John (Jack) C. Lewin, MD; William Zoghbi, MD


October 11, 2011

Editorial Collaboration

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John (Jack) C. Lewin, MD: Hello, I'm Dr. Jack Lewin, Chief Executive Officer of the American College of Cardiology (ACC) in Washington, DC. I'm here today at the United Nations (UN) Summit on Non-Communicable Diseases in New York City, and joined by the President Elect of the ACC, Dr. Bill Zoghbi.

Bill, this is quite a challenge and a big first for the UN to actually take a stand on what is the number 1 killer in the United States and in the world. What do you think of the meeting so far, and what do you think about the goals that are laid out in the declaration?[1]

William Zoghbi, MD: I think this is a landmark meeting. It is a first for the body of the UN at the high-level summit meeting to be able to address the number 1 killer in the world and in the United States, just like you said. There was a declaration in this meeting to improve on the current status of noncommunicable diseases and to decrease the incidence of morbidity and mortality caused by them. This declaration was adopted unanimously without even a vote, so I think this a significant first step in combating noncommunicable diseases in the world and in the United States.

Dr. Lewin: We have been waiting a while for it. You're an academician, you're also an esteemed clinician respected by the whole cardiovascular community, and you work often with [extremely] sophisticated imaging equipment at very complicated centers. Is this whole thing going to be about all that kind of complicated technological medicine? How do you think this is going to be focused?

Dr. Zoghbi: Believe it or not, I think, it is simple. If we address the very basic principles of the [known] risk factors in these noncommunicable diseases, and they share the whole spectrum of cardiovascular disease, diabetes, and cancer, [then it is] very simple. People were having a problem adopting them, and they're not high tech.

We're not talking about imaging. We're talking about healthy lifestyles -- exercise, not smoking, and knowing what your blood pressure is and making sure that your blood pressure is controlled, which also means a healthy diet, lower salt intake, and an overall healthy lifestyle.

If we can affect that, it's probably even much more impressive than any new medication that we can bring onboard, or even any testing that we could do to prevent morbidity and mortality from these diseases. It is a very simple message in a way. However, we have challenges to affect it still in the United States and certainly throughout the world, because these diseases constitute about 80% of the mortality and morbidity around the world.

The Million Hearts Campaign

Dr. Lewin: Well, in some ways, these noncommunicable diseases are sort of communicable, in the sense that the developing world seems to be catching up to our lifestyle and moving in the direction of obesity, diabetes, and greater risk for hypertension and so forth. Do you think that the United States is going to play a leadership role and should the ACC play a leadership role outside of our own borders and boundaries?

Dr. Zoghbi: I'm proud that in the United States just recently, a few days ago, that there was a Million Hearts campaign, which is along the line of trying to look at the ABCS (aspirin, blood pressure, cholesterol, and smoking), which is very important.

What we like about it, and also what has been in this declaration, is the collaboration between governmental agencies and private industries, converging altogether to try to send this strong message on how you can, with simple things, really prevent these noncommunicable diseases that are so deleterious.

It's not only from a morbidity and mortality point of view, but also from a productivity point of view. If you think about developing countries, the chronicity of these diseases influences at least 30% of the productivity of that working force, which is tremendous.

Going back to the Million Hearts campaign, this is a wonderful campaign that the ACC was instrumental in putting thought behind and was certainly collaborating very strongly with all the other organizations, which I think will be very important.

Dr. Lewin: Well, that's exciting. I mean, 800,000 people will die in this country of preventable heart attacks and strokes in the next year, and probably 20 million people or more in the world. Of course, we've seen a 30% reduction in mortality in the United States in the last 10 years thanks to all the wonderful things we can do. On the other hand, in regards to these prevention strategies, we really lagged in getting behind this kind of focus.

Dr. Zoghbi: The interesting thing is we've had a 30% reduction in mortality over these 25 plus years. But certainly the curve of increasing metabolic syndrome, diabetes, and morbid obesity, unfortunately, has not plateaued. So, having this in the background, just imagine, if we can conquer this at the same time, how much reduction in these morbidities and mortalities we will have.

Dr. Lewin: In contrast, just imagine if we don't somehow reduce the pipeline of diabetes, obesity, hypertension, and risk factors heading our way; we'll never have enough cardiology professionals. We will not have the teams needed to treat that kind of problem, and the world isn't ready for that.

Dr. Zoghbi: Talking about teams, it is not necessarily that you need the physician or the very highly specialized individual to be able to affect that. These are simple messages that can be affected by so many, not only in the cardiovascular or healthcare team, but even individuals in various settings who can basically affect that change.

Dr. Lewin: I'm glad you brought that up because I was impressed today by the Surgeon General's talk and some of the things Secretary Sebelius said in her address, that the actual design of the community is going to be critical to get people walking and to encourage people to exercise more, and to get kids out of the houses and away from the video games.

Dr. Zoghbi: We have to be cognizant of the ethnic diversity -- where to affect it and how to affect it. We have to be able to speak the language and speak to the various health habits so that in whatever group we're talking about-- be it in this country or another -- we have to be able to affect that change and be sensitive to the habits or lifestyles that individuals have in that particular community. These are very important.

Another challenge we are talking about is how do you measure this? How do you measure the change, because if you don't measure it, you don't know the prevalence and how you can affect it or will affect it down the line?

Dr. Lewin: Some of our viewers know our message "You can't manage if you can't measure. And what you don't measure you can't manage." We've learned in cardiology that you've got to have ways to see what progress you're making. You've got to track whether the message is really getting there: to lower the blood pressure, to improve the diet, to improve the exercise, to see whether we are having an impact on obesity and diabetes and hypertension, and whether smoking is really being reduced or are we just spinning our wheels.

Dr. Zoghbi: Another thing that came out today from some of the conferences on how to affect change, particularly when it relates to diet and being overweight and obesity, is making sure that we don't paint this as immediate gratification or an immediate goal. Small changes will have a longer effect, like diets that may decrease just the caloric intake a bit.

Dr. Lewin: The sodium.

Dr. Zoghbi: The sodium. [We] will go a long way in achieving that and encouraging individuals to burn a few more calories -- to do a few things. I know we're technically very savvy in so many ways, but [with] every technological development, be it at home or in the workplace, the net effect is some satisfaction, but also, certainly, a decrease in caloric expenditure. We have to make sure that whatever it is that we walk more, we take the stairs, we do things, we exercise, we go to the gym, etc. You don't have to go to the gym; you can do it in your environment, so [exercise] doesn't have to be costly.

Dr. Lewin: Stress, as well, is a big factor. For cardiologists in practice and for cardiovascular and advanced practice nurses, the whole cardiovascular team out there, we're sort of caught up with the people who have gone a little too far down the road of risk. What can we do, and what should we do? What's our role going to be as we try to impact these early signs, the prevention side, and changing lifestyles? What can we do?

Dr. Zoghbi: The physician, be it a cardiologist or otherwise, is seeing a segment of the population, and most of them are symptomatic. We really are touched when we see this individual in the office or whatever setting. They are not really coming out to say [to us], "Well, what can I do for prevention?" In addition to taking care of individuals or patients who are coming in and decreasing the risk factors, hopefully they can instruct their families about that as we have to out in the community.

Dr. Lewin: Now we have a Website called Cardio Smart and we've had an emphasis on team care of late. These aren't things that we talked about 5 or 10 years ago, and you have said to the cardiology community that patient-centered care is where we need to go. How does that perhaps impact here?

Dr. Zoghbi: The patient has to be at the center, at the forefront, of what we do because [for] all of us, that's our mission -- to impact care and improve quality and longevity at the same time. We have to address these risk factors, particularly for noncommunicative diseases, and we have the tools.

Cardio Smart is a great Website for teaching and educating, not only for our patients, but also for the community at large. Physicians need to have this on their mind. We have to think and to engage. Everyone talks about not having enough time, so we're working on tools that would facilitate the cardiovascular care team or the healthcare team to get this education and this engagement between the care team and the patient -- hopefully, not yet to be the patient -- to decrease the risk factors as much as possible and give them some of these positive feedback tools, back and forth between the care team and the individual.

Putting the patient at the center and having this interaction I think will be more effective. Education [of the patient] is really at the center of this campaign.

Dr. Lewin: Who would have thought that cardiology would be putting kiosks in pharmacies and retail outlets where people's blood pressure and body mass index, risks for diabetes, all of those things would actually get measured [along with] with text messaging to the patient. These are radical things for doctors to be thinking about doing, but that's [an example of] reaching out to the patient and making it effective.

Dr. Zoghbi: It's reaching out to the patient, and at the same time making use of what technology has evolved into to try to have a better reach, and, hopefully, a better effect and better outcome.

Dr. Lewin: And going to where patients are. They're not in the doctor's office all the time; they're somewhere else. This has been a great conversation. Thank you very much, Dr. Zoghbi.

Dr. Zoghbi: Thank you, Jack.

Dr. Lewin: Again, from the UN Summit on Non-Communicable Diseases, I'm Jack Lewin and this is Bill Zoghbi. It is an exciting time in trying to reach out to save a million lives here, maybe 20 million in the world, to reduce the risks for heart disease everywhere for people at early stages. Thanks for being with us.


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