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Cardiovascular Disease Research and Resources

image from Gregg at Creative Commons

What Is Cardiovascular Disease?

The term CVD includes diseases involving the heart and circulatory system. Some of the most common, and serious, forms of CVD are listed here.

Coronary Artery Disease

Coronary artery disease (CAD, also known as atherosclerotic heart disease) is the most common type of heart disease in the United States and often leads to heart attacks. The condition is caused by plaque buildup (atherosclerosis) in the lining of arteries that supply blood to the heart. This plaque, often made up of cholesterol, causes the arteries to narrow over time, blocking blood flow. These plaques can erode or rupture, leading to blood clots and blockages in the artery.

Heart Attack

In a heart attack (also called myocardial infarction or cardiac arrest), blood flow to part of the heart muscle is insufficient, usually due to a blood clot. Coronary artery disease is the main cause of heart attacks; however, a severe spasm or sudden contraction of a coronary artery can also stop blood flow to the heart muscle.

High Blood Pressure

High blood pressure (also called hypertension) is characterized by blood flowing through blood vessels at higher than normal pressures. Blood pressure when the heart beats and pumps blood, known as systolic pressure, is the first number in a blood pressure measure. The second number, called diastolic pressure, signifies pressure when the heart is at rest between beats. Pressures above 120/80 mm Hg weaken and damage blood vessels, leading to conditions such as heart attack, heart failure, peripheral vascular disease and stroke. About one in three US adults have high blood blood pressure, defined as systolic pressure at or above 140 mm Hg or diastolic pressure at or above 90 mm HG, or otherwise diagnosed by a health professional.1

Blood pressure that is too low (called hypotension) can also be a symptom of cardiovascular diseases such as heart failure, heart attack and valve problems. Systolic pressures below 90 mm Hg and diastolic pressures below 60 mm Hg are considered lower than normal.

Stroke

A stroke occurs when blood does not flow properly to the brain, injuring brain tissue. This can result from a clot that blocks the flow of blood (called an ischemic stroke) or a rupture of a blood vessel in the brain, leading to bleeding (called a hemorrhagic stroke). Each year, 795,000 people in the US are estimated to suffer strokes, and roughly 130,000 will die of the event.2

Heart Failure

Heart failure occurs when the heart is unable to pump a sufficient supply of oxygen-rich blood to the body. Due to weakening or stiffening of the heart muscle, heart failure can result from coronary artery disease or high blood pressure. About 5.8 million people in the United States have heart failure, and about half of those who develop heart failure will die within five years of diagnosis.3

Congenital heart defects are not included here but are discussed on our Birth Defects page.

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Cardiovascular disease (CVD) is a leading cause of death both worldwide and in the United States, with mortality rates increasing worldwide.4 In 2014, CVD was responsible for more than 17 million deaths globally. Although it is traditionally understood as a disease arising from diet, obesity, poor physical fitness and family history, research is finding effects from the environment—from air pollution to lead poisoning—on CVD risk.

Prevalence and Costs of Cardiovascular Disease

WHO2015CVD

Top 10 causes of death globally, 2015,5 showing ischaemic heart disease and stroke as the top causes; click to zoom

An estimated 17.5 million people died from CVDs in 2012, representing 31 percent of all global deaths.6 CVD is the leading cause of global mortality.7 The burden is not limited to high-income countries, as 80 percent of CVD deaths occur in low- and middle-income countries.8

CVDrates2015

Worldwide rates of cardiovascular disease.9 DALYs are disability-adjusted life years. One DALY can be thought of as one lost year of "healthy" life;10 click to zoom.

In the United States, more than 85 million people live with at least one type of cardiovascular disease, with roughly half of those aged 60 or older. CVD remains the leading cause of death in the US, with roughly 800,000 deaths (31 percent of the US total) in 2014 resulting from these diseases.11

CVDratesUS2008-2010

Heart disease mortality rates in the US, 2008-2010;12 click to zoom

Trends in Cardiovascular Disease

Rates of CVD are increasing worldwide, up almost 41 percent between 1990 and 2013. One reason for this rise is low- and middle-income countries' success in preventing and treating communicable diseases such as malaria and influenza. Because risk for CVD increases as we age, rates rise as people live longer. However, other factors also contribute to rising rates, such as increasing rates of smoking, physical inactivity, poor diet, and hypertension—all known CVD risk factors.13

In high-income countries, the trends show the opposite: deaths from cardiovascular disease have been falling for decades. A 2015 study surmised that recent declines in CVD rates in high-income countries "are probably due to the combined effect of birth cohorts' decreased exposure to tobacco smoking, improvements in diet, and improved treatment of cardiovascular disease and cardiometabolic risk factors targeting the prevention of cardiovascular disease, and improved treatment of cardiovascular disease."14

In the United States, rates peaked in the 1950s and 1960s and since then have fallen. Age-adjusted mortality decreased 30 percent for heart disease and 36 percent for stroke from 2000 to 2010, but the declines in these rates slowed after 2011.15

graph showing declining rates of cardiovascular mortality

Trends in cardiovascular mortality in the US16 Even as rates drop in the US, they are rising worldwide.

Several factors have contributed to this decrease in cardiovascular mortality in the US:17

  • Improvements to medical treatment of CVD and its precursors
  • Better management of blood pressure and cholesterol
  • Lower rates of smoking
  • Improved physical activity

Even though great progress has been made in bringing down the US mortality rate, CVD is still the leading cause of death, causing almost one in four deaths in the US—a rate still slightly above the cancer mortality rate.18

Costs of Cardiovascular Disease

A 2010 report by the Harvard School of Public Health estimated that CVD worldwide was responsible for $863 billion in costs per year from medical costs and loss of life-years and productivity. The authors of that report projected that these costs could rise to $1.044 trillion ($1,044,000,000,000) by 2030.19

Environment and Cardiovascular Disease Associations

This table summarizes various lifestyle, medical and toxicant exposure risk factors for cardiovascular disease, many of which are discussed in more detail following the table. References for lifestyle and medical risk factors are included in the discussions below. All toxicant listings are from CHE's Toxicant and Disease Database except as noted. 

Disease or Condition

Medical / Lifestyle Risk Factors

Toxicants

Strong Evidence*

Good Evidence*

Coronary artery disease, peripheral vascular disease, atherosclerosis

Physical inactivity

Tobacco use

Carbon disulfide
Lead
Particulate air pollution (soot)
Tobacco smoke

 

Arsenic

Bisphenol A (BPA)20
Cadmium
Carbon monoxide
Dinitrotoluenes
Dioxins / TCDD
Mercury
TNT (trinitrotoluene)

Heart attack (myocardial infarction)

Physical inactivity

Unhealthy diet

Tobacco use

High stress

Carbon disulfide
Carbon monoxide
Cyanide
Dihalomethanes
Hydrogen sulfide
Methylene chloride
Nitrates / nitrites
Particulate air pollution (soot)
Tobacco smoke 

Arsenic

Bisphenol A (BPA)21
Lead

Noise22

Styrene

Chest pain (angina)

Diet high in sodium and fat

Physical inactivity

Tobacco use

 

Bisphenol A (BPA)23

Heart failure

Coronary heart disease

Heart attack

High blood pressure

Diabetes

Tobacco use

Diet high in fat, cholesterol and sodium

Physical inactivity

Obesity

 

 

Air pollution24

Cadmium25

Cardiomyopathy

Family history of cardiomyopathy, heart failure, or sudden cardiac arrest

Connective tissue disease

Coronary heart disease

Heart attack

Muscle conditions such as muscular dystrophy26

Alcoholism or cocaine abuse

Carbon monoxide

Cobalt

Arsenic
Cadmium

Lead

Stroke (cerebrovascular disease)

High blood pressure

High cholesterol

Heart disease

Diabetes

Overweight or obesity

History of stroke

Tobacco use

Excessive alcohol consumption

Poor diet

Physical inactivity

Tobacco smoke

 

Air pollution, including particulates (soot)

Cadmium

Estrogens / DES

Lead

Noise27

Arrhythmias

Increasing age

High blood pressure

Obesity

European ancestry

Diabetes

Heart failure

Ischemic heart disease

Hyperthyroidism

Chronic kidney disease

Excessive alcohol consumption

1,1-dichloroethane

Antimony

Arsenic

Carbon monoxide

Chlorofluorocarbons (CFCs)

Cyanide

Dihalomethanes

Methylene chloride

Nitrates / nitrites

Particulate air pollution (soot)

Pesticides, including carbamates and organophosphates

 

1,1,1-trichloroethane

1,2-dichloroethane

Air pollution28

Arsine

Carbon disulfide

Carbon tetrachloride

Chloroform

Ethyl bromide

Ethyl chloride

Isopropyl chloride

Lead

Methyl bromide

Methyl chloride

Solvents, including acetone, benzene,

tetrachloroethylene (PCE), toluene, trichloroethylene (TCE) and xylene

Tobacco smoke29

High blood pressure (hypertension)

Overweight or obesity

Family history of high blood pressure

Diet high in sodium

Physical inactivity

Excessive alcohol consumption

Tobacco use

 

Air pollution30

Carbon disulfide

Lead

Mercury31

Arsenic

Bisphenol A (BPA)32

Carbon monoxide

Noise33

Some PCBs34

Thallium (and related salts)

 

Vasculitis

Chronic hepatitis B or C

Autoimmune diseases such as lupus, rheumatoid arthritis, and scleroderma

Tobacco use

 

Silica

*"Strong evidence" and "good evidence" are described on our About the Toxicant and Disease Database webpage.

Developmental Origins of Health and Disease (DOHaD)

Conducting research on adults in England and Wales during the 1980s and 1990s, Dr. David Barker found that infants of lower birth weights were at an increased risk of dying from ischemic heart disease in adulthood. The trio of papers he subsequently published, outlining the important role played by environmental exposures and nutrition during pregnancy and early childhood, paved the way for the theory of Developmental Origins of Health and Disease (DOHaD).35

Underlying DOHaD theory is the idea that early life is a time of tremendous plasticity in development during which children are particularly susceptible to environmental factors. The health effects of these environmental factors may then persist long into adulthood. Environmental exposures in utero or early in a child's life can have wide-ranging and long-term effects on cardiovascular health in adulthood.

That effects of childhood exposures do not simply disappear in adulthood indicates the inadequacy of treating CVD exclusively in adults, only after they are at high risk for the disease or have been diagnosed. Evidence suggests that resources could be effectively aimed at decreasing childhood exposure to conditions known to increase risk of CVD later in life, such as poor nutrition and exposures to stressful situations, rather than simply treating the disease after it arises.

Developmental Origins of Health and Disease was described in detail in a 2015 CHE presentation and is further described in a 2010 article in the Proceedings of the National Academy of Sciences of the United States of America.

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Cardiovascular Disease Risk Factors

Lifestyle Factors

Nutrition

Food Choices: What Drives Our Options?

Dietary choices are not only due to individual preferences but are promoted or restricted by environmental and societal factors:

  • Customers often view foods high in fat and sugar as cheaper or more readily prepared than vegetables and whole grains. In fact, many of these foods are cheaper for customers, in part because current agricultural policies promote the production of grains and some high-fat foods over vegetables and fruits.
  • The availability and affordability of fresh fruits and vegetables can vary widely by neighborhood, influenced by socioeconomic status and ethnicity. The existence of "food deserts" with limited or no access to fresh food limits neighborhood access to nutritious choices.36 See our Food and Agriculture Environment page for more information on both agricultural policy and food availability.
  • The ability of individuals to pay for sufficient and nutritious food is influenced by economic systems where they live.
  • Advertisements and cultural influences can also shift people towards or away from particular foods.
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Nutrition is the most important factor influencing heart health. Diet not only influences weight and obesity but can have strong impacts on insulin sensitivity and diabetes, inflammation throughout the body, low-density lipoprotein (LDL) levels, and oxidative stress, among others.37 While new research on dietary health is ongoing, and recommendations continue to evolve, researchers have enough understanding of how most foods can improve or impair cardiovascular health to provide evidence-based advice.

CVDdiet

The placement of each food/factor is based on its net effects on cardiometabolic health, across all risk pathways and clinical end points, and the strength of the evidence, from a 2016 comprehensive review;38 click to zoom

Research has revealed that focusing on a single aspect of diet—such as “low-fat” or “low-carb” options—does not produce much benefit to cardiovascular health. Not all fats have the same effect on cardiovascular disease risk, and not all carbohydrates influence health equally. Focusing on the whole diet is more productive. Eating more fruits, vegetables, fish, whole grains, nuts and beans is tied to improved cardiovascular health and is correlated with lower rates of coronary heart disease and stroke.39

Vegetable oils such as extra virgin olive oil, although they are high in fat, have protective effects against cardiovascular disease. The PREDIMED trial in 2013 found that participants given extra virgin olive oil and nuts and recommended to follow a Mediterranean diet high in fish, vegetables, fruit and white meats saw a nearly 30 percent decrease in major cardiovascular events when compared to participants following a low-fat diet.40 On the other hand, foods that are high in sugar, sodium and industrial trans-fats show harm to cardiovascular health, with greater incidence of heart disease and stroke among people who eat greater quantities of these.41

Physical Activity

walking in the woods

image from Dwayne at Creative Commons

Regular exercise is important for maintaining cardiovascular health, with even 30 minutes of walking per day associated with a lower risk of coronary heart disease, stroke, and overall cardiovascular disease. More activity generally provides greater benefits.42

Exercise has been shown to decrease blood pressure and reduce insulin resistance, both of which are important cardiovascular disease risk factors.43

Tobacco Smoking

Tobacco smoking is well established as a contributor to cardiovascular disease risk. Smoking-induced cardiac damage comes from two major mechanisms: direct adverse effects on the myocardium and indirect effects on the myocardium through comorbidities such as atherosclerotic syndromes and hypertension that eventually damage and remodel the heart.44

Alcohol Consumption

While light or moderate alcohol consumption may have modest beneficial effects regarding ischemic heart disease and ischemic stroke, occasions of heavy drinking—both sporadic and chronic—increase the risk of most major cardiovascular disease categories.45

Toxicants

While evidence indicates that lifestyle factors are dominant over chemical exposures in increasing CVD risk,46 a 2016 report from the World Health Organization estimated that 35 percent of the risks for ischemic heart disease were from environmental exposures, especially these:

vehicle pollution
image from Luc at Creative Commons

These exposures also contribute to risk:

WHO similarly concluded that 42 percent of stroke risks are attributable to the environment, primarily indoor and outdoor air pollution (including ozone and secondhand tobacco smoke); leadjob strain; chemicals such as PCBs, dioxins, phthalates and pesticides; and radiation.47 Clearly, environmental exposures are significant contributors to CVD.

Secondhand Smoke and Indoor Smoke

lit cigarette

image from Raul Lieberwirth at Creative Commons

Secondhand smoke, or environmental tobacco smoke (ETS) can influence the cardiovascular system in several ways: increasing inflammation, insulin resistance and arterial resistance, or decreasing metabolism and HDL cholesterol levels.48 ETS is known to increase platelet formation, which may damage the lining of the arteries and increase the risk of blood clots.

Although secondhand smoke may seem less serious compared to smoking, effects are seen even at low exposures.49 As exposure time increases, risks quickly approach those of smokers.50 Aggregated results of dozens of studies looking at the effects of secondhand smoke (SHS) on cardiovascular disease show an increased risk of stroke of roughly 23 percent51 and an increased risk of heart disease between 25 and 30 percent.52

Other sources of smoke in indoor air, such as cooking stoves and wood stoves, also contribute to cardiovascular disease risk, with indoor cooking stoves a substantial contributor in developing countries.53

Air Pollution

urban air pollution

image from V.T. Polywoda at Creative Commons

Particulate matter pollution−from combustion (burning of wood, fossil fuels and other materials), mining, dust and other sources−is a primary environmental contributor to cardiovascular disease risk.54 Particulates are a hazard both indoors and outdoors. See our Built Environment page and Air Quality pages for information on sources of pollution.

A 2014 report from the World Health Organization on air pollution estimated that globally seven million deaths were associated with both indoor and outdoor air pollution in 2012, with the majority of those coming from cardiovascular disease, primarily ischemic heart disease and stroke.55 Fine particle pollution has been associated with risk of ischemic heart disease, arrhythmias, heart failures and cardiac arrest, in addition to overall cardiovascular mortality.56  Exposure to ambient air pollution can reduce life expectancy up to several years and was responsible for approximately 24 percent of the global burden of ischemic heart disease (in disability-adjusted life years) in 2012.57

Exposure to pollution appears to increase both the immediate and longer-term risks of cardiovascular events. Studies suggest that air pollution can activate inflammatory pathways−leading to atherosclerosis−and interfere with heart rhythm.58

Arsenic

Long-term exposure to high levels of arsenic in drinking water has been associated with a thickening of small and medium-sized arteries in children and young adults and may increase the risk of CVD-related death, although evidence to date is not conclusive.59

Lead

Lead poisoning is associated with an increased risk of cardiovascular disease risk, with several studies showing a small but significant rise of hypertension after lead exposure.60 Lead exposure has also been associated with a significant increase in CVD mortality, myocardial infarction (heart attack), stroke, ischemic heart disease and atherosclerosis.61

Cadmium   

Some evidence indicates that much of the increased risk of peripheral arterial disease arising from smoking results from exposure to cadmium in cigarettes.62 A 2013 review of the health effects of cadmium exposure showed elevated risks of cardiovascular disease, coronary heart disease, stroke and peripheral artery disease.63 Evidence suggests that cadmium may act to increase CVD risk through atherosclerosis, initiating the buildup of plaques in the arteries.64

Infectious Disease and Cardiovascular Disease Risk

Well established links exist between CVD and some infectious diseases, possibly because systemic inflammation seen in infections can have damaging effects on blood vessels and the heart, increasing the risk for heart disease later in life:

  • Periodontal disease—an infection of the gum tissue often precipitated by poor oral hygiene—has been associated with cardiovascular disease, although it is not clear whether the infection causes CVD itself.65
  • Inflammation throughout the body as seen in herpes simplex 1 and Chlamydia pneumoniae may increase risk for cardiovascular disease.66
  • People living with human immunodeficiency virus (HIV) have a greater risk of CVD.67

Stress and Cardiovascular Disease

Contributors to Chronic Stress

Common stressors:

  • Poverty and socioeconomic stress
  • Community violence and/or crime
  • Household violence
  • Housing instability
  • Discrimination/perceived racism
  • Work-related stresses
  • Adverse childhood experience

Those of low socioeconomic status or subject to routine discrimination, plus others who are subjected to chronic stress, are at risk for high allostatic load. A 2006 study found that levels of stress hormones are significantly higher among those of lower socioeconomic status, independent of race and age. Perception of discrimination can also lead to chronic stress, associated with higher blood pressure among both adults and children.68

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In a stressful environment, the cortical centers of the brain naturally respond by initiating the release of  hormones such as cortisol and adrenaline throughout the body to better react to the stressor.69 This response can include increases in blood pressure, heart rate and blood glucose. When the stressor passes or is resolved, the body is able to return to its previous state and downregulate the stress-induced hormones. This process of self-regulation and homeostasis is called allostasis and is explained in more detail on our Psychosocial Environment webpage.

However, with repeated or chronic stress, the body’s ability to regulate the stress response is impaired. Allostatic load, defined as “the wear and tear on the body and brain resulting from chronic overactivity or inactivity of physiological systems that are normally involved in adaptation to environmental challenge,”70 can create a chronic state of heightened cardiovascular activation and decrease the regulation of inflammation.71 In circumstances of chronic stress, a person is at greater risk of developing high blood pressure, atherosclerosis, myocardial infarction and coronary heart disease.72

Epigenetic Factors

DNA model

image from Wellcome Images at Creative Commons

Epigenetics, a relatively new area of study, may inform us how some environmental exposures can interact with genes to influence CVD risk. Though genes are passed down from parents to children and typically do not change throughout a person’s life, environmental exposures and stressors can influence how the body expresses genes. We can think of genes as being "turned on" or "turned off", with some genes present but not activated. Some environmental exposures or experiences can activate, or express, genes by marking DNA, often by a process called methylation. This process is not the same as a mutation and does not alter the underlying DNA, but these marks and their effects can remain with a person throughout his or her lifetime and may even be passed down generations. See our Gene-Environment Interactions page for a fuller discussion of epigenetics.

Measurements of epigenetic changes or differences have allowed researchers to look at the mechanisms through which environmental exposure may affect cardiovascular health. For instance, researchers have found different levels of DNA methylation when comparing people exposed to different levels of air pollution.73 Different levels of methylation are also seen when comparing patients with hypertension, ischemic heart disease, and stroke to those without these conditions.74 Environmental exposures may affect epigenetic regulation through several of the inflammatory responses they induce.75

Comorbidities and CVD Risk

What Is Metabolic Syndrome?

Metabolic syndrome is a collection of conditions that sharply increase a person’s risk for cardiovascular disease, diabetes and stroke. People with three or more of the following conditions are considered to have metabolic syndrome:

  1. Abdominal obesity, as excess fat in the stomach area is a greater risk factor for heart disease than excess fat in other parts of the body, such as on the hips. A waistline of 40 inches or more in men or of 35 inches or more in women is considered a risk.
  2. Fasting blood glucose levels above 100mg/dL
  3. Elevated blood pressure, with either systolic blood pressure above 130 or diastolic blood pressure above 85.
  4. High levels of triglycerides in the blood, over 150mg/dL
  5. Low HDL cholesterol levels, below 40g/dL in women or below 50g/dL in men

Information is from the National Institutes of Health.76

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Several comorbidities are important for assessing cardiovascular disease risk.

  • Diabetes patients develop cardiovascular disease at greater rates than those without diabetes, and those who develop cardiovascular disease tend to have poorer prognoses than those without diabetes.77
  • Individuals with metabolic syndrome have a 53 percent increase in risk of developing CVD and 75 percent increase in risk of death from CVD.78
  • High blood pressure can injure blood vessels, increasing the risk of stroke, atherosclerosis and other cardiovascular diseases.79
  • Kidney disease is both a cause and a consequence of cardiovascular disease. Risk of death from cardiovascular disease can be 10 to 30 times greater in dialysis patients compared to the regular population.80

The Life Course Model

Over the course of a person’s life, chronic stressors and other factors can have a cumulative effect, increasing the risk of cardiovascular disease at each stage. When children are exposed to regular stressors, such as housing instability, childhood maltreatment and other adverse experiences, or regular discrimination, their immediate risk of cardiovascular events increases, but so too does their lifetime risk. The life course model suggests that a person’s risk of disease is influenced by exposures at every age. Similar to a person’s allostatic load, lifetime risk of a disease is an accumulation of risks earlier in life, from developmental exposures to those in childhood, adulthood and old age.

CardiovascularDiseaseLifecourseModel

A life course model, created by Nancy Hepp and Tom Austin from several sources;81 click to zoom.

Prevention and Policy

Cardiovascular disease is an enormous worldwide public health threat, but opportunities are available at the personal, community, national and global levels to improve heart health and effectively prevent CVD.

Personal Prevention

Diet

Because diet is the biggest factor in CVD risk, CVD-prevention efforts must address dietary choices. Consuming a diet with a variety of fruits, vegetables, fish, unsaturated vegetable oils, nuts and beans, and which is also low in sugars, red and processed meats and refined grains is particularly effective. The American Heart Association publishes diet and lifestyle recommendations.

Physical Activity

The World Health Organization, Centers for Disease Control and the American Heart Association all recommend these levels of physical activity at a minimum each week for adults 18-64:82

weightlifting

image from Franchise Opportunities at Creative Commons

  • 150 minutes of moderate-intensity aerobic activity, or 75 minutes of vigorous-intensity aerobic activity, or some comparable combination of these.
  • Two muscle-strengthening activities that work all major muscle groups (legs, hips, back, abdomen, chest, shoulders and arms).

These guidelines are adjusted for children, for older adults and for pregnant and postpartum women. Please see the CDC guidelines for more information.

Cigarette Smoking and Alcohol Use

Refraining from smoking and exposures to secondhand smoke may reduce lifetime risk of CVD. Because exposures can start before birth and continue throughout childhood, families and entire households—and not just individuals—need to address cigarette smoking at home.83 Eliminating excessive alcohol consumption, even just occasional heavy drinking, also reduces risk. The American Heart Association does not recommend any alcohol consumption.84

Chemicals and Other Exposures

Reducing personal exposures to noise, air pollution and chemicals listed in the table above may reduce CVD risk. More information about sources of exposure and avoiding those exposures is published on our related webpages, available through the links in the table.

Regional, National and International Prevention

Cardiovascular Disease and the Social Ecological Model of Health

Our health and well-being are profoundly shaped by many aspects of the social and environmental setting in which we live. The laws and policies of our countries, states or provinces, and cities can influence the conditions in which we live, work and play. These laws and policies can also influence our access to health care, our education and the food we eat as well as our social interactions and community networks. Our social and community environments can influence the personal lifestyle and health choices we make and the effects those choices can have on our bodies.

In the ecological model of health, risks and exposures for a disease like CVD are viewed as interrelated and interconnected. For instance, a person’s race can influence exposure to microaggressions and discrimination that then cause stress. Access to education can influence social status, earning power, the ability to afford adequate housing and food, and on and on. These experiences influence opportunities in the workplace and personal relationships at home and can contribute to personal choices that influence health. Because cardiovascular disease is influenced by many of these factors, at many levels of the environment, they are integral to discussing cardiovascular disease prevention and treatment.

The social ecological model of health helps us to understand how factors influencing changes at one level of influence are situated within the larger model, and how such changes can influence other levels. Find more information on the Psychosocial Environment page.

psychosocial model

graphic by Lorelei Walker, PhD

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Cities, counties, states and countries can influence cardiovascular health at the population level by promoting and enabling beneficial individual activities and by regulating harmful factors.

Diet

The structure of food production systems can promote healthier eating. Governmental subsidies, taxes and regulations can have tremendous influence on the availability of fresh fruits and vegetables as opposed to refined grains and foods high in sugar and fat. Some examples of how government involvement influences food choices:

fresh fruits

image from Army Medicine at Creative Commons

  • In 2012, the US Department of Agriculture updated the minimum nutritional standards for the national school breakfast and lunch programs to align with current nutritional science regarding a healthy diet for children across different age groups.85
  • Federal agricultural policies have contributed to dramatic changes in the US food supply since the 1930s, encouraging overproduction of commodity grain and oilseed crops such as corn and soybeans. Subsidies have fueled the rise of these calorie-dense crops in our food supply in the form of added fats and sugars, and their cheap availability as feed for livestock has contributed to an increase in less-healthy meat and dairy choices.86 Shifting subsidies and incentives toward more nutrient-dense food choices could bring the prices of these foods down and promote more healthy eating.
  • The 2010 federal Affordable Care Act includes provisions requiring large retail food chains and vending machine operators to disclose calorie content of items on menus and in machines and also provide other important nutritional information.87
  • Some localities have used zoning or licensing laws and incentive programs to regulate the location and density of fast food outlets or to promote the availability of healthy foods in neighborhood corner stores.88
  • Cities, states or federal agencies have set minimum nutrition standards for foods served in child care settings, regulated the use of trans fats, or taxed sugary beverages to decrease consumption rates.89 Early research shows that taxing unhealthy food choices reduces their consumption.90 In 2017 the US Food and Drug Administration banned trans fats specifically to reduce coronary heart disease and prevent thousands of fatal heart attacks every year.91

Physical Activity

The design or retrofitting of buildings, neighborhoods and transportation systems can encourage physical activity:

feet climbing stairs

photo from Fit Approach at Creative Commons

  • The inclusion of safe, accessible stairways as an option to elevators, as well as other innovations in building design92
  • Adding inviting parks, trails and playgrounds to neighborhoods, and enhancing the safety and attractiveness of public walkways93
  • Providing safe, convenient public transit94
  • Building bicycle lanes or trails95

See more about how the built environment influences physical activity on our Built Environment webpage. Increasing active tranportation at the population level may also provide extra benefits from reduced air pollution. 

Cigarette Smoking and Secondhand Smoke

The following policy actions, supported by the American Heart Association in a 2016 policy statement, are all associated with lower smoking rates in a population.96 These policies may also decrease exposure to secondhand smoke:97

  • Bans on public and workplace smoking
  • Tobacco excise taxes
  • Funding for tobacco cessation and prevention programs
  • Advocating for greater insurance coverage for smoking cessation programs
  • Rasing the minimum age for purchasing tobacco products

Following the national trend, Seattle adopted a “Smoking in Public Places” policy in 2005 prohibiting smoking in workplaces and indoor public places, including restaurants and bars. The Washington State Department of Health touts the law as having led to a decrease in secondhand smoke, indoor air pollution and smoking overall.98 Aggregating the effects of many smoke-free policies throughout the US shows a 39 percent decrease in chest pain, coronary heart disease and sudden cardiac death, as well as roughly 15 percent decrease in myocardial infarction, coronary syndrome, coronary events, ischemic heart disease and stroke.99

The 2009 Family Smoking Prevention and Tobacco Control Act (FSPTCA, also known as the tobacco control act) granted the US Food and Drug Administration authority to regulate tobacco products.100

Alcohol Use

Regulatory efforts to reduce excessive consumption of alcohol show promise in improving cardiovascular health.101

Air Pollution

signing the 1990 Clean Air Act

President George HW Bush signs the 1990 Clean Air Act; image from the US Environmental Protection Agency

In the US, National Ambient Air Quality Standard (NAAQS) were established with the 1990 Clean Air Act, with the primary goal of protecting public health, particularly for groups at greater risk, including children and the elderly. These standards are updated every five years to ensure they keep pace with our scientific understanding of the risks of air pollution. The American Heart Association supports full implementation of the Clean Air Act, tightening regulation of sources of air pollution, and other meastures to reduce air pollution, both indoors and outdoors.102

Worldwide, policies promoting cleaner air draw from reports including these:

  • The World Health Organization's biennial “Global Status Report on Noncommunicable Diseases” whose stated target audience is ministers of health.103
  • The Institute for Health Metrics and Evaluation at the University of Washington reports on the global burden of disease, including cardiovascular disease, with the aim to inform and guide policymakers.104
  • The American Heart Association's 2010 policy update on air pollution and cardiovascular disease105

Regulations to monitor and reduce air pollution have been extremely effective in decreasing cardiovascular disease risk in the US. In 2011 the US Environmental Protection Agency (EPA)  estimated that 130,000 heart attacks and 86,000 emergency department visits were prevented in 2010 because of Clean Air Act regulations of fine particlulates and ozone.106

Chemicals and Other Exposures

Policy initiatives to reduce chemical, radiation, noise and other exposures could also reap cardiovascular benefits. The implementation of the Frank R. Lautenberg Chemical Safety for the 21st Century Act will determine the direction of chemical regulation in the US.

To date, typical discussions of prevention interventions focus heavily on lifestyle and biologic risk factors.107 However, addressing all contributors to cardiovascular disease risk, including chemical and other exposures, will be necessary to prevent avoidable disease and death.

More information about cardiovascular diseases can be found in the resources in the right sidebar.


This page was last revised by practicum student Tom Austin, Nancy Hepp and Lorelei Walker, PhD, in September 2017. Read more about Tom's practicum, including his review summary.

CHE invites our partners to submit corrections and clarifications to this page. Please include links to research to support your submissions through the comment form on our Contact page.

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