This section, multilevel policies, reviews the impact that has been and can be made by health policy changes at multiple levels, strategies and resources for increasing adherence to population prevention recommendations, and how changes at the microlevel and macrolevel of the environment can provide opportunities and rewards for healthy behaviors and disincentives for unhealthy behaviors. Policies that support primary prevention of cardiovascular disease require the participation of numerous stakeholders at multiple levels, such as governmental and regulatory agencies. Such policy changes support a healthy lifestyle, as in designated smoke-free areas; laws that mandate that food purveyors reduce sodium and fat content or, eliminate trans-fats; and availability of safe parks and bike and walking trails; and also provide a supportive environment that in turn reinforces adherence to primary prevention. Health-related policies have a major impact at the societal level in both developed and developing countries; thus, it is important to understand the role that policy plays in promoting a healthier lifestyle and the prevention of cardiovascular disease. This section discusses how health policies can impact primary prevention and adherence to healthful recommendations, with examples focused on physical activity and diet.
MacLean SJ,MacLean DR.(Transnational) affairs of the heart: political economy and the globalization of cardiovascular disease Global Health Gov. 2008;2 (2): 1-19
2.
Woodward D,Drager N,Beaglehole R,Lipson D.Globalisation and health: a framework for analysis and action Bull World Health Organ. 2001;79 (9): 875-881
3.
Leurent HRK,Voáte J,Yach D.Wellness in the workplace: a multi-stakeholder health-promoting initiative of the World Economic Forum Am J Health Promot. 2008;22 (6): 379-380
4.
Wood DA,Kotseva K.Should cardiovascular disease prevention be undertaken by doctors or policymakers and politicians? Dialogues Cardiovasc Med. 2009;14 (2): 83-98
5.
Morel CM,Acharya T,Broun D.Health innovation networks to help developing countries address neglected diseases Science. 2005;309 (573): 401-404
6.
Goff DC,Brass L,Braun LT.Essential features of a surveillance system to support the prevention and management of heart disease and stroke: a scientific statement from the American Heart Association councils on epidemiology and prevention, stroke, and cardiovascular nursing and the interdisciplinary working groups on quality of care and outcomes research and atherosclerotic peripheral vascular disease Circulation. 2007;115 (l): 127-155
7.
Mokdad AH,Ford ES,Bowman BA.Prevalence of obesity, diabetes, and obesity-related health risk factors, 2001 JAMA. 2001;289 (l): 76-79
8.
Miller NH,Hill M,Kottke T,Ockene IS.The multilevel compliance challenge: recommendations for a call to action. A statement for healthcare professionals Circulation. 1997;95 (4): 1085-1090
9.
Gregson J.System, environmental, and policy changes: using the social-ecological model as a framework for evaluating nutrition education and social marketing programs with low-income audiences J Nutr Educ. 2001;33 (1): 4-15
10.
Oetzel JG,Ting-Toomey S,Rinderle SConflict communication in contexts: a social ecological perspective The SAGE Handbook of Conflict Communication. Oetzel JGTing-Toomey S, ed. Thousand Oaks, CA: Sage; 2006:
11.
Lloyd-Jones DM,Leip EP,Larson MG.Prediction of lifetime risk for cardiovascular disease by risk factor burden at 50 years of age Circulation. 2006;113 (6): 791-798
12.
Prevalence of fruit and vegetable consumption and physical activity by race/ethnicity-United States 2005 MMWR. 2007;56 (13): 301-304
13.
Eilat-Adar S,Xu J,Zephier E,O'Leary V,Howard BV,Resnick HE.Adherence to dietary recommendations for saturated fat, fiber, and sodium is low in American Indians and other US adults with diabetes J Nutr. 2008;138 (9): 1699-1704
14.
Adherence to Long-Term Therapies: Evidence for Action. Geneva, Switzerland: World Health Organization; 2003:
15.
Artinian NT,Fletcher GF,Mozaffarian D.Interventions to Promote Physical Activity and Dietary Lifestyle Changes for Cardiovascular Risk Factor Reduction in Adults. A scientific statement from the American Heart Association Circulation. 2010;122:406-441
16.
Leischow SJ.Setting the national tobacco control agenda JAMA. 2009;301 (10): 1058-1060
17.
Ludwig DS,Brownell KD.Public health action amid scientific uncertainty: the case of restaurant calorie labeling regulations JAMA. 2009;302 (4): 434-435
18.
Lopez R.Urban sprawl and risk for being overweight or obese Am J Public Health. 2004;94 (9): 1574-1579
19.
Joshu CE,Boehmer TK,Brownson RC,Ewing R.Personal neighbourhood and urban factors associated with obesity in the United States J Epidemiol Community Health. 2008;62 (3): 202-208
20.
Ewing R,Brownson RC,Berrigan D.Relationship between urban sprawl and weight of United States youth Am J Prev Med. 2006;31 (6): 464-474
21.
Booth KM,Pinkston MM,Poston WSC.Obesity and the built environment J Am Diet Assoc. 2005;105 (5 suppl l): S110-S117
22.
Quam L,Smith R,Yach D.Rise to the global challenge of the chronic disease epidemic Lancet. 2006;368 (9543): 1221-1223
23.
CDC's LEAN Works! A Workplace Obesity Prevention Program. Determine Incentives and Rewardshttp://www.cdc.gov/leanworks/pro-mote/incentives.html Accessed July 23, 2010.
24.
Health EnglandIncentives for Prevention in Health England Report No. 3http://www.healthengland.org/publications/HealthEnglan-dReportNo3.pdf2009 Accessed August 1, 2010.
25.
Sutherland K,Christianson JB,Leatherman S.Impact of targeted financial incentives on personal health behaviour. A review of the literature Med Care Res Rev. 2008;65 (6): 36S-78S
26.
Fischer Aggarwal BA,Liao M,Mosca L.Physical activity as a potential mechanism through which social support may reduce cardiovascular disease risk J Cardiovasc Nurs. 2008;23 (2): 90-96
27.
Seeman TE.Health promoting effects of friends and family on health outcomes in older adults Am J Health Promot. 2000;14 (6): 362-370
28.
Christianson JB,Leatherman S,Sutherland K.Lessons from evaluations of purchaser pay-for-performance programs. A review of the evidence Med Care Res Rev. 2008;65 (6): 5S-35S
29.
Lu C,Schultz AB,Sill S,Petersen R,Young JM,Edington D.Effects of an incentive-based online physical activity intervention on health care costs J Occup Environ Med. 2008;50 (11): 1209-1215
30.
Pearson SD,Lieber SR.Financial penalties for the unhealthy? Ethical guidelines for holding employees responsible for their health Health Aff. 2009;28 (3): 845-852
31.
World Health OrganizationA guide for population-based approaches to increasing levels of physical activityhttp://www.who.int/di-etphysicalactivity/physical-activitypromotion-2007.pdf2007 Accessed August 1, 2010.
32.
Cirera L,Tormo MJ,Chirlaque MD,Navarro C.Cardiovascular risk factors and educational attainment in Southern Spain: a study of a random sample of 3091 adults Eur J Epidemiol. 1998;14 (8): 755-763
33.
Shapo L,Pomerleau J,McKee M.Physical inactivity in a country in transition: a population-based survey in Tirana City, Albania Scand J Public Health. 2004;32 (l): 60-67
34.
Trojani M,Palmieri L,Vanuzzo D.C. Gruppo di Ricerca delFOsservatorio Epidemiológico [Occupational and leisure time physical activity: trend in the Italian population] G Ital Cardiol. 2006;7 (7): 487-497
35.
Smetanova BS,Lukl E,Slachta J,Stejskal RP.Steps to health Prakt Lekar. 2006;86 (8): 443-445
36.
Cardón G,Labarque V,Smits D,Bourdeaudhuij ID.Promoting physical activity at the pre-school playground: the effects of providing markings and play equipment Prev Med. 2009;48 (4): 335-340
37.
Lichtenstein A,Appel L,Brands M.Diet and lifestyle recommendations revision 2006: a scientific statement from the American Heart Association Nutrition Committee Circulation. 2006;114 (l): 82-96
38.
Gidding SS,Lichtenstein AH,Faith MS.Implementing American Heart Association Pediatric and Adult Nutrition Guidelines: a scientific statement from the American Heart Association Nutrition Committee of the Council on Nutrition, Physical Activity and Metabolism, Council on Cardiovascular Disease in the Young, Council on Arteriosclerosis, Thrombosis and Vascular Biology, Council on Cardiovascular Nursing, Council on Epidemiology and Prevention, and Council for High Blood Pressure Research Circulation. 2009;119 (8): 1161-1175
39.
Corbalan MD,Morales EM,Canteras M,Espallardo A,Hernandez T,Garaulet M.Effectiveness of cognitivebehavioral therapy based on the Mediterranean diet for the treatment of obesity Nutrition. 2009;25 (7–8): 861-869
40.
Ranetbauer M,Hackl JM.Nutritional habits in 15-year-old students J Ernahrungsmedizin. 2007;9 (4): 14-19
41.
Siero FW,Broer J,Bemelmans WJ,Meyboom-de Jong BM.Impact of group nutrition education and surplus value of Prochaska-based stage-matched information on healthrelated cognitions and on Mediterranean nutrition behavior Health Educ Res. 2000;15 (5): 635-647
42.
Exl-Preysch B-M,Muhlemann P,Stauble-Tercier N,Gex C,Ryser H.Preventive nutrition for children. [Nutrition education for children and young people] Schweiz Zeitschrift Ganzheitsmedizin. 2002;14 (3): 150-157
43.
World Health OrganizationThe European tobacco control report 2007http://www.euro.who.int/_data/assets/pdf_file/0005/68117/E89842.pdf Accessed August 1, 2010.
44.
van Berkel TF,Boersma H,Roos-Hesselink JW,Erdman RA,Simoons ML.Impact of smoking cessation and smoking interventions in patients with coronary heart disease Eur Heart J. 1999;20 (24): 1773-1782
45.
World Health Organizationwww.who.gov Accessed May 30, 2005.
46.
Lloyd-Jones DM,Hong Y,Labarthe D.Defining and setting national goals for cardiovascular health promotion and disease reduction: the American Heart Association's Strategic Impact Goal Through 2020 and Beyond Circulation. 2010;121 (4): 586-613
47.
Dall TM,Fulgoni VL,Zhang Y,Reimers KJ,Packard PT,Ast-wood JD.Potential health benefits and medical cost savings from calorie, sodium, and saturated fat reductions in the American diet Am J Health Promot. 2009;23 (6): 412-422
48.
Stokols D.Translating social ecological theory into guidelines for community health promotion Am J Health Promot. 1996;10:282-298
49.
Stokols D,Grzywacz JG,McMahan S,Phillips K.Increasing the health promotive capacity of human environments Am J Health Promot. 2003;18:4-13
