Primordial CVD Prevention, Maternal Health, and Advocacy to Improve Outcomes Now & Into the Future
August 15, 2022
Guest: Donald M. Lloyd-Jones, MD, ScM, FAHA
Cardiovascular disease prevention can–and should–begin before patients develop any risk factors. Learn about strategies for primordial prevention (including maternal risks of CVD), reducing health disparities, and how they can be applied in clinical practice–no matter where patients are in their lifespan. Our guest for this conversation is Don Lloyd-Jones, past president of the American Heart Association, and Chair of the Dept. of Preventive Medicine at Northwestern University.
[00:00:00] Welcome to Heart to Heart Nurses, brought to you by the Preventive Cardiovascular Nurses Association. PCNA's mission is to promote nurses as leaders in cardiovascular disease prevention and management.
Geralyn Warfield (host): Well, welcome back to our audience and we are very honored to be here with Don Lloyd Jones and he is going to introduce himself and we're going to get into several different topics today you are not going to want to miss. So, Dr. Lloyd-Jones, please introduce yourself, please.
Don Lloyd-Jones (guest): Thank you, Geralyn. It's great to be with you. So, I am Don Lloyd Jones. I'm a cardiologist and cardiovascular epidemiologist. I'm the Chair of the Department of Preventive Medicine at Northwestern University in Chicago, and have the real honor of being the President of the American Heart Association this year.
Geralyn Warfield (host): So, as again, I've said before, we are so honored to have you here and you have such a breadth of information for us to try and take advantage of while we have you here in the podcasting studio, but, well, let's go ahead and get [00:01:00] started about primordial prevention of cardiovascular disease. Can you talk a little bit more about that and what that might look like maybe in clinical settings?
Don Lloyd-Jones (guest): Sure. So, you know, I think many people have not, maybe, heard this term before, so it might be worth defining it. And the way I think about prevention is in buckets. So, tertiary prevention is really what we refer to when a patient is in the emergency department, in the midst of an acute stroke or an acute heart attack. What do we need to do to keep them alive?
Secondary prevention people will be familiar with, right? Once they've had that heart attack or stroke, how do we prevent the next episode? Primary prevention, where we spend a lot of our time, people have risk factors, and we want to prevent that first heart attack.
But primordial prevention is really the new kid on the block, actually first defined in 1978. But if you look at across the literature at the citations, there's this huge uptick that happens in 2010, from, essentially, three citations a year referring to primordial prevention, now in the several hundreds per [00:02:00] year and growing. And the reason that change happened is, because in 2010, the American Heart Association really put a premium on defining primordial prevention, defining something that we want to strive for, which is positive cardiovascular health.
And the way to achieve that is through primordial prevention. So, what is does it mean? What primordial prevention means is we're not going to let people develop risk factors in the first place, because once they've developed hypertension, or diabetes, or cholesterol, we can treat those things very effectively in primary prevention. But we can't put the horse all the way back in the barn.
Too many of those people will have a sudden cardiac death event as their first event. Or we'll go on still to have a heart attack or stroke because we can't completely restore the lowest risk. So, in primordial prevention, we're really taking a life course approach to try to start early in life, continue through young adults to middle-age to make sure we keep that blood pressure as low as possible, as [00:03:00] long as possible.
So, as you can imagine, what we're talking about here is, both population level interventions, but especially individual interventions to make sure we're optimizing lifestyle so that the blood pressure doesn't start to go up in our twenties and thirties.
Geralyn Warfield (host): That's a really, not very novel, based on the years that you were talking about that this has been in literature, but for most of us, that is a really novel consideration. So how would that look in clinical practice? Let's say you are a primary care provider. What would that look like? I heard you talk about the hypertension and controlling that, but what would the conversation maybe be to try and make that really approachable to a patient?
Don Lloyd-Jones (guest): Yeah, well, I think it is always really important to frame this in a positive framework, meaning, you know, “If we can keep your really excellent blood pressure where it is today for the next 20 years, you won't need to take medication, in fact, you know, when that time comes like your parents are. And in fact, you know, we can actually avoid you having a stroke or a heart attack [00:04:00] in your fifties and sixties.”
“We’ll will actually help you avoid cancer, if we follow these lifestyle approaches as well. We'll help you actually live longer and healthier, longer without many of these chronic diseases of aging. So, the time to start,” my pediatric patient or my young adult patient, “is now.”
“And the way we are going to achieve this is through keeping you active. Every single day, trying to move a little bit more. Keeping your weight healthy. At a minimum, let's not let you gain any more weight. Let's hold the line where you are. And, if we need to, let's figure out strategies that work for you to reduce some weight, if you need to.”
And critically important, the thing that's upstream from all of this, of course, is our eating pattern. So, getting people focused on a more plant-forward eating pattern. Helping them understand how to avoid sodium that's in the processed food supply, how to eat food that looks like food, and really enjoy that because it can, it can actually help all the other things that happen downstream.
Geralyn Warfield (host): So, I suspect you probably [00:05:00] have some resources that you could point to so that our providers could have some additional information.
Don Lloyd-Jones (guest): Yeah. Yeah. So, a great place to start is with the Life's Simple Seven website of the American Heart Association, where a patient or a provider can go enter very simple information about a patient’s eating pattern, their physical activity pattern, what their weight is, do they smoke, and their current levels of cholesterol, blood pressure, and blood sugar, and they'll get their cardiovascular health score.
And they'll also get a lot of great tips about how to improve those things that might get a red light or a yellow light instead of a green light, so that they can improve their cardiovascular health through primordial prevention strategies, get mostly focused on lifestyle, and then achieve, again, that longer, healthier life span, which is I think is the, really the goal of primordial prevention.
Geralyn Warfield (host): I really liked that idea. I kind of wish I was not at this point in my life and could go back a little bit further and be part of that trajectory towards better [00:06:00] health throughout life.
Don Lloyd-Jones (guest): What's really important to know though, is it is never, ever too late. Yes, the earlier you start, the bigger the impact will be, but it is never too late—and we can show from a lot of population-level data, that people will make changes in their fifties, sixties and seventies can actually extend their health span, even by doing it then. Yes, we'd love to have them do it in their twenties, thirties, and forties, because it will have a bigger, longer impact, but it is never too late. And it's important to emphasize that as we empower our patients at every stage of the life course.
Geralyn Warfield (host): Well, speaking, having a long-term impact, we've had a situation around the globe in the last couple of years, and I think we're all very familiar with what's happened. But if you could talk a little bit about how COVID and CVD—those interrelationships—and what we might be looking at both short-, medium- and long-term.
Don Lloyd-Jones (guest): Yeah, this is really important. And, you know, I think we, we know the devastating impact that COVID has had around the globe with millions and millions of deaths coming up on a million deaths here in the spring of 2022 in the United States [00:07:00] all too quickly. But I think it's important to remember what put us at risk for this virus to have such a devastating impact.
It was obesity. It was hypertension. It was diabetes. The same things that made our population unhealthy and gave us such high levels of cardiovascular disease and cardiovascular deaths were actually the very same things that put us at risk for the virus. That sort-of low-level inflammation and the unhealthiness of our immune systems related to obesity, diabetes, and hypertension are the very things that made it more likely that those patients would also have complications from the virus.
And so, I think we've learned, we really need to get back to thinking about these chronic conditions and how they make the whole population unhealthy, not just around cardiovascular disease and stroke, but for these other reasons as well. So, it was the fertile soil that I think the virus found. But what's really important to know, also, is that as we've gone through this pandemic, we've seen a [00:08:00] number of problems that have increased cardiovascular disease, death rates, both directly and indirectly related to the virus.
The stresses of an infection certainly increase the risk of heart attack and stroke for maybe as long as six to 12 months after the acute infection, interesting data about that. Unfortunately, we've seen as the different waves have gone through patients voting with their feet, staying at home when they're having severe symptoms, that might be a heart attack or stroke, not going to the emergency room because they're worried about the virus and then presenting either too late for us to be able to intervene or sometimes presenting dead, unfortunately.
And so we've seen marked increases, maybe 50,000 more deaths in the last two years each, due to cardiovascular disease, because of these kinds of acute problems that aren't being addressed. And that's the pandemic sort of getting in the way of our usual systems of care.
But then also we've seen patients deferring or avoiding care for those chronic [00:09:00] conditions. In the summer of 2020, the American Heart Association did a national survey and 41% of patients were saying they were deferring or avoiding their routine clinic visits to manage obesity, hypertension, diabetes, cholesterol. And then, even by the next summer of 2021, it was still 20% of patients. So, those patients had disconnected from their usual sources of care.
And we know, and I'm seeing these patients back now and we desperately want them back because blood pressure has gone far out of control and it takes time to get those things back under control. So, particularly marginalized populations, underrepresented, under-resourced communities. We've seen devastating impacts there, and we're going to see ripple effects for probably years to come because we've lost control of some of those really critically important cardiovascular risk factors. And I'm worried.
I'm hopeful because we have new ways maybe to reach patients through telehealth, through home blood pressure monitoring. We can empower [00:10:00] people, but we need to get them back in first to be able to activate that.
Geralyn Warfield (host): Such great information that you're sharing with us. We're going to take a quick break and then we'll be right back with Don Lloyd-Jones.
Geralyn Warfield (host): And we're back with Don Lloyd-Jones. We are so thrilled to be able to have this conversation with him. I know that there's a number of things that you wanted to discuss in our time today. And one of those had to do with gestational and maternal risks of cardiovascular disease. So, I'm wondering if you could launch into that topic for us.
Don Lloyd-Jones (guest): Certainly. And you know, it's going to be along the lines of some of the things we've already talked about in terms of primordial prevention. You know, maybe the first thing I'll say is that healthy moms have healthier babies. And those, those healthier babies, in turn, launch into healthier trajectories across their life course.
So, it's really important that we think about having healthier moms preconception, because we know that moms that go in already having weight problems or blood pressure problems, more likely to have adverse pregnancy outcomes. That [00:11:00] affects mom's health, also affects the baby's health.
But we've done some interesting research. If we know what the cardiovascular health status is of a woman in second trimester, we can actually predict what the cardiovascular health status of her child will be 10 to 14 years later.
Geralyn Warfield (host): Oh my gosh.
Don Lloyd-Jones (guest): Pretty robustly. Really interesting. So, that the sort of priming that happens within the uterine environment for that child is incredibly important to understand how they're going to handle stresses, how they're going to handle calories, later downstream, this sort of imprinting that happens through epigenetic mechanisms in utero can actually decide whether the child is going to launch to a higher trajectory or maybe not be able to achieve that higher trajectory.
So, we’ve got to get our moms healthier for so many different reasons, but maybe the most stark and important reason is among all industrialized high-income countries, the U.S. is dead last in maternal mortality. A shocking, horrible statistic. [00:12:00] And we are the only country, high-income industrialized country, in which our rates are getting worse over the last 20 years. Everyone else's rates are getting better. We are getting worse. If we can't protect moms at the time of birth, what are we doing as a society?
Because, again, it feeds forward into higher risk for their kids as well. And then we have another generation of unhealthy moms and dads who have unhealthy children. We need to, we need to arrest this cycle and we need to do it right now. And that, again, we must focus earlier in life on healthier lifestyles so that we can arrest this cycle.
And it's not evenly distributed. What's, you know, tragic here is just like COVID, just like the opportunities to be able to participate in healthy lifestyles, maternal mortality rates are two times higher in American Indian, native indigenous populations, three times higher in Black women compared with white or Hispanic women. Unacceptable, and we must, [00:13:00] must do better at getting those women access to healthcare, the ability to pay for healthcare, and the relationships that are ongoing through the pregnancy, and after. Because if a woman has gestational diabetes or a hypertensive disorder pregnancy, she's at much higher risk to develop those things later, after her pregnancy, to have long-term diabetes, to have long-term hypertension.
And too many of those women don't get, you know, back into care, or don't stay connected with the health system after they've had their child. Understandable, but there are easy policy ways we can address this, you know, through better Medicaid coverage that will cover mom for a longer period of time after birth, so that she gets the care she needs as well.
Geralyn Warfield (host): Just such thought-provoking statistics you've provided us and heart-wrenching, literally and figuratively. I, you know, I'm just, like the audience, just amazed at the fact that we're not getting any better. And the time is now for us to act. [00:14:00] So, what are some actions our listeners can, can do today to make a difference for all these populations of individuals who are facing struggles that are, if we're not careful, insurmountable?
Don Lloyd-Jones (guest): Yeah. So, I'm a big believer in advocacy. You know, I think we can do what we can do at our individual level. We can actually affect our families and our near communities, right, with promoting healthier lifestyles. Let's all get up and go for a walk. Let's choose healthier foods to have for dinner. Let's eat them together and to have that enjoyable experience around eating food. So, so there are many, many things we can do at our individual level, but we need to tilt the playing field so that those default choices, that we're forced to make, are healthier.
And that's where advocacy, I think, is so important. We need to work with our community leaders so that there are safe places for kids to play, you know, afterschool basketball programs, parks, where they can go and play safely, [00:15:00] where hopefully, you know, either whether it requires police, you know, patrols or parent patrols or whatever it is so that those kids can, can be in places where they can run around and play safely, hopefully for 60 minutes every day, which is really how they'll launch, you know, more healthily.
Thinking about the food supply in our schools, getting sugar-sweetened beverages out of our schools, making sure that every single one of our communities and states has tobacco 21 laws so that no one under 21 can buy combustible tobacco or vaping products. We do not need another generation of individuals hooked on nicotine. And those vaping products are extremely efficient nicotine addiction delivery systems. That's all they're there for. This has big tobacco's playbook all over again. We must rise up and fight against this, and we have really powerful ways to do that with our advocacy tools.
Thinking even a little bit more broadly, you know, let's talk to our senators and congresspeople. It's time for [00:16:00] the farm bill again. Rather than subsidizing big ag corn and soybeans, how about subsidizing fruits and vegetables? That actually would lead to a healthier population with reduced disparities in health, and everybody living longer better. Isn't that what societies are supposed to do for ourselves?
So, you know, that may seem daunting, but getting involved at the school level, getting involved and getting to know your community and state level representatives, they are so hungry for our knowledge, as clinicians, as physicians, as nurses, as parents, you know, about what could be done, that they will talk to anybody.
And, you know, what's really helpful to know is that these strategies are actually cost-saving. You know, and that's often the bottom line for our policymakers is, well, this is going to cost money, but actually it will be cost saving because we will have fewer adverse pregnancy [00:17:00] outcomes. We will have healthier children, with less asthma, with less obesity, with less chronic diseases, even in younger ages.
And that will turn into fewer heart attacks, strokes, and cancers down the line as well. So, these are cost saving strategies and it is…maybe it takes a lot of activation energy to be an advocate, but once you do it, you'll be hooked. I promise you.
This year as AHA President, this has been the most energizing, these have been the most energizing activities that I've done, I’ve testified before Congress for a day. Amazing. I've been working with Senator Durbin’s staff on public health funding priorities, just to see, again, how hungry they are for knowledge and how you can make a difference. Please get out there and do it. It's amazing.
Geralyn Warfield (host): I wish you all could see the enormous smile that I'm seeing across the table from me. You can just feel the energy. You can just sense the optimism and that's really the important part here—that we all can make a difference. [00:18:00] Dr. Lloyd Jones, is there anything else that I neglected to ask that you would like to touch on today?
Don Lloyd-Jones (guest): No. You know, I think three incredibly important issues:
- Primordial prevention: let's start young, but it's never too late, you know, using lifestyle to improve and enhance our lifespan and our health span.
- Let's help our moms be healthier. And that's policies, yes, but that's also launching our children into healthier trajectories so that they're healthier moms and dads and their kids are then healthier.
- And then, finally, be an advocate. You know, we can make a difference and actually create a healthier environment for all of us.
Geralyn Warfield (host): Dr. Lloyd-Jones, it's been an honor to have you here speaking with us today. Thank you so very much for your time. This is your host Geralyn Warfield, and we'll see you soon.
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