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 counseling 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 to 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 greater than or equal to 35 years reported taking aspirin daily or every other day to reduce their risk for heart attack 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 less than 0.01) 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, 82.8% (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

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 behaviors (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 disease 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 Prev Med 1996;12:238-41.

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

8. Kreuter MW, Scharff DP, Brennan LK, Lukwago SN. Physician recommendations for diet and physical activity: which patients get advised to change? Prev 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.

TABLE 1. Prevalence of reported physician advice and individual behavior to reduce risk for heart disease or stroke, by selected
characteristics -- seven states and Puerto Rico, Behavioral Risk Factor Surveillance System, 1997
========================================================================================================================================================================================
                                                 Physician advice                                                          Individual behavior
                                    -----------------------------------------              -----------------------------------------------------------------------------------------
                                    Eat fewer high-fat                                     Eat fewer high-fat                                        Use aspirin to reduce risk
                                 or high-cholesterol foods      Exercise more           or high-cholesterol foods             Exercise more          of heart attack or stroke*
                       Sample    -------------------------     -----------------        ---------------------------         ------------------       --------------------------
Characteristic         size+         %           95% CI&        %         95% CI            %                95% CI          %          95% CI            %            95% CI
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
State
  Arizona              1,890       41.9          +/-3.1        44.8       +/-3.1           75.5             +/-2.8          72.9       +/-2.9            23.0          +/-3.3
  Iowa                 3,564       28.8          +/-1.7        32.6       +/-1.7           68.0             +/-1.8          53.9       +/-1.9            23.8          +/-1.9
  Louisiana            1,637       41.5          +/-2.8        44.0       +/-2.9           66.2             +/-2.8          63.0       +/-2.6            20.9          +/-2.8
  Oklahoma             1,874       40.4          +/-2.7        39.9       +/-2.7           67.6             +/-2.5          56.3       +/-2.7            19.2          +/-2.4
  Pennsylvania         3,565       38.3          +/-1.8        39.2       +/-1.8           62.3             +/-1.9          57.8       +/-1.9            18.5          +/-1.8
  Puerto Rico          2,242       69.7          +/-2.2        70.4       +/-2.1           75.2             +/-2.1          71.2       +/-2.1            15.1          +/-2.2
  Virginia             3,501       39.0          +/-2.4        36.5       +/-2.4           65.0             +/-2.5          56.5       +/-2.5            19.6          +/-2.3
  Wyoming              2,386       31.2          +/-2.0        35.0       +/-2.2           66.2             +/-2.5          59.0       +/-2.5            23.4          +/-2.4

Sex
  Men                  8,647       39.6          +/-1.4        40.2       +/-1.4           63.5             +/-1.4          60.1       +/-1.5            21.8          +/-1.5
  Women               12,012       43.2          +/-1.2        44.3       +/-1.3           70.1             +/-1.2          61.4       +/-1.3            17.8          +/-1.2

Age (yrs)
  18-34                5,441       28.3          +/-1.6        31.2       +/-1.7           57.1             +/-1.9          60.3       +/-1.8             --
  35-49                6,508       40.0          +/-1.7        42.1       +/-1.7           69.0             +/-1.7          60.7       +/-1.7             7.8          +/-0.9
  50-64                4,233       56.6          +/-2.1        55.4       +/-2.1           76.5             +/-1.8          63.2       +/-2.1            23.9          +/-2.0
  65-74                2,617       53.7          +/-2.6        52.0       +/-2.6           72.8             +/-2.4          61.8       +/-2.5            35.8          +/-2.7
    >=75               1,763       46.2          +/-3.3        42.9       +/-3.3           66.8             +/-3.1          55.8       +/-3.3            36.7          +/-3.4

Race/ethnicity
  Non-Hispanic white  15,737       38.1          +/-1.1        38.7       +/-1.1           67.3             +/-1.1          59.9       +/-1.1            21.3          +/-1.1
  Non-Hispanic black   1,406       45.3          +/-3.3        47.9       +/-3.4           60.6             +/-3.3          59.2       +/-3.3            13.2          +/-3.0
  Hispanic             2,933       59.7          +/-2.3        60.7       +/-2.3           71.2             +/-2.2          67.9       +/-2.2            14.3          +/-2.0
  Other@                 509       33.6          +/-6.3        36.4       +/-6.4           58.1             +/-7.6          56.0       +/-7.6            16.9          +/-6.5

Education
  <High school         2,882       45.6          +/-2.5        44.2       +/-2.5           58.9             +/-2.6          54.2       +/-2.5            24.3          +/-2.5
  High school          7,245       39.4          +/-1.5        41.1       +/-1.5           62.5             +/-1.6          58.0       +/-1.6            19.5          +/-1.5
  Some college         5,419       40.4          +/-1.8        42.1       +/-1.9           69.4             +/-1.9          62.7       +/-1.9            20.3          +/-1.9
  College or more      5,061       43.5          +/-2.0        43.5       +/-2.0           75.4             +/-1.7          66.7       +/-1.9            16.9          +/-1.8

History of
  cardiovascular
  disease
  Not reported        18,965       38.9          +/-1.0        40.0       +/-1.0           65.9             +/-1.0          60.3       +/-1.0            15.2          +/-0.9
  Reported             1,694       73.8          +/-2.8        70.3       +/-2.9           79.3             +/-2.8          66.5       +/-3.0            61.4          +/-3.5

Total                 20,659       41.5          +/-0.9        42.3       +/-0.9           66.9             +/-0.9          60.7       +/-1.0            19.7          +/-0.9
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
*  Asked of persons aged >= 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.
&  Confidence interval.
@  Numbers for races other than black and white were too small for meaningful analysis.
========================================================================================================================================================================================

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