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t PREV~:NTIVE MEDICINE 10,i265--269 0981) FORUM: The U.S. Air Force HEART Program Model1 XLIN BAN|A JACOBSON D~visiar~ of t~e~tth B~h~av~er. ~ra~riemr ,i~e'alt~r Foan~telt~m,, 320~ ~a~t 43rd New York. New York 10017 The goal of the H~:alth £v~laalion and Ri~k Tabulation (HEART),Program is to r~d'uc¢ a~iv~d~aty ~-~,nre g~v_en a se~Ieetiv¢ ¢ifnica:} ~ree~ vascular incident in the next 8 years. At two of the four bases~ intervention in th~ form-of behavior modification, small-group treatment for smoking cessation and/or blood lipid/ weight reduction is offered to volunteers who have been found at above-average risk. In addition, two bases (one with the intervcntlon present and one with the intervention absent) have a bascwide education component consisting ofevents and activities which teach spe- cific techniques of CVD prevention. INTRODUCTION The goal of the Health Evaluation and Risk Tabu, lafion (HEART) program: is to reduce the incidence of cardiovascular disease (CVD).in active-duty U.S. Air Force personnel. Zhe program~designed by teams of specialists from the Ameri- can Health Foundation and' Booz, Allen and Hamil~on~is now midway through an IS-month operations period. During this period, the design of the program is demonstrated at four Air Force. bases in the United States. The purpose of the demonstration is to test the model system's capability of determining risk of ischemic vascular disease among active-duty Air Force personnel and of reducing that risk through various means of intervention. Major functions of the HEART system model are risk screening and .assess- ment, risk reduction, communitY: education, and data collection. These tasks are performed within five program components, as foliows~ .... • Risk screening. Determination of an individual's risk of a cardiovascular incident (CVI) through a selective clinical examination and responses to a health habits and history questionnaire. Specifically, risk determination is based on sys- tolic blood pressure value, smoking habits, level of total serum cholesterol, and the presence or absence of glucose intolerance. • Operations research model. Used to determine each person's statistical risk of experiencing a CVI within the next 8 years, based on screening results. Those whose CVI risk levels are above a predetermined threshold are found eligible for intervention (risk reduction). • Risk reduction. A behavior modi.fication, small group intervention approach applied to those persons who are found eligible and who volunteer for interven- tion. Groups are held in smokin~ cessation and blood lipid/weight reduction. Hypertension education di[cu~sion grou~s are also offered. ' ' Project funded under Contract F33615-80-C-0611 for the U.S. Air Force. School of ~erospace Medicine. 003<t 265 0091-743.~/81/030265-05502.00/0 Copy~k~ (~) I~1 by Ae.~demi~ Press, !~. NOTICE: THIS I~tATEIlIAL MAY BE PROTECTED BY. COPYRIGHT LAW (TffLE 17 U. S. "*COD~ T105280095

LIN BANIA JACOBSON • Basewide education. A public health education program aiming to reduce CVD risk factors among active-duty personnel and other members of the base community. • HEART information system. A data base storing information" on HEART participants for use in .determining CVI risk and in program management. The risk se-re-re-re-re-re-re,~ng eompo~a~nt operates iden~fiea~¥ .on all four ~emgns~tration bases. All active-dut3t' personnel receive th~'e same C~VI risk se~ert at ,ea~eh~ ba, se. However, the type of intergention offered differs from base to base, as follows: • Pease AFB (lFortsmou.tk, N.H.)--f~t.1 i.nt~rvemion: risk reduction and pattie profil, avera On 49, or A'f CDC- York. • Carswell AFB (Ft. Worth, Tex.)--no intervention: control base Operating the HEART program on each demonstration base is a team consisting of a registered nurse/base project manager, one full-time and one part-time medi- cal technician, and a data coordinator. Additionally, teams at the two risk reduc- tion bases, Pease and Charleston, contain two health counselors each. At Pease, basewide education is performed by a health counselor; at Reese, these functions are carried out by the base project manager. This paper discusses the risk screening and basewide education components, and gives an overview of ~he risk reduction component. Papers dgewhere in this Foru,m detail the operations., research model and costs of CVD to the U.S. Air Force, the risk reduction component, an'd ,program eva.luatton. HEART RISK SCREENING COMPONENT The purpose of the risk screening component is to gather clinical and health data-- to establish a cardiovascular risk profile for each active duty Air Force partici- pant. All personnel receive an initial screen and an identical screen 9 months later, to assess changes in the interim. Each person is required to complete and submit a- health history and habits questionnaire before th.e clinical appointment. Participants are screened by squadron and scheduled by their first sergeants. Personnel are notified of appointment time by mail; included in the materials they receive are reminders to fast for 8 hr before the screen and brochures describing HEART and its potential impact on their health status.' The screening program operates Monday through Friday mornings from 8:00 to noon. The screen consists of the following tests: • Blood pressure determination; • Height/weight, lean body mass measurements; • Flexed bleep determination (men); • Skinfold thickness determination (women); • Venipuncture for determination of total serum cholesterol, high-density lipo- protein, serum thiocyanate, and serum glucose levels; • Ecolyzer tests for determination of level expired carbon monoxide. Referrals to the base medical facility are made immediately for participants found medically at risk. An exit interview is held with all participants for whom risk factors are identified during screening. On all bases except the control base, ~i~td~x next for e~ statu., motin heren Par The r time. At invite modi! weigt positi reduc way, to in~ Inh perso is ext cardl, that s aerie: healt] and t and s progr enter Ori tion ~ ing c orien reduc T!05280096

luce kRT ~tion ,ase. ~WS," and sting nedi- ease, tions .ents, a. this ;. Air ~ data art~ci- _ _lager,_ ~mit a ~.ants. s they ribing ~:00 to y lipo- ipants whom I base, FORUM: THE U.S. AIR FORCE HEART PROGRAM 267 participants are told they will receive the results of their screen and a CVI risk profile in the mail. Also, follow-up activities are explained to potentially above- average risk ea,ndidates at Pease and Charleston. On all bases, persons requiring verification of elevated blood pressure (i.e., age 49or younger,. >~ 140/90.; age 50.or over, ~> I60/955. are invited back three times over a 2-week period to. be tesl~ed with, a :random. zero m*ad~dler devio¢. A fi'ozen sem~m bloo~d~ ~pve~c~en, for 6~arch p~er~on' i~~ackag~d' maid sMppe-a t~ a CDC-certified laboratory of the American Health Foundation in Valhalla, New York, for analysis. Results arc rcturne, d: as quick:iT as possible to eae~base for the Vad'e~ (expressed as the ~ha~-o,f ~x~pgri~nci, ng a next 8 years, per 1,000), a health passport indicating the desired levels or values for each of the clinical tests, a letter indicating above-average or average risk status, a booklet explaining the meaning of clinical results, and a brochure pro- moting behavior change in areas of smoking, nutrition, physical activity, and ad- herence to blood pressure control regimens. Participants are similarly provided with the results .of their 9-month resereea. The results of the first and second screen are provided to the control group at this time. HEART RISK REDUCTION COMPONENT At Pease and Charleston, .those participants found el'igible for risk reduction are invited to join a risk factor reduction program. The program consists of behavior modification, small-group intervention in smoking cessation and/or blood lipid/ weight reduction. It should be noted here that the program is designed to produce • positive results in a public health context, or, in other words, results that yield a _reduction in average (population) risk for smoking and elevate_d blood lipid._ !n this way, the program differs from the intensive clinical approaches that can be given -to individuals.- . ~ ~ Initiation of the risk reduction program. After receiving their results packages, persons eligible for risk reduction are phoned by a health counselor. An invitation is extended to attend a brief counseling session to learn about the meaning oftheir cardiovascular screening results and what help is available to improve them. At that session, the participant is encouraged to take the first step toward corrective action by making a commitment to participate in the risk reduction program. The health counselor explains the meaning of probability of a cardiovascular incident and the parameters of the risk reduction program, including its purpose, format, and special procedures. Persons who decide to enter the HEART risk reduction program sign a Risk Reduction Program Agreement. Those who choose not to enter risk reduction at that time are told they may enter at a later date. Orientation sessions. Interested participants are invited to attend two orienta- tion group sessions before the group program for their ~pecific risk factor (smok- ing cessation and/or blood lipid/weight reduction) begins. The purpose of the orientation is to prepare participants for life-style changes necessary to effect reduction in their level of risk. Completion of the sessions indicates the indi- TI05280097

LINBANIA JACOBSON vidual's readiness to progress either to the smoking cessation or the blood lipid/ weight reduction program. Smoking cessa#o~ program. The HEART smoking cessation pro, gram offers techniques for quitting and support for smoking cessation efforts through focal, group programs, single-session counseling, maintenance phases, and, for those whO. have .not suge~ed'ed in quittir~g and wish only ,to. '~duee smoking, tar and The cessation phase of this program merges with the maintenance phase, pro- vtdha.g neophyte ~smokers with, coatin.~ous support ~hrough grcup discussion and Blood lipidlweig&r reduction program. The blood lipid/weight reduction pro- gram combines treatment for elevated blo~ lipid with that for excess body weight. From a behavioral standpoint, problems of both hypercholesterolemia and overweight stem, in large part, from inappropriate eating behavior. In both condi- tions, the dietary guidelines and the process of changing food behaviors are the same. At the completion of focal group sessions, participants are introduced to the maintenance stage. This stage is designed to provide continuing suppg~ for the ~dueation about b~havio~l changes suggested during the orientation and focal group sessions. ~aintenanee s~o~ is provided through ta~ed telephone messages nnd main- t~n~nee sessions ~h a h~lth, counselor, ;~.~he~:des~d~Yo~ ~f ~he .blood lipid/ wright reduction prog~m is found in the paper detailing risk reduction (1). The hypertension program. The control ofhype~ension in the HEART program requires the adoption of clinical methodologies suitable to a young population. The hype~ension treatment program includes two components linked together to provide an integrated approach: modification in food pattern (weight loss and salt restriction), and, for those for whom food modification does not prove effec- tive in lowering blood pressure, refer! to the base.medical .facility fo~ pharma- cologic therapy. Persons in pharmacologic treatmentparticipate simulP~heously in the hype~ension education group program. Hypeaension education groups. The two hypeaension discussion group ses- sions are educational rather than behavioral in nature. The group's prima~ aim is to impart and reinforce information so that pa~icipants will appreciate the lifelong and potentially serious nature of hypertension. At the same time, participants learn about effective means of controlling hypertension, and are guided in discov- ering and discussing practical techniques for successfully maintaining treatment regimens. Reinfi~rcementfor hypertension management. All hype~ensive persons are pe- riodically monitored for blood pressure levels and adherence to clinical regimens and nutritional guidelines. Ongoing individual sessions are scheduled as neces- sa~. Hype~ension taped telephone messages are also made available. Details of the hypertension program are provided elsewhere in this Fo~m. The atmos" above- tion, a basew smoki, taught HEA~ athon, ling h~ includ. HEAI~ HEAl: placin~ Ackn Robert Hamiltc !. Art T!05280098

lipid/ offers focal ~hose ~ and • pro- FORUM: THE U.S- AIR FORCE HEART PROGRAM 269 HEART BASEWIDE EDUCATION COMPONENT The purpose of the basewide education component is to create a supportive atmosFhere for risk screening and' risk reduction activities and to motivate above-average risk persons to, initiate and maintain behavioral changes. In addi- ,~oa,. activities of the ,comp.onem aim, to. educate and mo~}vate base medical per- ~e educatton, spec~c sk~is in reducing cardiovascular risk related to smoking cessation, modifying' eating patterns, and lowering blood p~ssure are body ia and =ondi- re the to the or the focal main- .~gram :ion. gether ~s and effec- :arma- ~ously athon," and CVD education lectures; and managerial education aiming at control- ling health risks through environmental management. Activities of this last sort include HEART's participation in the Base Menu Planning Committee, flagging HEART-rated diet items on the dining hall menu, posting visual displays of HEART-rated diet menu items with caloric and cholesterol contents noted, and placing limited smoking area signs in appropriate public rooms on base. ACI~NOWLED:G M,EN,T A~n0~,lcdgmen~ ~s made o.f !~he effor, t.s,of thee otl~er AH,F staff members who compose this group-- l~0fi'~i B~u.no~ J~i~nr~e Nisita~ 'Don P~we.ll'. aOd: Ma.rsha Witten~as well as several Booz, Allen and .IRW~f.Ron,.~t~sultan~t~ .who~ eon~t rlb ut~l~ ~o't'h~6' p~,~g~t. REFERENCE 1. Arnold. C. B.. and Jacobson, L. Risk reduction in the u,s. Air Force primaw prevention HEART' program. Prey. Med. 10, 270-276 (1981). p ses- aim is felong ipants iscov- ttment tre pe- :imens ncces- ails of T!05280099