Each issue of the Journal of Cardiovascular Nursing has several pages devoted to Preventive Cardiovascular Nurses Association (PCNA) news, current activities, and reviews of new research relevant for prevention-focused cardiac nurses. In this issue, you will find an interesting overview of an initiative called Complete Streets to promote better and safer access to walkable and bike-friendly roadways, a research review of a study on the severity of metabolic syndrome (METS) and cardiovascular disease (CVD) risk reduction for persons with prediabetes, a case study related to adoption of a plant-based diet, and an exciting experience of 1 PCNA member's advocacy experience. We hope you find these articles enriching and of use to your teaching, advocacy, and practice.
Promotion of Physical Activity: The National Physical Activity Plan, Complete Streets, and Sharing the Road Initiatives
The National Coalition for Promoting Physical Activity's recently released National Physical Activity Plan1 emphasizes the important relationship between the nature of the built environment and whether people perform physical activity. They suggest changes in transportation, land use, and community design in an effort to reduce sedentariness and promote movement and active behaviors. For thoroughfares and intersections to be more user-friendly for physical activity, preventive cardiovascular nurses in general and PCNA advocates can work with community groups to (1) invest in bicycle and pedestrian infrastructure and transit, (2) change neighborhood plans so people have places to which they can walk or bike, (3) advocate for funding and policies that increase active transportation and physical activity, and (4) invest in and institutionalize the collection of data to inform policy and measure the impact of active transportation on physical activity.1
Depending on where your patients live, they might be able to take advantage of the Complete Streets initiative2 now underway in many cities and towns across America. What is Complete Streets? Since 2004, this national nonprofit coalition, run by public interest organizations and transportation professionals, has been committed to implementing Complete Streets practices in regard to transportation networks. The idea is that streets are for everyone, and it focuses on the redesign of current roads as well as plans for future road projects. The emphasis is on safe access to encourage active transportation for walkers, cyclists, and those needing safe paths and areas near public transportation (bus and train stations). In the short term, its mission is safe access for all road users regardless of ability, age, or mode of transportation. In the long term, a selling point is that it will make cities and towns better places to live.
Preventive cardiovascular nurses can become active in their local community groups or work with patients to start an initiative locally. This initiative is another way to promote physical activity to reduce cardiovascular risk factors at the population level. To assist, the initiative's website provides the Best Community Street Projects chosen annually, fact sheets, case studies, webinars, and reports of successful street designs.
Each Complete Street design has a different look, but the changes all follow a theme of increasing physical activity and, at the same time, reducing transportation woes and traffic costs. Examples of strategies are bike lanes or wide paved shoulders, special bus lanes, sidewalks, frequent and safe crossing opportunities, median islands, accessible pedestrian signals, narrower travel lanes, accessible public transportation stops, curb extensions, and roundabouts. You might have noticed that some of these changes are already occurring in your community.
Since 2016, the Sharing the Road initiative,3 through a consortium of state judges and national highway authorities, has focused on the interface between drivers and cyclists on our roads. One major solution was to pass laws for drivers to keep a safe distance (3 ft) when passing a cyclist, giving them room when overtaking them. These laws, as well as “share the road” signs that you might have seen in your community, promote safety so that exercisers can gain positive health benefits from active transportation.4
- National Coalition for Promoting Physical Activity. National Physical Activity Plan. http://ncppa.org/national-physical-activity-plan. Accessed January 2019.
- Smart Growth America. Improving lives by improving communities. What are Complete Streets? https://smartgrowthamerica.org/program/national-complete-streets-coalition/publications/what-are-complete-streets. Accessed January 2019.
- National Center for State Courts and the National Highway Traffic Safety Administration. Traffic resource center for judges. http://home.trafficresourcecenter.org/~/media/Microsites/Files/traffic-safety/SharingtheRoad.ashx. Accessed January 2019.
- Mueller N, Rojas-Rueda D, Cole-Hunter T, de Nazelle A, Dons E, Gerike R, … Nieuwenhuijsen M. Health impact assessment of active transportation: a systematic review. Prev Med. 2015;76:103–114. doi:10.1016/j.ypmed.2015.04.010.
Karen Larimer's Sweetened Beverage Tax Experience
Karen Larimer Correa, RN, CVNS, FPCNA of Chicago, IL, recently received PCNA's Advocacy Award for CVD Prevention. Here, she recounts her recent advocacy experiences.
As a nurse, scientist, and health advocate, I have seen the harmful effects of a sugar-laden diet. Let's be honest, one doesn't have to be in the health field to appreciate the impact of sugar on the American diet. Therefore, when given the opportunity to be a spokesperson for a sweetened beverage tax, I jumped at it. Cook County's initiative to impact health through policy was consistent with my work in this area and my belief in the ecological model recognizing that policy can impact the determinants of health.
Partnering with the Board President, Toni Preckwinkle, the American Heart Association took on the challenge of supporting a sweetened beverage tax. To move a sweetened beverage tax (a penny per ounce) forward, it was critical that we have a clear argument in our defense of the tax. We wrote letters, advertised through various media outlets, and gave testimony at Board meetings. I was called on to give interviews with the press. It was critical to drive home the point that chronic illness, such as diabetes and heart disease, is on the rise, and heart disease is the number 1 cause of death in all adults. These diseases are linked to high consumption of sugar. Sugar's number 1 source in our diet is sugary beverages. We argued that lowering consumption could be an incredible benefit to the health of the county as well as generate revenue for an ailing county health system budget.
We shared evidence with the public and legislators that lower-income and minority communities are targeted by the beverage industry and, unfortunately, are the communities that suffer the most from the adverse health effects of sugary beverages. These same lower-income and minority communities have disproportionately high rates of diabetes and other chronic diseases.
It was critical in our messaging that a sugary beverage tax was going to be just 1 important piece of the health puzzle. However, it's a piece that could be achieved relatively quickly and begin to have an impact. Public health experts state that taxes can be one of the most effective policy strategies in achieving health equity. More so, the World Health Organization recommends that countries implement taxes on sugary beverages to help lower consumption and, in turn, reduce the prevalence of heart disease, diabetes, and tooth decay. Mexico has done so and has since seen a positive impact of this strategy.
Although we had the scientific support and significant financial support from the American Heart Association and Bloomberg Philanthropies, it was an uphill climb in a city (Chicago) and county where citizens felt “taxed to death.” Another huge hurdle was the pressure of the food and beverage industry, as well as “Big Soda.” They had virtually endless resources to advertise and lobby against the tax. The tax passed; however, it was overturned 6 months later.
This battle is not over for me or public health advocates. As advocates, we draw strength from one another and especially our professional colleagues like those at PCNA to continue to increase awareness of the impact of sugary beverages. Advocacy for health is all about timing, collaborating, compromising, and relationship building. Moreover, in the words of the American Heart Association, “being a relentless force for a world of longer, healthier lives.”
A Case Study About Plant-based Diets: Healthy or Just Hype?
L.W. is a 55-year-old white woman seen in the office by the cardiology advanced practice nurse for evaluation and treatment of hyperlipidemia. She presented with an Agatston coronary artery calcium score of 272; a score of 100 to 399 indicates an intermediate risk for a coronary event.1 Her weight at the clinic visit was 151 lb with a body mass index (BMI) of 27.6. Her lipid panel results were as follows: cholesterol, 263; triglycerides (TRIG), 146; high-density lipoprotein (HDL), 56; and low-density lipoprotein (LDL), 178. Lifestyle modification strategies were discussed with the patient. After careful discussion with the cardiologist and team, she made the decision to attempt lifestyle modification with the understanding that medication may still be required to lower lipid levels in the future. She was asked to incorporate lifestyle changes such as improved dietary and exercise habits and follow-up in 2 months. The patient returned in 2 months reporting that, after much research, she chose to eliminate animal protein from her diet and she adopted a plant-based diet. At her follow-up visit, she stated that she was feeling great, and her weight had dropped to 142 lb (BMI, 26) since the previous visit. Her post–lifestyle intervention lipid results showed the following: cholesterol, 145; TRIG, 83; HDL, 48; and LDL, 80.
A plant-based diet is gaining increasing attention because it has been associated with cardiovascular and other health benefits such as lower cardiovascular events.2 Various types of vegetarian diets and veganism are considered plant based.3 The consumption of whole grains, nuts, legumes, fruits, vegetables, and nonhydrogenated vegetable oils is accentuated in a diet that is healthful and plant based.4
Because cardiovascular nurses and other members of the healthcare team may be asked questions about these diets, it is important to continue to review the evidence for practice regarding heart-healthy nutrition and diets. Several observational studies have shown at least a 24% decrease in coronary disease in vegetarians when compared with omnivores and a 22% lower rate of stroke mortality in men who ate vegetarian diets.4 In addition, blood lipids are improved, and insulin sensitivity is heightened, which lowers risk for CVD and type 2 diabetes (T2DM).4 Not all plant-based foods are healthy, however; white potatoes and refined grains, for example, are negatively associated with cardiovascular health.2
In this actual clinical case study of L.W., weight loss combined with a change to a plant-based diet and improved exercise led to improved BMI and lipid panel, and a reduced risk for a CVD event. Although she has made great strides in her lifestyle management, her provider may decide to discuss pharmacological therapies such as a statin to lower her LDL even further. The addition of medication will also enhance the benefits from L.W.'s lifestyle changes and further reduce her future CVD risk.
L.W. has exhibited how a healthful plant-based diet in conjunction with routine physical activity can positively affect her cardiovascular health and should continue to be encouraged to maintain this lifestyle by her healthcare team. There is strong evidence to support that plant-based diets are beneficial. Additional future studies are warranted to further explore the comprehensive benefits of a plant-based diet.4
- van der Bilj N, Joemai RM, Geleijins J et al. Assessment of Agatston coronary artery calcium score using contrast enhanced CT coronary angiography. Am J Roentgenol. 2010;195:1299–1305. https://www.ajronline.org/doi/pdf/10.2214/AJR.09.3734
- Williams KA, Patel H. Healthy plant-based diet: what does it really mean? J Am Coll Cardiol. 2017;70(4):423–445. https://doi.org/10.1016/j.jacc.2017.06.006
- National Kidney Foundation. Plant-based diet or vegetarian diet: what is the difference? https://www.kidney.org/atoz/content/plant-based-diet-or-vegetarian-diet-difference. Accessed December 28, 2018.
- Satija A, Hu FB. Plant-based diets and cardiovascular health. Trends Cardiovasc Med. 2018;28(7):437–441. https://doi.org/10.1016/j.tcm.2018.02.004
Using the New Metabolic Syndrome Severity Z Score to Track Risk During Treatment of Prediabetes
A cornerstone of preventative cardiovascular nursing is education and counseling on lifestyle behaviors and change. Have you ever wondered if all that intense focus on lifestyle makes a difference in either the behaviors, risk factors, or progression to either T2DM or CVD for your patients with METS? Efforts to prevent diabetes are key given the risk it confers toward CVD. A recently reported analysis of data1 from the Diabetes Prevention Program (DPP) supports efforts to reduce components of METS of waist circumference, glucose, and systolic blood pressure to reduce the risk of T2DM and CVD.
The DPP was originally conducted as a randomized controlled trial to test prediabetes treatments, including usual care, metformin, or intensive lifestyle modification.2 Around 3234 persons (mean age, 50.6 years) with prediabetes participated between 1996 and 1999. The intensive lifestyle modification component had goals of achieving and maintaining greater than 7% reduction in body weight. It used a strategy of a low-calorie, low-fat diet and moderate physical activity such as brisk walking of around 150 minutes per week. After 2.8 years of follow-up, the trial was stopped early because of the superior achievement of lifestyle intervention over metformin and usual care in the onset of T2DM.
Metabolic syndrome is defined by the Adult Treatment Panel III as the presence of abnormal values in 3 of 5 criteria: elevated waist circumference, high blood pressure, high TRIG, low HDL, and high fasting glucose. DeBoer and colleagues1 created a METS severity score based on sex and ethnicity, which they labeled MetS-Z, thus augmenting the “present/not present” or dichotomous nature of these criteria, and they validated it in previous studies.2,3 The MetS-Z was further applied to the DPP data to determine whether reductions in MetS-Z were associated with a reduced risk of T2DM and CVD. For risk of T2DM within 1 to 5 years, they found the strongest associations with 1-year changes in MetS-Z and waist circumference. For risk of CVD, the greatest relationship was with a 1-year change in MetS-Z, glucose, and systolic blood pressure. Using mediation analysis to determine what factors created by the lifestyle modification were associated with risk, the T2DM effect was mediated by changes in MetS-Z, waist circumference, glucose, and TRIG at 1 year, whereas the effect of metformin was mediated by MetS-Z and glucose. Importantly, the overall change in waist circumference as a marker of visceral obesity was a high-risk predictor within the lifestyle intervention. A reduction in waist circumference was associated with a reduced risk for both T2DM and CVD.
Helping patients make lifestyle changes that address METS severity and specifically reduce elevated glucose and waist circumference could be essential for reducing the risk for future T2DM and CVD. Reduction of METS components and its overall severity score may be enhanced by emphasizing to at-risk patients not only the presence of abnormal values but also their severity. The calculator is found at http://mets.health-outcomes-policy.ufl.edu/calculator/. Further study may help determine whether tracking initial severity and early responses to treatment are beneficial in motivating patients with METS to make crucial lifestyle changes to reduce their T2DM and CVD risk.
- DeBoer MD, Filipp SL, Gurka MJ. Use of a metabolic syndrome severity z score to track risk during treatment of prediabetes: an analysis of the diabetes prevention program. Diabetes Care. 2018;41(10):dc181079.
- Knowler WC, Barrett-Connor E, Fowler SE, et al; Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002;346:393–403.
- DeBoer MD, Gurka MJ, Woo JG, Morrison JA. Severity of the metabolic syndrome as a predictor of type 2 diabetes between childhood and adulthood: the Princeton Lipid Research Cohort Study. Diabetologia. 2015;58:2745–2752.
- DeBoer MD, Gurka MJ, Golden SH, et al. Independent associations between metabolic syndrome severity and future coronary heart disease by sex and race. J Am Coll Cardiol. 2017; 69:1204–1205.