Heart Truth: NYC's Public-Health Policies Linked to Lower CVD

Marlene Busko

October 18, 2013

MONTREAL, QC — A decade of health policies and health-promotion messages in New York City aimed at preventing cardiovascular disease have pushed heart-disease rates downward faster than they have elsewhere in the US, according to the city's health commissioner. "Making healthy choices easy ought to be our goal at the population level," Dr Thomas Farley said during the opening ceremonies of the Canadian Cardiovascular Congress (CCC) 2013 .

Since 2002, when Mayor Michael Bloomberg took office and began implementing policies to battle smoking and obesity, the life expectancy of New Yorkers has risen by 36 months vs an average increase of 21.6 months in the rest of the country, Farley noted. Half of this increase was from decreased heart disease—probably the result of the ban on smoking in public places.

Even though challenges remain—for example, the battle to ban supersize sugary drinks remains before the courts—"we are making progress, and we're going to keep fighting," Farley told heartwire after the lecture. For the first time, "we are seeing [small] reductions in child obesity, and we are very excited about that," he added.

According to Farley, physicians play a valuable role in counseling patients about the benefits of a healthy lifestyle, but they also need to actively support public policies that make it easier for people to make healthy choices.

Targeting Key Behaviors

Introducing public policy that changes the way people live "is an extremely powerful way to promote health at a population level," Farley explained. Hundreds of years ago, to successfully eradicate smallpox, cholera, and yellow-fever epidemics in the city, "we could have asked people to wash their hands," he noted. "Instead, we developed safe water and sewage systems."

He pointed out that at last year's meeting, Dr Clyde Yancy (Northwestern University, Chicago, IL) said that if people undertook seven preventive behaviors, they would have a 90% chance of living to age 90. The behaviors are: get active, stop smoking, follow a healthy diet, achieve and maintain a healthy weight, know and control blood pressure, manage diabetes, and know and control cholesterol. The New York City approach has incorporated these at a policy level, promoting smoking cessation and healthy diet and activity habits.

Encouraging Smoking Cessation

The city used a multipronged strategy to get its citizens to stop smoking. In 2002, it banned smoking in public places. Currently, it has the highest taxes on cigarettes in the country—$6.86 per pack. When focus groups revealed that smokers were afraid of suffering but not of dying, they implemented a hard-hitting ad campaign that shows a patient with lung cancer "suffering every minute."

The prevalence of smoking dropped from 21% in 2002 to 15.5% in 2012, "which represents about 300 000 fewer smokers . . . and saves an estimated 1500 lives a year," Farley said. Despite this success, "our fight against tobacco continues," he stressed. "It is still our number-one target as we respond to promotion by industry."

Focusing on Diet, Calories, and Physical Fitness

Close to 60% of adults in New York City are overweight or obese—"a problem of normal people in an abnormal environment," according to Farley.

To turn this around, the public-health department focused on increasing consumption of fruits and vegetables and making people aware of calories, sugary drinks, trans fat, and sodium.

The city established standards for food and beverage vending machines that deliver millions of meals and snacks to New York City government employees. It is also working with retailers to increase the prominence of healthy foods and set up a system of street vendors who sell only fruits and vegetables, in targeted neighborhoods.

In 2006, the New York Board of Health voted to restrict artificial trans fat in 24 000 restaurants, one of the first major cities to take this step, Farley noted. That initiative appears to have paid off. Then, in 2008, the city implemented a policy requiring that fast-food restaurants post the calorie content of foods. This resulted in a small but meaningful effect: 15% of consumers read the calorie content, and these individuals then eat 100 fewer calories.

Sugary drinks are a key source of calories, Farley reminded his audience. In the Coca Cola museum in Atlanta, an ad from the early 1950s shows that a 64-ounce bottle was considered family size. Today, this half-gallon drink, which contains the equivalent of 50 packets of sugar and 800 calories, is a large single serving. In response, the New York department of health designed an ad campaign with the slogan "Are you pouring on the pounds?"

The city has also led a successful campaign to lower the sodium content in food. Americans consume far too much—3400 mg/day instead of less than 2300 mg or 1500 mg a day—and 80% comes from packaged food, Farley said. New York City created the National Salt Reduction Initiative —which represents 90 cities and states—with the goal of reducing sodium by 25% in five years. Last year, 21 companies met voluntary sodium-reduction targets for such products as Heinz ketchup (15% lower) and Kraft singles American cheese (18% lower).

Although New Yorkers do not exercise as much as other Americans, they are fit because they walk a lot—to the subway and up and down stairs, Farley observed. The city plans to build more bike lanes and create more parks to encourage physical activity.

Public Policies to Prevent CVD

Speaking with heartwire after Farley's presentation, CCC scientific program committee chair Dr Andrew Krahn (University of British Columbia, Vancouver) noted that the public-policy approaches undertaken in New York will be key to combating CVD. And this may require a shift in focus.

"Our traditional model of care is around a physician-patient encounter, and we need to look at the healthcare system in a much more comprehensive way," he said. "When patients show up with an acute MI we've got outstanding people that act quickly, but [disease prevention through healthcare policies] is something we've been less attentive to."


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