Appalachian Health and Well-Being

5. The Heart of Appalachia

111 5 The Heart of Appalachia Ann L. McCracken and E. Kelly Firesheets Heart disease,a the leading cause of death of both men and women in the United States, costs an estimated $475 billion for health care services, medications , and lost productivity in 2009.1 Among adults over 20 years of age, some 80 million Americans, or 38 percent of men and 34 percent of women , are currently living with one or more types of cardiovascular disease. This form of heart disease affects the heart itself or the blood vessel system, especially the veins and arteries leading to and from the heart. Nationally, more than 830,000 people die of cardiovascular-related conditions every year.2 Rates of heart disease are not equally distributed across the U.S. population . According to reports from the Centers for Disease Control and Prevention (CDC),3 some of the highest rates of heart disease are in Appalachian areas, including southern Ohio, West Virginia, and eastern Kentucky . In 2008, 8.1 percent of West Virginians reported that they had been diagnosed with angina or coronary heart disease—the highest percentage in the country and nearly twice the national average of 4.3 percent.4 Four of the five states with the highest heart disease death rates (West Virginia , Pennsylvania, Mississippi, and Alabama) contain Appalachian counties (only Oklahoma, which ranks second, does not).5 Nearly 15 percent of hospitalizations in the 406 Appalachian-designated counties in 2000 were due to heart disease, exceeding hospitalizations due to chronic obstructive pulmonary disorders, all cancers, stroke, and diabetes combined. Eastern Kentucky, southern West Virginia, and western Virginia have particularly high rates of hospitalization for heart disease.6 Barnett and coauthors7 point out that disease incidence is influenced 112 McCracken and Firesheets by social, economic, behavioral, psychological, and physiological risk factors , while disease mortality is affected by the speed of diagnosis and the efficacy of medical care. Death certificate data from 1990 to 1997 reveal that heart disease was the leading cause of death among elderly men and women in Appalachia. Elderly white men living in Appalachia had higher death rates than those who lived outside the region.6 These data are not surprising, given that heart disease is generally considered a disease of the elderly; more than 83 percent of people who die of coronary artery disease are aged 65 or older.8, 9 However, young Appalachians are not immune to heart problems. In fact, nearly a third of hospitalizations for heart disease in Appalachia were for individuals between 35 and 64 years of age.6 These statistics have led many to believe that the risk factors for heart disease may be more prevalent among Appalachians than non-Appalachians . This chapter explores that proposition by presenting the known risk factors for heart disease and reviewing national and regional data on their prevalence among Appalachians. Additional evidence regarding the prevalence and relative effect of various risk factors is provided through a case study analysis of heart disease among Appalachians in the Greater Cincinnati metropolitan area. The chapter ends with research and policy recommendations that address the prevalence of heart disease among Appalachians. Risk Factors for Heart Disease To improve the heart health of individuals in Appalachia, it is important to understand the risk factors influencing their long-term health. Some of these factors, such as age, sex, and heredity, cannot be changed, while others can be manipulated. For example, in a case-controlled study of fiftytwo countries, nine risk factors subject to change accounted for greater than 90 percent of the likelihood of having an initial acute heart attack. These factors are cigarette smoking, abnormal blood lipid levels, hypertension , diabetes, abdominal obesity, lack of physical exercise, low daily fruit and vegetable consumption, alcohol overconsumption, and low scores on a psychosocial index that included depression, locus of control, perceived stress, and life events.10 Risk factors can be grouped using a variety of other frameworks as well. Practitioners and health researchers have identified health, lifestyle, and behavioral factors that increase the risk of developing The Heart of Appalachia 113 heart disease.11 Others examining the relationships between socioeconomic status and health outcomes group risk factors in two categories— compositional and contextual. Compositional factors focus on the individual , such as health, lifestyle, and behavior, whereas contextual factors are shared by all individuals in a similar environment.6 Both types are relevant in Appalachia; however...