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Advocate Spotlight: Joan Enderle

Early in my career as a dietitian, I learned firsthand how one person can make an impact and that a small group of individuals can shape policy at a local, state and national level. Those early experiences built my confidence to expand advocacy work to include the American Heart Association (AHA) as a volunteer. I am an active member of the You’re the Cure network.   

In June 2006, I began my career with the AHA, as the director of the Go Red For Women initiative in North Dakota.  Since that time, my role has been varied to include ND Communication Director, media advocacy, Mission: Lifeline public education campaign, and a number of special projects. 

This month I am transitioning to a new position with AHA as the regional campaign manager for the ANCHOR grant partnership program. North Dakota was selected as one of 15 markets to leverage our strategic priorities through new and expanded partnerships to accelerate population-based strategies that will reduce chronic disease and health disparities. Specific focus on procurement with our work toward increased access to environments with healthy food or beverage options in the Bismarck/Mandan communities. 

This is a natural transition that fits my strengths and passion as it builds on my professional education and past experiences. The impact of policy and environmental changes on behavior and diet are of special interest to me. I’ve seen the widespread impact of policy and environment changes to improve nutrition in home, work, school, faith communities and community settings. Nutrition changes to include increased fruit and vegetable consumption, sodium reduction, decreased sugar sweetened beverages, lower fat and increased low fat dairy consumption. 

The first couple months, I will be focused on gathering community needs assessment data, identifying and meeting with key stake holders and potential partners prior to the writing and implementation of a 12 month community action plan. 

I look forward to visiting with YTC advocates and community members as the ANCHOR grant moves forward.   Contact me at or call 701-658-3046 to get involved.

Note:  Joan is pictured with her granddaughter, Madilynn. 

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It's Time to Get Moving

Adults are spending more time at work than ever before - including more time at computers and desks with less time being active.   As a nation, we are becoming more inactive.  Studies have shown that people who have a low level of activity double their risk of heart disease. 

 “The good news is you can start to fix the problem by encouraging your family, community and company to get moving” said Dr. Richard Howard, board certified interventional cardiologist with Sanford Health and medical chair of the Bismarck/Mandan Heart Walk.   “I daily discuss exercise programs with my patients and frequently encourage the use of pedometers as an inexpensive, easy to use way to measure his/her baseline activity and set goals to increase steps little by little”. 

On April 1, National Walking Day, we encouraged Americans to lace up their sneakers and take 30 minutes out of their day to get up and walk. It was a great way to raise awareness of the importance of physical activity and to get on the right path to a healthier way of life. Statistics show people stick to walking plans more than any other form of physical activity.   Walking is free, easy, social and great exercise.  A walking program is flexible and can be done just about anywhere. 

The American Heart Association recommends adults strive for 150 minutes of physical activity per week, while kids should get 60 minutes of physical activity a day.  Thirty minutes five times a week is an easy goal to remember.  You’ll benefit even if you divide your time into two or three sessions per day of 10 to 15 minutes each.

If you don’t think you’ll make it of 30 minutes, set a more reachable goal. You can work up toward your overall goal by increasing your time each week as you get stronger.  Remember, something is always better than nothing.  Don’t let all-or-nothing thinking keep you from doing what you can every day.   

In addition to taking time out of your day to get up and walk, consider forming a team to participate in one of the local American Heart Association North Dakota Heart Walks in May.  You can form a team with friends, family, neighbors or co-workers.  The event is an opportunity for people to improve their health and simultaneously raise funds to help fight heart disease and stroke.  It is a fun family environment that promotes heart-healthy living (healthy cooking demonstrations, kids zone, health screenings, survivor story, etc.) 

North Dakota Heart Walks:

To find the North Dakota Heart Walk near you go to 

For more information about walking and living a healthy lifestyle visit:

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Legislature Approves Stroke System of Care

Great news on stroke care for North Dakota!  The North Dakota legislature passed our stroke bill unanimously in both houses and last week it was signed by Governor Dalrymple.  What does this mean for North Dakota and stroke?

The North Dakota Stroke System of Care includes all the stakeholders involved with stroke awareness, education, response, treatment and rehabilitative care.  It includes hospitals of all sizes, EMS community, 911 dispatch, neurologists and other specialty physicians, critical access hospital directors of nursing, hospital stroke coordinators, the North Dakota Department of Health, UND Center for Rural Health, American Heart Association and North Dakota elected officials.  All partners play a key role in our Stroke System of Care. 

What does that mean for those who experience stroke?  First of all, we want to prevent stroke whenever possible.  Attention to sodium intake, diet, exercise is key.  Second, we want early intervention and recognition of stroke symptoms so that patients get to definitive care as soon as possible.  Education, recognition, intervention and treatment are all a part of the North Dakota System of care. 

The stroke system of care will develop regional transport plans based on hospital designation and capabilities.  It will target the leading risk factor for stroke – high blood pressure – and provide education and awareness to help prevent stroke from happening in the first place.  There will be continued education to improve upon care measures and track performance.  The stroke system of care will aim toward more timely activation of 9-1-1 so that EMS can initiate care sooner for improved outcomes.  It will work to address the growing trend of younger stroke victims and greater access to rehabilitative services.

While this bill was being discussed among legislators, it was noted that our legislature makes investments in infrastructure for roads, bridges, water and other key economic development needs.  Therefore, investment in our health care systems of care is also an important investment for North Dakota.  It was that kind of mindset, and consistent, effective communication by our volunteer advocates who helped to secure this legislative victory. 

We couldn’t be prouder of North Dakota for taking this step forward to address stroke in our state.  It provides an outstanding model for other states to follow. 

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Legislative Update - Report from the Front Lines

North Dakota lawmakers gave their initial stamp of approval to nearly 600 bills before breaking for a three-day recess last Thursday, and a new state revenue forecast in mid-March will set the stage for the second half of the session.

For the last 37 days, lawmakers have been busy working on bills in their respective chambers. House and Senate lawmakers advanced a combined 599 bills – 70 percent of the 852 bills introduced – during the session’s first 38 days, while 249 bills failed and four were withdrawn. The vast majority of the bills will now be taken up in the opposite chamber which means it's time for cross-over.  That's when they start working on bills passed by the other chamber.

Most refer to the past two months as the “first half”.  AHA has always looked at session in thirds – first third sorting through the bills that survive to cross-over, second third giving the other chamber an opportunity to work, and then the important part of the legislative session - conference committee work.  This is when six legislators, 3 from each chamber, can meet to work through differences in each chamber’s work.  Last session, when our CPR in Schools funding bill had an opportunity to go to conference committee, we opted to encourage going with one chamber’s version, feeling we didn’t want to risk what we secured by that point.  This session, with several important areas of AHA interest in agency budget bills, we will be actively engaged in that 3rd part of session committee work during April.

Here is how we have fared so far:

  • Stroke System of Care (HB 1323):  This bill passed unanimously in House Human Services and the full House.  It was heard Wednesday, March 4 in Senate Human Services.  The bill is doing well due to: 1) stakeholder support of updating the century code to reflect important elements of system work; 2) survivor stories showing the impact of coordinated response and rehabilitation care; and 3) successful outcomes of our ND stroke work.  For example, the percent of acute ischemic stroke patients who arrived at the hospital within 2 hours of time last known well and for whom IV t-PA was initiated within 3 hours increased from 30.9% in 2010 to 80.9% in 2013.  This treatment improvement helps to reduce brain loss due to stroke by clearing out clots preventing blood flow to areas of the brain. That is significant!
  • Funding Bills:  Our priority issues have been challenged by the revenue forecasts at the beginning of session.  Given oil production is up in North Dakota, we hope the new projections in March will help move these funding areas forward:
    • Senate Action:  The Senate continues with strong support for CPR being taught in schools, and has added language into the Department of Public Instruction agency budget to continue funding, and to extend the resources to the junior high level.  We appreciate DPI’s support of this continued invest also.
    • House Action:  The House opted to not add in new funding opportunities into the Department of Health budget, and made cuts into the Governor’s proposed budget.  However, we know our advocates have been impactful on the needs for the key heart and stroke funding priorities, and during conference committee work we may gain some traction.  So as HB 1004 makes it way to the Senate, we are focused on:
      • Cardiac System of Care funding:  With available grant funding coming to an end, the cardiac system needs a small base of funding to continue its work of public, EMS and hospital collaborative work to ensure timely, appropriate care for acute cardiovascular events.
      • EMS Database system:  Our EMS responders are working with outdated programs for capturing response runs, which no longer receive vendor support.  This is a request for mostly one time funding, and if successful, will provide our acute care field providers with improved health information and also our state with invaluable information related to field care.
      • Million Hearts Funding:  We know high blood pressure and tobacco use are driving cardiac and stroke events.  Yet no prevention funding is available to start addressing the leading risk factor – high blood pressure, and that funding support for smoking cessation access falls short of CDC guidance.

And of course there are a number of other bills we are watching and engaging on as appropriate.  It’s been a busy first half!

Our advocates have been instrumental in our progress to date.  I love hearing from legislators on committees and in the halls saying they are hearing from you.  Your voice does make a difference as we work the halls.  Keep up the great work as we navigate the next two core decision-making opportunities!

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What's Up with School Nutrition?

There is a lot of discussion out there about school nutrition – and we couldn’t be happier about that!  Students consume 35% - 50% of their daily caloric intake at school where they are often exposed to junk foods and sugar-sweetened beverages that have little to no nutritional value.  Parents – and students – have concerns about the nutritional value of the foods their kids are consuming at school. Schools are in a unique position to provide a healthy environment by promoting and providing nutritious meals. 

CLICK HERE for an informational video about school nutrition. 

Here is what we know:  In December 2010, the President signed the Healthy Hunger-Free Kids Act, which gave the U.S. Department of Agriculture (USDA) the authority to update national nutrition standards for school meals and establish nutrition standards for other foods sold in schools throughout the school day.  As a result, in school year 2013-2014, nearly 90% of schools in the National School Lunch Program (NSLP) met nutritional standards, up from 14% in 2009-2010.  That means an overwhelming majority of children are receiving heart-healthy lunches while at school. 

We also know that a healthy school environment, including healthy nutrition, helps improve children’s physical well-being, enhances learning, minimizes behavior problems and increases attendance. 

The evidence is overwhelming that the new school meal standards are working.  Going into child nutrition reauthorization for 2015, the American Heart Association advocates for:

  • Continued support to schools for effective implementation of the federal nutrition standards for school meals.
  • Continued strong implementation of Smart Snacks in School standards. These standards include reducing sodium; eliminating trans fat; decreasing saturated far; minimizing fried foods; offering healthy beverage options; and increasing the offering of fruits and vegetables, whole grains, seafood, and low-fat dairy. 
  • Continued robust technical assistance by the USDA to support schools in implementing nutrition standards, effective nutrition education, and nutrition promotion and model local wellness policies with effective implementation and evaluation. 
  • Investments in kitchen equipment and infrastructure that can help schools serve healthier meals. 


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Advocate Spotlight: Sharon Buhr, Susan Milender, and Andrea Winter

Valley City, North Dakota

School Wellness is all about partnerships in Valley City. In 2012 when schools were asked to revise and strengthen their school wellness policies, the local nutrition and exercise partnership, Barnes ON THE MOVE Partnership (OTM-17 members strong), stepped forth and volunteered to work with Valley City Public Schools (VCPS).  Sharon Buhr, MPH, LRD was the chair of OTM and also chair-person of the local school board.  She teamed up with Susan Milender, LRD, who was then the Nutrition Services Director of VCPS to take the lead.

Together they established the process for the revision, setting a timeline using the WELSAT tool for evaluation of the present policy, included administration, teachers, parents and students and then ended up back at the school board in the summer of 2012 with the final product.

The VCPS Wellness Policy recognizes that the school can have a positive effect on the community.  The policy identifies that anyone who uses the school and chooses to serve a food, must also serve a fruit or vegetable so that there will always be a healthy choice available.

To help the various school booster clubs meet the nutrition guidelines of the wellness policy (as well as other community booster clubs) Sharon and Susan, along with Andrea Winter, LRD chose to hold a “Healthy Concession Food Expo” in both 2013 and in 2014.  They again looked to partner with other groups, such as the students in Fuel Up to Play 60 and the Girl Scouts.    An array of fast, healthy and easy to prepare foods were served for attendees to sample.  Follow up after the event proved the success of the event as more clubs added healthier items (that were featured at the expo) to their menu. 

For more information on the “Healthy Concession Food Expo” or other VCPS Wellness Policy ideas, contact Sharon Buhr at 845-6456 or  For a copy of the VCPS Wellness Policy go to and click on policies.

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Governor Dalrymple Proclaims Heart and Stroke Day in North Dakota

Governor Dalrymple met with AHA volunteers, survivors and staff on Monday, February 9th and proclaimed it Heart and Stroke Day in North Dakota.  Heart and Stroke Day is an opportunity to raise awareness about cardiovascular disease and stroke, and to bring attention to opportunities to improve health and well-being through legislative policy.  During his remarks, Governor Dalrymple reminder legislators and other visitors to the Capitol that while we have made significant strides in improving outcomes for heart disease, it is still our state's number one killer of adults. The Governor also noted that stroke is the leading preventable cause of disability and eighty percent of cardiac events can be prevented with a healthy lifestyle. 

We are proud of the work that has already been done to improve cardiac and stroke care in North Dakota. The Governor noted that North Dakota has championed improved emergency response and newborn screenings for congenital heart defects and has set a standard for other states to follow on strong stroke and cardiac systems of care. 

The Governor concluded his remarks urging all citizens to recognize that living healthier leads to longer, fuller and more active lives with less disease care in the later years and to call 9-1-1 at the first signs of heart attack or stroke symptoms. 


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Advocates Raise Their Voices on Heart and Stroke Issues

The legislative session is well underway in Bismarck.  AHA advocates from across North Dakota recently traveled from all corners of the state to participate in Heart and Stroke Day at the Capitol to raise awareness for heart disease and stroke.  More than 50 volunteer advocates, survivors, spouses, caregivers, emergency responders, and hospital partners participate in the 2-day event in Bismarck. 

We are pleased that our Stroke Bill, HB 1323, passed unanimously out of House committee and on the House floor.  This bill is important to clarify language related to stroke care already being done, and to serve as a model for other states to follow when it comes to stroke response and outcomes. We know our advocates will continue to raise their voices with their Senators when the bill comes before the Senate. 

We are working on several Appropriations requests that are also critical to improving heart and stroke care in our state.  Our Cardiac Systems of Care request will continue to build upon progress that has already been made in cardiac response, and will provide sustainability for statewide training and public education. 

Our work on CPR in Schools last session provided funding support for schools who want to provide CPR training to their students.  Only a small portion of this appropriation was used so we are working to protect those funds to enable more schools to provide this life-saving training.  Knowing CPR is the first response in the system of care for sudden cardiac arrest.

We are encouraging legislative support for Million Hearts funding to address the serious health concern of hypertension.  This funding will provide awareness and education to help to know the risk factors for hypertension and provide prevention strategies. 

We are also supporting HB 1421 which would raise the tobacco tax in North Dakota and reduce tobacco use and the impact tobacco has on chronic disease in our state.  With rising health care costs continuing to dominate the North Dakota health policy agenda, raising the tobacco tax will provide much needed funding to address healthcare needs in our state.

Much work is yet to be done throughout the session, and we need our advocates to continue to engage lawmakers on all these issues.  Together, we can make North Dakota a heart-healthier place to live! 

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Advocate Spotlight: Shelly Arnold

Shelly Arnold North Dakota

As the Chair of the American Heart Association’s Advocacy Committee, I understand the importance of statewide programs and the need to integrate work among all types of healthcare professionals. Heart attack and stroke are two life changing events that can sometimes be prevented by living a healthy lifestyle and visiting with a healthcare provider about your overall health and risk of heart attack or stroke.

The first step towards living a healthy lifestyle starts with you. Living a healthy lifestyle is key to preventing strokes and heart attacks. Make sure you are paying attention to the food you eat and the amount of exercise you get. Just a brief walk every day along with a healthy diet can decrease your risks for a heart attack or stroke. 

If you or a family member experiences any signs or symptoms of a heart attack or stroke, Tertiary hospitals such as Sanford Health along with rural hospitals, local emergency medical services and air medical services all serve a unique role in providing you the best care possible. Don’t hesitate to call 911, these emergency providers are ready and willing to help you, by providing the best possible care and will transport you to the most appropriate healthcare facility in the shortest amount of time.

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More Concerns about E-Cigs

As more research comes available and more studies are being done on the effects of e-cigarettes, today the New England Journal of Medicine raises a new worry about electronic cigarettes – exposure to formaldehyde.  You remember formaldehyde, right?  Who could forget that awful-smelling chemical used in your high school biology class to dissect frogs?  Turns out, formaldehyde is formed when the propylene glycol and glycerol in e-cigarette liquids and oxygen are heated together.   

According to an article in today's Los Angeles Times Science Now, The World Health Organization’s International Agency for Research on Cancer says formaldehyde can cause leukemia and nasopharyngeal cancer. The U.S. Environmental Protection Agency considers the chemical a probably human carcinogen. 

Let's not kid ourselves.  The study coauthor James Pankow, a chemistry professor and expert on cigarette smoke dangers at Portland State University, said the line between e-cigarettes and tobacco cigarettes was growing fuzzier by the day.

“No one should assume e-cigarettes are safe,” he said in a statement. “For conventional cigarettes, once people become addicted, it takes numerous years of smoking to result in a high risk of lung cancer and other severe disease; it will probably take five to 10 years to start to see whether e-cigarettes are truly as safe as some people believe them to be.” 

For more on this story, CLICK HERE.  

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