategies to reduce the risk for heart disease and stroke include lifestyle changes (e.g., eating fewer high-fat and high-cholesterol foods) and increasing physical activity. The U.S. Preventive Services Task Force and the American Heart Association (AHA) recommend that, as part of a preventive health examination, all primary-care providers counsel their patients about a healthy diet and regular physical activity (2,3). AHA also recommends low-dose aspirin use as a secondary preventive measure among persons with existing CVD (4). To determine the prevalence of physician counseling about cardiovascular health and changes in individual behaviors, CDC analyzed data from the Behavioral Risk Factor Surveillance System (BRFSS) for seven states and Puerto Rico. This report summarizes the results of that analysis, which indicate a lower prevalence of counseli ng and behavior change among persons without than with a history of heart disease or stroke.

BRFSS is a random-digit-dialed telephone survey of the noninstitutionalized U.S. population aged [greater than or equal]18 years. In 1997, 20,847 adults in seven states (Arizona, Iowa, Louisiana, Oklahoma, Pennsylvania, Virginia, and Wyoming) and Puerto Rico responded to questions about CVD preventive behaviors and physician counseling. Respondents indicated whether a doctor had advised them to eat fewer high-fat or high-cholesterol foods or to exercise more to lower their risk for developing heart disease or stroke. Persons also reported whether they were eating fewer high-fat or high-cholesterol foods or were exercising more to lower their risk for heart disease or stroke. Persons aged [greater than or equal to]35 years were asked if they took aspirin every day or every other day and whether they did so to reduce their chance for a heart attack or stroke. Data were aggregated and weighted according to state population estimates, and prevalence estimates and standard errors were calculated using SUDAAN (5).

Overall, 41.5% of persons reported receiving physician advice to eat fewer high-fat or high-cholesterol foods, and 42.3% reported receiving physician advice to exercise more (Table 1). The prevalence of reported physician dietary advice ranged from 28.8% (Iowa) to 69.7% (Puerto Rico), and the prevalence of advice to exercise ranged from 32.6% (Iowa) to 70.4% (Puerto Rico). Women were more likely than men to report receiving physician dietary or exercise advice, and middle-aged persons were more likely than younger or older persons to report receiving such advice. The prevalence of reported receipt of physician advice was higher for Hispanic adults than for adults of other racial/ethnic groups. The prevalence also was higher for persons with less, than a high school education than for persons with higher educational attainment.

Approximately two thirds of persons reported eating fewer high-fat or high-cholesterol foods to lower their risk for heart disease and stroke, and 60.7% reported exercising more to lower their risk. Approximately 20% of persons aged [equal to or greater than]35 years reported taking aspirin daily or every other day to reduce their risk for heart attach or stroke. More women than men reported changes in diet. More men than women reported aspirin use. The prevalence of dietary and exercise changes were higher among persons in the middle age groups, and aspirin use was greatest among persons in older age groups. Dietary and exercise changes were greatest among Hispanic adults and were directly related to education level. Aspirin use was highest among white adults and decreased significantly (p<0.0l) with greater educational attainment.

Overall, 7.5% (95% confidence interval [CI]=[plus or minus]0.5) of persons reported a history of heart attack or myocardial infarction, angina or coronary heart disease, or stroke. Of these, 73.8% reported receiving physician advice to eat fewer high-fat and high-cholesterol foods, and 70.3% reported receiving physician advice to exercise more. Among persons who did not report heart attack, heart disease, or stroke, 38.9% reported receiving physician dietary advice and 40.0%, physician exercise advice. Among persons reporting heart attack, heart disease, or stroke, 79.3% indicated eating fewer high-fat and high-cholesterol foods, 66.5% reported exercising more, and 61.4% reported taking aspirin regularly to reduce their risk for heart attack or stroke. Among persons not reporting heart attack, heart disease, or stroke, the prevalences were 65.9%, 60.3%, and 15.2%, respectively.

Among persons who reported receiving physician dietary advice, 82.3% (95% CI=[plus or minus]1 .1) also reported that they were eating fewer high-fat and high-cholesterol foods, compared with 55.6% (95% CI=[plus or minus]1.3) of persons who did not report receiving such advice. Among persons who reported receiving physician exercise advice, 74.7% (95% CI=[plus or minus]1.3) reported that they were exercising more, and 50.5% (95% CI=[plus or minus]1.3) of those who did not report receiving such advice reported more exercise. Regardless of reported history of heart attack, heart disease, or stroke, a higher percentage of persons who received physician dietary or exercise advice reported engaging in the respective risk-reduction behavior.

Reported by the following state BRFSS coordinators: B Bender, MBA, Arizona; A Wineski, Iowa; R Jiles, PhD, Louisiana; N Hann, MPH, Oklahoma; L Mann, Pennsylvania; L Redman, MPH, Virginia; M Futa, MA, Wyoming; Y Cintron, MPH, Puerto Rico. G Haldeman, Louisiana Health Care Review, Inc., Baton Rouge. Cardiovascular Health Br, Div of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note: The findings in this report underscore the importance of physician dietary or exercise counseling for influencing behavior changes to reduce the risk for heart disease and stroke. In the BRFSS, more persons reported being engaged in dietary and exercise changes to reduce their chances of heart disease and stroke than reported receiving physician advice to engage in these behaviors. This difference suggests that persons are receiving public health messages from sources other than health-care providers. Nonetheless, the BRFSS data suggest that persons who received dietary and exercise counseling were more likely than persons who did not receive advice to report engaging in these activities. Some physicians may not counsel their patients because they lack training in counseling and believe that their counseling is not effective (6,7). In addition, physicians may direct counseling based on the presence of risk factors (e.g., high cholesterol and overweight) than by actual dietary or exercise behav iors (8), thus limiting the potential effectiveness of preventive counseling.

The findings in this report are subject to at least three limitations. First, BRFSS data do not discern the amount or quality of physician advice received or actual dietary or exercise levels or behaviors. For example, although most persons reported exercising more, approximately 60% of persons in the United States do not engage in regular physical activity, and 25% are sedentary (9). Second, because the data were self-reported, the findings are subject to recall bias and overreporting or underreporting of behaviors and existing disease. Third, estimates for Hispanic adults were influenced by the inclusion of data from Puerto Rico. When persons from Puerto Rico were excluded from analyses, estimates of physician counseling and individual behaviors among Hispanics remaining in the sample were lower than those presented. The greater prevalence of reported physician counseling among persons in the lowest education group also was influenced by data from Puerto Rico and by a greater prevalence of reported heart d isease and stroke in the lowest education group than in other groups.

Health-care providers should counsel their patients about primary and secondary prevention. In addition, patients should discuss with their providers ways of reducing their risk for heart disease and stroke.

References

1. American Heart Association. 1999 heart and stroke statistical update. Dallas: American Heart Association, 1998.

2. US Preventive Services Task Force. Guide to clinical preventive services. 2nd ed. Baltimore: Williams & Wilkins, 1996.

3. Grundy SM, Balady GJ, Criqui MH, et al. Guide to primary prevention of cardiovascular diseases: a statement for health care professionals from the Task Force on Risk Reduction. Circulation 1997;95:2329-31.

4. Hennekens CH, Dyken ML, Fuster V. Aspirin as a therapeutic agent in cardiovascular disease: a statement for health care professionals from the American Heart Association. Circulation 1997;96:2751-3.

5. Shah BV, Barnwell BG, Bieler GS. SUDAAN user's manual, version 6.4. 2nd ed. Research Triangle Park, North Carolina: Research Triangle Institute, 1996.

6. Yeager KK, Donehoo RS, Macera CA, Croft JB, Heath GW, Lane MJ. Health promotion practices among physicians. Am J Prey Med 1996;12:238-41.

7. Ammerman AS, DeVellis RF, Carey TS, at al. Physician-based diet counseling for cholesterol reduction: current practices, determinants, and strategies for improvement. Prey Med 1993;22:96-109.

8. Kreuter MW, Scharlf DP, Brennan LK, Lukwago SN. Physician recommendations for diet and physical activity: which patients get advised to change? Prey Med 1997;26:825-33.

9. CDC. Physical activity and health: a report of the Surgeon General. Atlanta: US Department of Health and Human Services, CDC, 1996.

Prevalence of reported physician advice and individual behaviour to reduce
risk for heart disease
or stroke, by selected characteristics-seven states and Puerto Rico,
Behavioral Risk Factor Surveillance System 1997




Characteristic               Sample [size.sup.+]
State
 Arizona                            1,890
 Iowa                               3,564
 Louisiana                          1,637
 Oklahoma                           1,874
 Pennsylvania                       3,565
 Puerto Rico                        2,242
 Virginia                           3,501
 Wyoming                            2,386
Sex
 Men                                8.647
 Women                             12,012
Age (yrs)
 18-34                              5,441
 35-49                              6,508
 50-64                              4,233
 65-74                              2,617
[equal to or greater than]75        1,763
Race/ethnicity
 Non-Hispanicwhite                 15,737
 Non-Hispanic black                 1,406
 Hispanic                           2,933
 Other(n)                            509
Education
 <High school                       2,882
 High school                        7,245
 Some college                       5,419
 College or more                    5,061
History of
 cardiovascular
 disease
 Not reported                      18,965
 Reported                           1,694
Total                              20,659


                             Physician advice
                             Eat fewer high-fat or high-fat
                             or high-cholesterol foods
Characteristic               %
State
 Arizona                     41.9
 Iowa                        28.8
 Louisiana                   41.5
 Oklahoma                    40.4
 Pennsylvania                36.3
 Puerto Rico                 69.7
 Virginia                    39.0
 Wyoming                     31.2
Sex
 Men                         39.6
 Women                       43.2
Age (yrs)
 18-34                       28.3
 35-49                       40.0
 50-64                       56.6
 65-74                       53.7
[equal to or greater than]75 46.2
Race/ethnicity
 Non-Hispanicwhite           38.1
 Non-Hispanic black          45.3
 Hispanic                    59.7
 Other(n)                    33,6
Education
 <High school                45.6
 High school                 39.4
 Some college                40.4
 College or more             43.5
History of
 cardiovascular
 disease
 Not reported                38.9
 Reported                    73.8
Total                        41.5




                                                Exercise more
Characteristic                95% [CI.sup.ss]         %
State
 Arizona                     [plus or minus]3.1     44.8
 Iowa                        [plus or minus]1.7     32.6
 Louisiana                   [plus or minus]2.8     44.0
 Oklahoma                    [plus or minus]2.7     39.9
 Pennsylvania                [plus or minus]1.8     39.2
 Puerto Rico                 [plus or minus]2.2     70.4
 Virginia                    [plus or minus]2.4     36.5
 Wyoming                     [plus or minus]2.0     35.0
Sex
 Men                         [plus or minus]1.4     40.2
 Women                       [plus or minus]1.2     44.3
Age (yrs)
 18-34                       [plus or minus]1.6     31.2
 35-49                       [plus or minus]1.7     42.1
 50-64                       [plus or minus]2.1     55.4
 65-74                       [plus or minus]2.6     52.0
[equal to or greater than]75 [plus or minus]3.3     42.9
Race/ethnicity
 Non-Hispanicwhite           [plus or minus]1.1     38.7
 Non-Hispanic black          [plus or minus]3.3     47.9
 Hispanic                    [plus or minus]2.3     60.7
 Other(n)                    [plus or minus]6.3     36.4
Education
 <High school                [plus or minus]2.5     44.2
 High school                 [plus or minus]1.5     41.1
 Some college                [plus or minus]1.8     42.1
 College or more             [plus or minus]2.0     43.5
History of
 cardiovascular
 disease
 Not reported                [plus or minus]1.0     40.0
 Reported                    [plus or minus]2.8     70.3
Total                        [plus or minus]0.9     42.3


                                                Individual behavior
                                                Eat fewer high-fat
                                                or high-cholesterol foods
Characteristic               95% CI             %
State
 Arizona                     [plus or minus]3.1 75.5
 Iowa                        [plus or minus]1.7 68.0
 Louisiana                   [plus or minus]2.9 66.2
 Oklahoma                    [plus or minus]2.7 67.6
 Pennsylvania                [plus or minus]1:8 62.3
 Puerto Rico                 [plus or minus]2.1 75.2
 Virginia                    [plus or minus]2.4 65.0
 Wyoming                     [plus or minus]2.2 66.2
Sex
 Men                         [plus or minus]1.4 63.5
 Women                       [plus or minus]1.3 70.1
Age (yrs)
 18-34                       [plus or minus]1.7 57.1
 35-49                       [plus or minus]1.7 69.0
 50-64                       [plus or minus]2.1 76.5
 65-74                       [plus or minus]2.6 72.8
[equal to or greater than]75 [plus or minus]3.3 66.8
Race/ethnicity
 Non-Hispanicwhite           [plus or minus]1.1 67.3
 Non-Hispanic black          [plus or minus]3.4 60.6
 Hispanic                    [plus or minus]2.3 71.2
 Other(n)                    [plus or minus]6.4 58.1
Education
 <High school                [plus or minus]2.5 58.9
 High school                 [plus or minus]1.5 62.5
 Some college                [plus or minus]1.9 69.4
 College or more             [plus or minus]2.0 75.4
History of
 cardiovascular
 disease
 Not reported                [plus or minus]1.0 65.9
 Reported                    [plus or minus]2.9 79.3
Total                        [plus or minus]0.9 66.9




                                                Exercise more
Characteristic               95% CI                   %
State
 Arizona                     [plus or minus]2.8     72.9
 Iowa                        [plus or minus]1.8     53.9
 Louisiana                   [plus or minus]2.8     63.0
 Oklahoma                    [plus or minus]2.5     56.3
 Pennsylvania                [plus or minus]1.9     57.8
 Puerto Rico                 [plus or minus]2.1     71.2
 Virginia                    [plus or minus]2.5     56.5
 Wyoming                     [plus or minus]2.5     59.0
Sex
 Men                         [plus or minus]1.4     60.1
 Women                       [plus or minus]1.2     61.4
Age (yrs)
 18-34                       [plus or minus]1.9     60.3
 35-49                       [plus or minus]1.7     60.7
 50-64                       [plus or minus]1.8     63.2
 65-74                       [plus or minus]2.4     61.8
[equal to or greater than]75 [plus or minus]3.1     55.8
Race/ethnicity
 Non-Hispanicwhite           [plus or minus]1.1     59.9
 Non-Hispanic black          [plus or minus]3.3     59.2
 Hispanic                    [plus or minus]2.2     67.9
 Other(n)                    [plus or minus]7.6     56.0
Education
 <High school                [plus or minus]2.6     54.2
 High school                 [plus or minus]1.6     58.0
 Some college                [plus or minus]1.9     62.7
 College or more             [plus or minus]1.7     66.7
History of
 cardiovascular
 disease
 Not reported                [plus or minus]1.0     60.3
 Reported                    [plus or minus]2.8     66.5
Total                        [plus or minus]0.9     60.7





Characteristic               95% CI
State
 Arizona                     [plus or minus]2.9
 Iowa                        [plus or minus]1.9
 Louisiana                   [plus or minus]2.6
 Oklahoma                    [plus or minus]2.7
 Pennsylvania                [plus or minus]1.9
 Puerto Rico                 [plus or minus]2.1
 Virginia                    [plus or minus]2.5
 Wyoming                     [plus or minus]2.5
Sex
 Men                         [plus or minus]1.5
 Women                       [plus or minus]1.3
Age (yrs)
 18-34                       [plus or minus]1.8
 35-49                       [plus or minus]1.7
 50-64                       [plus or minus]2.1
 65-74                       [plus or minus]2.5
[equal to or greater than]75 [plus or minus]3.3
Race/ethnicity
 Non-Hispanicwhite           [plus or minus]1.1
 Non-Hispanic black          [plus or minus]3.3
 Hispanic                    [plus or minus]2.2
 Other(n)                    [plus or minus]7.6
Education
 <High school                [plus or minus]2.5
 High school                 [plus or minus]1.6
 Some college                [plus or minus]1.9
 College or more             [plus or minus]1.9
History of
 cardiovascular
 disease
 Not reported                [plus or minus]1.0
 Reported                    [plus or minus]3.0
Total                        [plus or minus]1.0



                             Use aspirin to reduce risk of heart
                             attack or [stroke.sup.*]
Characteristic               %
State
 Arizona                     23.0
 Iowa                        23.8
 Louisiana                   20.9
 Oklahoma                    19.2
 Pennsylvania                18.5
 Puerto Rico                 15.1
 Virginia                    19.6
 Wyoming                     23.4
Sex
 Men                         21.8
 Women                       17.8
Age (yrs)
 18-34                         --
 35-49                        7.8
 50-64                       23.9
 65-74                       35.8
[equal to or greater than]75 36.7
Race/ethnicity
 Non-Hispanicwhite           21.3
 Non-Hispanic black          13.2
 Hispanic                    14.3
 Other(n)                    16.9
Education
 <High school                24.3
 High school                 19.5
 Some college                20.3
 College or more             16.9
History of
 cardiovascular
 disease
 Not reported                15.2
 Reported                    61.4
Total                        19.7





Characteristic                     95% CI
State
 Arizona                     [plus or minus]3.3
 Iowa                        [plus or minus]1.9
 Louisiana                   [plus or minus]2.8
 Oklahoma                    [plus or minus]2.4
 Pennsylvania                [plus or minus]1.8
 Puerto Rico                 [plus or minus]2.2
 Virginia                    [plus or minus]2.3
 Wyoming                     [plus or minus]2.4
Sex
 Men                         [plus or minus]1.5
 Women                       [plus or minus]1.2
Age (yrs)
 18-34
 35-49                       [plus or minus]0.9
 50-64                       [plus or minus]2.0
 65-74                       [plus or minus]2.7
[equal to or greater than]75 [plus or minus]3.4
Race/ethnicity
 Non-Hispanicwhite           [plus or minus]1.1
 Non-Hispanic black          [plus or minus]3.0
 Hispanic                    [plus or minus]2.0
 Other(n)                    [plus or minus]6.5
Education
 <High school                [plus or minus]2.5
 High school                 [plus or minus]1.5
 Some college                [plus or minus]1.9
 College or more             [plus or minus]1.8
History of
 cardiovascular
 disease
 Not reported                [plus or minus]0.9
 Reported                    [plus or minus]3.5
Total                        [plus or minus]0.9


(*.)Asked of persons aged [equal to or greater than]35 years only;
excludes persons who reported that they could not take aspirin
because of stomach or health problems.
(+.)Numbers may not add to total because of missing data.
(ss.)Confidence interval.
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Publication:Morbidity and Mortality Weekly Report
Geographic Code:1U0PR
Date:Feb 5, 1999
Words:3000
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