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Rigorous evaluation of community-based programs can be costly, particularly when a representative sample of all members of the community are surveyed in order to assess the impact of a program on individual health behavior. Community-level indicators (CLIs), which are based on observations of aspects of the community other than those associated with individuals, may serve to supplement individual-level measures in the evaluation of community-based programs or in some cases provide a lower-cost alternative to individual-level measures. Because they are often based on observations of the community environment, CLIs also provide a way of measuring environmental changes--often an intermediate goal of community-based programs. The Centers for Disease Control and Prevention convened a panel of experts knowledgeable about community-based program evaluation and cardiovascular disease (CVD) prevention to develop a list of CLIs, and rate their feasibility, reliability and validity. The indicators developed by the panel covered tobacco use, physical activity, diet and a fourth group that were considered 'cross-cutting' because they related to all three behaviors. The indicators were subdivided into policy and regulation, information, environmental change, and behavioral outcome. For example, policy and regulation indicators included laws and ordinances on tobacco use, policies on physical education, and guidelines for menu and food preparation. These indicators provide a good starting point for communities interested in tracking CVD-related outcomes at the community level.

Large, well-funded, community heart health programs (CHHPs) have successfully focused on improving the cardiovascular health status of entire communities. CHHPs attempt to reduce the prevalence of risk factors associated with high rates of coronary heart disease mortality: high blood pressure, elevated serum cholesterol, smoking, overweight, and sedentary lifestyle. Program components include community organization, needs assessment, priority and evaluation, and program maintenance. Organizing the community, assessing needs and resources, and setting priorities generally occur concurrently, followed by implementing interventions. CHHP activities include social marketing, direct behavior-change efforts (including skills training, health education, and contingency management), screening (including counseling and referral), and policy and environmental change. Because State-sponsored efforts will seldom have the resources of federally-funded demonstration projects, they must pay particular attention to the "3 As" of community interventions: affordability, acceptability, and adequacy. Attention to these principles and the critical program components outlined in this paper facilitate the planning, development, implementation and evaluation of the next generation of CHHPs.

Public health departments nation-wide are implementing community-based cardiovascular disease (CVD) prevention programs. Many such programs are turning for guidance to three research and demonstration projects: the Stanford Five City Project, the Pawtucket Heart Health Program, and the Minnesota Heart Health Program. This article summarizes some of the lessons learned in these projects and recommends strategies for the new generation of CVD prevention programs. The core of a successful program is the community organization process. This involves identification and activation of key community leaders, stimulation of citizens and organizations to volunteer time and offer resources to CVD prevention, and the promotion of prevention as a community theme. A wide range of intervention settings are available for health promotion. As is true for the workplace, places of worship are receptive to health promotion programs and have access to large numbers of people. Mass media are effective when used in conjunction with complementary messages delivered through other channels, such as school programs, adult education programs, and self-help programs. Community health professionals play a vital role in providing program endorsement and stimulating the participation of other community leaders. School-based programs promote long-term behavior change and reach beyond the school to actively involve parents. Innovative health promotion contests have widespread appeal and promote participation in other community interventions. In the area of evaluation, health program participation rates are appropriate primary outcome measures in most community-oriented prevention programs. Other program evaluation priorities include community analysis and formative evaluation, providing data to fine-tune interventions and define the needs and preferences of the community. It is premature to comment conclusively on the effectiveness of community-based CVD prevention programs in reducing population risk factor levels. However, it has been demonstrated that a broad range of intervention strategies can favorably modify the health behaviors of specific groups in communities such as employees and school children.

PURPOSE OF THE REVIEW. This review of the literature examines the relationship between abdominal fat distribution and specific health outcome measures, modifiable risk factors, the impact of intervention efforts, and the significance of measurement methods. SEARCH METHODS USED. The research material that was received was found through several on-line data bases, including MEDLINE and CINAHL, an examination of references from selected articles, a manual review of recent relevant journals, and interviews with several physicians and epidemiologists who are experts in this field of inquiry. Forty-three research articles were reviewed for the section on health risk outcomes and abdominal fat distribution. Twenty studies were reviewed in the section on modifiable variables associated with fat distribution. Finally, 10 studies which examined the effect of behavior change on fat distribution were included in this review. SUMMARY OF IMPORTANT FINDINGS. Recent research indicates that people whose body fat is deposited more in the central or abdominal area, especially the intra-abdominal area, than it is in the gluteofemoral area are at increased risk for cardiovascular disease. This risk is independent of, but exacerbated by, the degree of obesity. Several nonmodifiable factors such as age, gender, and menopause as well as some modifiable factors such as obesity, smoking, physical inactivity, and alcohol intake are positively associated with abdominal fat deposition. MAJOR CONCLUSIONS. Intervention results indicate that it is possible to decrease abdominal fat with total weight loss or smoking cessation.

Mailed invitations to participate in weight loss and/or smoking cessation correspondence programs to 31,400 households in a suburban community. Two programs were offered to randomized subsets of households, a 6-month correspondence program costing +5 and the same program for free but requiring a +60 deposit to be refunded based on success in weight loss or smoking cessation. Overall, sign-up included 1,304 people for weight loss and 142 for smoking cessation. The +5 program was about 5 times as popular as the incentive program. Validated weight change after 6 months averaged about 4 lb for the +5 program and 8 lb for the incentive program. Corresponding rates of smoking cessation were about 9% and 20%, respectively. We conclude that correspondence programs for the promotion of weight control and smoking cessation are potentially cost-effective methods for reaching individuals in the community at large, many of whom would not be interested in clinic-based programs. Issues meriting further research include recruitment, especially of smokers, and evaluation of the relative trade-offs in recruitment success versus efficacy of differing treatment approaches.