Divergent trends show mixed picture of national health

Although increasing diabetes and obesity rates have dire implications for heart disease, cardiac and overall death rates are down.

Current data indicate that heart disease, obesity and diabetes have all increased substantially in the United States since tracking these conditions began in earnest during the 1950s.

American Heart Association statistics indicate that in 2004, approximately 15.8 million people had CHD, and the disease caused approximately 452,300 deaths across all U.S. demographics. According to the CDC and the AHA, heart disease continues to be the nation’s No. 1 cause of death, followed by cancer and stroke.

Mixed message

“It’s a mixed message,” Roger S. Blumenthal, MD, professor of medicine and director of The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, said in an interview. “We’re doing a better job with CV mortality, but there’s going to come a point in time that with an increase in obesity, there’s also going be a need for a lot more medication use, and subsequently, an increase in cardiac events.”

Roger S. Blumenthal

Financial figures show that increased heart disease rates are costly. A 2006 CDC estimate shows the overall heart disease cost, in terms of lost productivity, health care services and medications, is $142.5 billion.

“We’re doing a pretty good job of treating people with an initial presentation of coronary disease, but with more diabetes anticipated in the next decade, we’ll start seeing younger people developing coronary disease and symptomatic disease,” said Blumenthal, a member of the Preventive Cardiology section of the Cardiology Today Editorial Board. “We need to identify people with higher risk and make sure that they get what we call the ABCs of management – aspirin, blood pressure control and cholesterol management.”

Diabetes and obesity

Obesity is a problem across all age groups, particularly among the young. The AHA reports that more than 140 million Americans older than 20 years are overweight and 66 million are obese. A 2005 Journal of the American Medical Association report attributed 112,000 excess deaths in 2000 to obesity relative to normal weight. The National Diabetes Information Clearing House also noted in 2005 that central obesity and metabolic syndrome are primary risk factors for both type 2 diabetes and heart disease. Excessive waist size — more than 40 inches in men and 38 inches in women — are indicators of central obesity and metabolic syndrome, risk factors for heart disease, high LDL and diabetes.

Elliot Rapaport

“We’ve become to some extent a nation of couch potatoes, watching TV, eating fast foods, not being careful of our total caloric intake,” Elliot Rapaport, MD, emeritus professor of medicine at the University of San Francisco School of Medicine, said in an interview. “Visceral adiposity is significantly associated with the development of insulin resistance, and since diabetes is associated with the likelihood of cardiovascular mortality in the future, we’re going to suffer the consequences.”

According to the CDC, diabetes was the No. 6 cause of death in the United States for 2004. In addition, the CDC estimated that there were 14.6 million people living with physician-diagnosed diabetes in 2005; another 6.2 million cases went undiagnosed. The CDC estimates that heart disease and stroke account for nearly 65% of deaths in people with diabetes, and that adults with diabetes have death rates about two to four times higher than adults without diabetes.

Early diabetes detection is critical, as the CDC estimate for patients with pre-diabetes — defined by the American Diabetes Association as fasting blood glucose between 100 mg/dL and 126 mg/dL — was around 56.5 million in 2004. Diabetes, however, can be managed with certain lifestyle changes.

“Patients with diabetes are being better managed today,” said Rapaport, section editor of the Preventive Cardiology section of the Cardiology Today Editorial Board. “Our cardiologists and family practice physicians are much more aware of this problem than they were perhaps a decade ago. I think we are more attentive in managing problems. Our overall management of patients with diabetes is significantly better today. The fundamental issue we continue to face is even better prevention, and one of the strong elements of that is the prevention of visceral obesity.”

Declining death rates

Given increasing levels of obesity, diabetes and heart disease, a rising death rate would seem like a logical result. But this seems to be where some of the conventional wisdom is contradicted.

Overall death rates have been trending down since the early 20th century across all demographic and economic strata. The National Center for Health Statistics reported that the average life expectancy hit a record high of 77.8 years in 2004, and the death rate bottomed out at a record low 800.8 per 100,000. The AHA noted that between 1994 and 2004, cardiovascular mortality rates fell 25%, and CHD mortality rates declined 33%. The overall diabetes death rate between 2003 and 2004 fell 3.2%.

“I think the combination of better attention to preventive cardiology, along with better medical and surgical management of patients with CHD, has been responsible for that decrease in mortality,” Rapaport said. “We can expect that there will be continued improvements in management of patients with CVD. People are living longer, and further advances in the management of coronary disease should continue the trend of falling mortality rates.” – by Eric Raible

For more information:

• Flegal KM, Gail M, Graubard BI, Williamson DF. Excess deaths associated with underweight, overweight and obesity. JAMA. 2005;293:1861-1867.