Geographic variation in cardiovascular disease risk factors among American Indians and comparisons with the corresponding state populations

American Indian Alcohol Use from a Sex-Specific Wellness Approach: Exploring Its Associated Physical, Behavioral, and Mental Risk and Protective Factors

PURPOSE

The top causes of death for American Indians (AIs), including heart and liver disease, are associated with alcohol use. Using the culturally based Framework of Historical Oppression, Resilience, and Transcendence (FHORT), the purpose of this article was to examine AI alcohol use from a sex-specific wellness approach, exploring its associated physical, behavioral, and mental risk and protective factors.

METHOD

Data were drawn from a cross-sectional survey with 479 AI adults in South Dakota. We employed a series of multiple hierarchical regression analyses to assess the associations of demographic (sex, age, marital status, income, and educational attainment), physical (Body Mass Index and cardiovascular risk), behavioral (smoking and health self-efficacy) and mental (depressive symptoms) factors with alcohol use.

RESULTS

Results indicated that surveyed males tended to drink three times that of females, and depressive symptoms were associated with higher levels of alcohol use.

DISCUSSION

This study highlights the need to examine AI alcohol use with sex in mind.

Cardiovascular Health among U.S. Indigenous Peoples: A Holistic and Sex-Specific Systematic Review

PURPOSE

The purpose of this systematic review is to examine mental, sociocultural, behavioral, and physical risk and protective factors related to cardiovascular disease (CVD) and related outcomes among U.S. Indigenous peoples.

METHODS

A total of 51 articles met the inclusion criteria of research focusing factors for CVD among U.S. Indigenous peoples (Mental n= 15; Sociocultural, n =17; Behavioral/Physical, n =19).

RESULTS

This review reveals clear risks for CVD, which tended to be elevated for females. Mental health problems (depression, anxiety, PTSD/trauma, alcohol and other drug (AOD) abuse) were clearly associated with CVD, along with enculturation, social support, and the social environment-including discrimination and trauma. Poor diet and obesity, diabetes, hypertension, cholesterol were behavioral or physical factors.

DISCUSSION

Overall, identified research was limited and in beginning stages, lacking more information on etiology of the interconnections across sex and the mental, sociocultural, and behavioral determinants of CVD.

Diabetes and Associated Cardiovascular Complications in American Indians/Alaskan Natives: A Review of Risks and Prevention Strategies

Diabetes mellitus (DM) is the seventh leading cause of death in the United States and the leading cause of death in the U.S. American Indian/Alaskan Natives (AI/ANs), who comprise only 2% of the total population. The AI/AN population has a high prevalence of DM in adults aged 20 years or older and is developing DM at a younger age than the general U.S.

POPULATION

DM is a major risk factor for cardiovascular disease (CVD), and mortality from CVD is higher in AI/ANs than the general population, as is the prevalence of stroke and 1-year poststroke mortality for both genders when compared to non-Hispanic whites. A genome-wide scan found a number of chromosome linkages in the AI/AN population that suggest that genetic factors may contribute to their high risk of DM and CVD. Importantly, studies also suggest that in addition to race/ethnicity, cultural norms and historic conditions play important roles in the prevalence of DM and CVD in this population. Therefore, multiple factors should be taken into consideration when establishing prevention programs to decrease the prevalence of obesity, diabetes, and CVD incidence among adults and children in the AI/AN population. Prevention programs should focus on behavioral risk factors and lifestyle changes like encouraging smoking cessation, healthy diet, and increased physical activity while taking into consideration cultural, economic, and geographic factors.

Determinants of Health-Related Quality of Life Among Older American Indians and Alaska Natives

During the past decade, health-related quality of life (HRQoL) has been recognized in both clinical and community health research as an important health outcome and a needed supplement to conventional health outcomes. The authors provide a profile of HRQoL and examine its determinants among American Indians and Alaska Natives aged 50 or older. Multivariate analyses of cross-sectional survey data from the 1996-1998 Centers for Disease Control Behavioral Risk Factor Surveillance System were conducted. Thirty-four percent of the sample reported fair or poor self-rated health. The mean number of poor health days in the past month ranged from 4 to 6 on different measures. Age, sex, education, annual household income, employment status, hypertension, and obesity were associated with aspects of HRQoL. Further research aimed at eliminating health disparities among this population should focus on identifying additional indicators of poor HRQoL and on understanding variables that mediate the relationship between disease and HRQoL.

Trends and disparities in stroke mortality by region for American Indians and Alaska Natives

OBJECTIVES

We evaluated trends and disparities in stroke death rates for American Indians and Alaska Natives (AI/ANs) and White people by Indian Health Service region.

METHODS

We identified stroke deaths among AI/AN persons and Whites (adults aged 35 years or older) using National Vital Statistics System data for 1990 to 2009. We used linkages with Indian Health Service patient registration data to adjust for misclassification of race for AI/AN persons. Analyses excluded Hispanics and focused on Contract Health Service Delivery Area (CHSDA) counties.

RESULTS

Stroke death rates among AI/AN individuals were higher than among Whites for both men and women in CHSDA counties and were highest in the youngest age groups. Rates and AI/AN:White rate ratios varied by region, with the highest in Alaska and the lowest in the Southwest. Stroke death rates among AI/AN persons decreased in all regions beginning in 2001.

CONCLUSIONS

Although stroke death rates among AI/AN populations have decreased over time, rates are still higher for AI/AN persons than for Whites. Interventions that address reducing stroke risk factors, increasing awareness of stroke symptoms, and increasing access to specialty care for stroke may be more successful at reducing disparities in stroke death rates.

Lessons learned in community research through the Native Proverbs 31 Health Project

Background

American Indian women have high rates of cardiovascular disease largely because of their high prevalence of hypertension, diabetes, and obesity. This population has high rates of cardiovascular disease-related behaviors, including physical inactivity, harmful tobacco use, and a diet that promotes heart disease. Culturally appropriate interventions are needed to establish health behavior change to reduce cardiovascular disease risk.

Community Context

This study was conducted in Robeson County, North Carolina, the traditional homeland of the Lumbee Indian tribe. The study’s goal was to develop, deliver, and evaluate a community-based, culturally appropriate cardiovascular disease program for American Indian women and girls.

Methods

Formative research, including focus groups, church assessments, and literature reviews, were conducted for intervention development. Weekly classes during a 4-month period in 4 Lumbee churches (64 women and 11 girls in 2 primary intervention churches; 82 women and 8 girls in 2 delayed intervention churches) were led by community lay health educators. Topics included nutrition, physical activity, and tobacco use cessation and were coupled with messages from the Proverbs 31 passage, which describes the virtuous, godly woman. Surveys collected at the beginning and end of the program measured programmatic effects and change in body mass index.

Outcome

Churches were very receptive to the program. However, limitations included slow rise in attendance, scheduling conflicts for individuals and church calendars, and resistance to change in cultural traditions.

Interpretation

Churches are resources in developing and implementing health promotion programs in Christian populations. Through church partnerships, interventions can be tailored to suit the needs of targeted groups.

Systematic review of health disparities for cardiovascular diseases and associated factors among American Indian and Alaska Native populations

BACKGROUND

American Indians and Alaska Native (AI/AN) populations experience significant health disparities compared to non-Hispanic white populations. Cardiovascular disease and related risk factors are increasingly recognized as growing indicators of global health disparities. However, comparative reports on disparities among this constellation of diseases for AI/AN populations have not been systematically reviewed.

OBJECTIVES

We performed a literature review on the prevalence of diabetes, metabolic syndrome, dyslipidemia, obesity, hypertension, and cardiovascular disease; and associated morbidity and mortality among AI/AN.

DATA SOURCES

A total of 203 articles were reviewed, of which 31 met study criteria for inclusion. Searches were performed on PUBMED, MEDLINE, the CDC MMWR, and the Indian Health Services.

STUDY ELIGIBILITY CRITERIA

Published literature that were published within the last fifteen years and provided direct comparisons between AI/AN to non-AI/AN populations were included.

STUDY APPRAISAL AND SYNTHESIS METHODS

We abstracted data on study design, data source, AI/AN population, comparison group, and. outcome measures. A descriptive synthesis of primary findings is included.

RESULTS

Rates of obesity, diabetes, cardiovascular disease, and metabolic syndrome are clearly higher for AI/AN populations. Hypertension and hyperlipidemia differences are more equivocal. Our analysis also revealed that there are likely regional and gender differences in the degree of disparities observed.

LIMITATIONS

Studies using BRFSS telephone surveys administered in English may underestimate disparities. Many AI/AN do not have telephones and/or speak English. Regional variability makes national surveys difficult to interpret. Finally, studies using self-reported data may not be accurate.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

Profound health disparities in cardiovascular diseases and associated risk factors for AI/AN populations persist, perhaps due to low socioeconomic status and access to quality healthcare. Successful programs will address social determinants and increase healthcare access. Community-based outreach to bring health services to the most vulnerable may also be very helpful in this effort.

SYSTEMATIC REVIEW REGISTRATION NUMBER

N/A.

The association of resilience with mental and physical health among older American Indians: the Native Elder Care Study

We examined the association of resilience with measures of mental and physical health in a sample of older American Indians (AIs). A validated scale measuring resilience was administered to 185 noninstitutionalized AIs aged>=55 years. Unadjusted analyses revealed that higher levels of resilience were associated with lower levels of depressive symptomatology and chronic pain, and with higher levels of mental and physical health. Resilience remained significantly associated with depressive symptomatology after controlling for demographic and other health measures. Our findings suggest that resilience among older AIs has important implications for some aspects of mental and physical health.

Ethnicity, livelihoods, masculinity, and health among Luo men in the slums of Nairobi, Kenya

BACKGROUND

Previous research suggests that ethnic self-identity has little consequence for objective health outcomes compared to the structural dimensions of ethnicity.

METHODS

Using qualitative data, we investigated perceptions of ethnicity in relation to health among Luo men in the slums of Nairobi, Kenya.

RESULTS

While recognizing the complicated cultural origin of poor health, responding Luo men stressed on gender and everyday livelihood situations as being more critical for their health than Luo customs. Recognition of the structural causes of ill-health among the men overlapped with lay notions derived from particular expressions of Luo culture in urban slum contexts. To some extent, respondents regarded the performance of their sense of ethnic identity as protective, though they also admitted to the health-damaging repercussions of some of the ways they enacted aspects of Luo culture.

CONCLUSION

Ethnic beliefs that link particular enactments of local customs with health outcomes may motivate the performance of cultural identity in ways that can produce critical health outcomes.

Arsenic exposure, diabetes prevalence, and diabetes control in the Strong Heart Study

This study evaluated the association of arsenic exposure, as measured in urine, with diabetes prevalence, glycated hemoglobin, and insulin resistance in American Indian adults from Arizona, Oklahoma, and North and South Dakota (1989-1991). We studied 3,925 men and women 45-74 years of age with available urine arsenic measures. Diabetes was defined as a fasting glucose level of 126 mg/dL or higher, a 2-hour glucose level of 200 mg/dL or higher, a hemoglobin A1c (HbA1c) of 6.5% or higher, or diabetes treatment. Median urine arsenic concentration was 14.1 µg/L (interquartile range, 7.9-24.2). Diabetes prevalence was 49.4%. After adjustment for sociodemographic factors, diabetes risk factors, and urine creatinine, the prevalence ratio of diabetes comparing the 75th versus 25th percentiles of total arsenic concentrations was 1.14 (95% confidence interval: 1.08, 1.21). The association between arsenic and diabetes was restricted to participants with poor diabetes control (HbA1c ≥8%). Arsenic was positively associated with HbA1c levels in participants with diabetes. Arsenic was not associated with HbA1c or with insulin resistance (assessed by homeostatic model assessment to quantify insulin resistance) in participants without diabetes. Urine arsenic was associated with diabetes control in a population from rural communities in the United States with a high burden of diabetes. Prospective studies that evaluate the direction of the relation between poor diabetes control and arsenic exposure are needed.

Using spatial analysis to demonstrate the heterogeneity of the cardiovascular drug-prescribing pattern in Taiwan

BACKGROUND

Geographic Information Systems (GIS) combined with spatial analytical methods could be helpful in examining patterns of drug use. Little attention has been paid to geographic variation of cardiovascular prescription use in Taiwan. The main objective was to use local spatial association statistics to test whether or not the cardiovascular medication-prescribing pattern is homogenous across 352 townships in Taiwan.

METHODS

The statistical methods used were the global measures of Moran's I and Local Indicators of Spatial Association (LISA). While Moran's I provides information on the overall spatial distribution of the data, LISA provides information on types of spatial association at the local level. LISA statistics can also be used to identify influential locations in spatial association analysis. The major classes of prescription cardiovascular drugs were taken from Taiwan's National Health Insurance Research Database (NHIRD), which has a coverage rate of over 97%. The dosage of each prescription was converted into defined daily doses to measure the consumption of each class of drugs. Data were analyzed with ArcGIS and GeoDa at the township level.

RESULTS

The LISA statistics showed an unusual use of cardiovascular medications in the southern townships with high local variation. Patterns of drug use also showed more low-low spatial clusters (cold spots) than high-high spatial clusters (hot spots), and those low-low associations were clustered in the rural areas.

CONCLUSIONS

The cardiovascular drug prescribing patterns were heterogeneous across Taiwan. In particular, a clear pattern of north-south disparity exists. Such spatial clustering helps prioritize the target areas that require better education concerning drug use.

Correlating pharmaceutical data with a national health survey as a proxy for estimating rural population health

BACKGROUND

Chronic disease accounts for nearly three-quarters of US deaths, yet prevalence rates are not consistently reported at the state level and are not available at the sub-state level. This makes it difficult to assess trends in prevalence and impossible to measure sub-state differences. Such county-level differences could inform and direct the delivery of health services to those with the greatest need.

METHODS

We used a database of prescription drugs filled in the US as a proxy for nationwide, county-level prevalence of three top causes of death: heart disease, stroke, and diabetes. We tested whether prescription data are statistically valid proxy measures for prevalence, using the correlation between prescriptions filled at the state level and comparable Behavioral Risk Factor Surveillance System (BRFSS) data. We further tested for statistically significant national geographic patterns.

RESULTS

Fourteen correlations were tested for years in which the BRFSS questions were asked (1999-2003), and all were statistically significant. The correlations at the state level ranged from a low of 0.41 (stroke, 1999) to a high of 0.73 (heart disease, 2003). We also mapped self-reported chronic illnesses along with prescription rates associated with those illnesses.

CONCLUSIONS

County prescription drug rates were shown to be valid measures of sub-state estimates of diagnosed prevalence and could be used to target health resources to counties in need. This methodology could be particularly helpful to rural areas whose prevalence rates cannot be estimated using national surveys. While there are no spatial statistically significant patterns nationally, there are significant variations within states that suggest unmet health needs.

Optimizing hypertension management in underserved rural populations

Rural populations across the United States have an increased likelihood of developing hypertension and diabetes, which are significant risk factors for cardiovascular disease (CVD), including stroke and myocardial infarction. Limited access to care due to geography or socioeconomic status significantly impairs control of hypertension in rural populations, resulting in poor health outcomes. Epidemiological studies suggest that the prevalence of uncontrolled hypertension and poor glycemic control are affected by race, increasing age, and residence in the rural southeastern United States. Optimization of the delivery of rural health care is needed to improve outcomes in patients with hypertension. New strategies such as programs targeting therapeutic inertia, home-based monitoring of blood pressure (BP), and Internet-based communication programs may significantly improve BP control rates among rural patients. Among hypertensive medications, angiotensin-converting enzyme inhibitors and angiotensin receptor blockers are recommended by consensus guidelines and may be particularly effective in rural, minority populations due to their secondary effects on decreasing CVD.

Family health history and health behaviors in Alaska native and American Indian people

BACKGROUND

Family history of diseases among American Indian and Alaska Native (AIAN) people may influence health.

METHODS

We examine the prevalence of family health history among a cohort of AIAN people (n= 10,374) enrolled in the Education and Research Towards Health (EARTH) Study. We evaluate the association between having a positive family history and health behaviors to determine if those reporting a family history were more likely to report lifestyles that put them at risk of developing these health conditions.

RESULTS

Among participants, 17.7% reported not knowing their family history and 23.5% preferred not to answer the family history component of the questionnaire. Eight percent of participants reported a family history of colorectal cancer, 7.9% a family history of breast cancer, 25.8% a family history of heart attack, and 46.7% a family history of diabetes. Obesity, physical activity, cholesterol, and perceived health were associated with family history.

CONCLUSIONS

Individuals with a family history of diseases may have lifestyles that influence their disease risk.

Cigarette smoking among American Indian youth in Minneapolis-St. Paul

BACKGROUND

Reported prevalence of cigarette smoking among American Indian youth is higher than other racial/ethnic minorities, and limited data indicate that this disparity is especially pronounced in the Upper Midwest of the U.S. The purposes of this study are to measure traditional and recreational tobacco use among American Indian youth in an urban Upper Midwest area, and to identify social and environmental factors associated with recreational tobacco use (cigarette smoking).

METHODS

A cross-sectional convenience sample of 336 American Indian youth aged 11-18 years was given a self-administered survey. Data were analyzed using bivariate chi-square tests and multivariate logistical stepwise regression.

RESULTS

Almost 37% reported some recreational smoking in the previous 30 days, with about three times as many in the group aged 16-18 years reporting smoking as in the group aged 11-13 years (p<0.0001). Social exposure to cigarette smoking was very strong; more than three fourths reported living with an adult who smokes, and 44% have a brother/a sister who smokes. Yet more than 65% report a household rule against their smoking, and 43% report a household rule against anyone smoking inside. Youth who smoke report buying cigarettes often and smoking on school property. Household rules against smoking and hearing of someone getting caught smoking at school have an independent negative association with likelihood of being a smoker.

CONCLUSIONS

These results indicate that American Indian youth in this area report high use of recreational tobacco, and the statewide focus on youth smoking prevention has not eliminated the disparity in smoking levels between American Indian youth and Minnesota youth overall. These findings suggest several pathways to reduce cigarette smoking among urban American Indian youth.

Regional differences in colorectal cancer incidence, stage, and subsite among American Indians and Alaska Natives, 1999-2004

BACKGROUND

Colorectal cancer (CRC) is a leading cause of cancer morbidity and mortality for American Indians and Alaska Natives (AI/ANs), but misclassification of race causes underestimates of disease burden.

METHODS

The authors compared regional differences in CRC incidence, stage at diagnosis, and anatomic distribution between AI/ANs and non-Hispanic whites (NHWs). To reduce misclassification, data from the National Program of Cancer Registries; the Surveillance, Epidemiology, and End Results Program; and the Indian Health Service (IHS) were linked. The analysis was limited to the 56% of AI/AN who live in IHS Contract Health Service Delivery Areas.

RESULTS

From 1999 to 2004, the overall incidence rate (per 100,000 persons per year) of CRC was 9% lower in the AI/AN population (46.3) than in the NHW population (50.8). However, AI/AN CRC incidence rates varied nearly 5-fold regionally, from 21 in the Southwest to 102.6 in Alaska. Compared with NHW rates, AI/AN rates were significantly higher in Alaska (rate ratio [RR], 2.03), the Northern Plains (RR, 1.39), and the Southern Plains (RR, 1.16) but were lower in the Pacific Coast (RR, 0.80), the East (RR, 0.65), and the Southwest (RR, 0.45). AI/ANs were diagnosed more often with advanced CRC than with localized CRC (RR, 1.92) compared with NHWs (RR, 1.48). Females more often had proximal CRC among both the AI/AN population (females, 40.1%; males, 33.5%) and the NHW population (females, 50.1%; males, 40.3%), although AI/ANs had a higher proportion of distal cancers overall.

CONCLUSIONS

CRC incidence rates in AI/AN populations varied dramatically between regions. Efforts are needed to make CRC screening a priority, overcome barriers to endoscopic screening, and to engage AI/AN communities in culturally appropriate ways to participate in prevention and early detection programs.

Trends and cardiovascular mortality effects of state-level blood pressure and uncontrolled hypertension in the United States

BACKGROUND

Blood pressure is an important risk factor for cardiovascular disease and mortality and has lifestyle and healthcare determinants that vary across states. Only self-reported hypertension status is measured at the state level in the United States. Our aim was to estimate levels and trends in state-level mean systolic blood pressure (SBP), the prevalence of uncontrolled systolic hypertension, and cardiovascular mortality attributable to all levels of higher-than-optimal SBP.

METHODS AND RESULTS

We estimated the relationship between actual SBP/uncontrolled hypertension and self-reported hypertension, use of blood pressure medication, and a set of health system and sociodemographic variables in the nationally representative National Health and Nutrition Examination Survey. We applied this relationship to identical variables from the Behavioral Risk Factor Surveillance System to estimate state-specific mean SBP and uncontrolled hypertension. We used the comparative risk assessment methods to estimate cardiovascular mortality attributable to higher-than-optimal SBP. In 2001-2003, age-standardized uncontrolled hypertension prevalence was highest in the District of Columbia, Mississippi, Louisiana, Alabama, Texas, Georgia, and South Carolina (18% to 21% for men and 24% to 26% for women) and lowest in Vermont, Minnesota, Connecticut, New Hampshire, Iowa, and Colorado (15% to 16% for men and approximately 21% for women). Women had a higher prevalence of uncontrolled hypertension than men in every state by 4 (Arizona) to 7 (Kansas) percentage points. In the 1990s, uncontrolled hypertension in women increased the most in Idaho and Oregon (by 6 percentage points) and the least in the District of Columbia and Mississippi (by 3 percentage points). For men, the worst-performing states were New Mexico and Louisiana (decrease of 0.6 and 1.3 percentage points), and the best-performing states were Vermont and Indiana (decrease of 4 and 3 percentage points). Age-standardized cardiovascular mortality attributable to higher-than-optimal SBP ranged from 200 to 220 per 100,000 (Minnesota and Massachusetts) to 360 to 370 per 100,000 (District of Columbia and Mississippi) for women and from 210 per 100,000 (Colorado and Utah) to 370 per 100,000 (Mississippi) and 410 per 100,000 (District of Columbia) for men.

CONCLUSIONS

Lifestyle and pharmacological interventions for lowering blood pressure are particularly needed in the South and Appalachia, and with emphasis on control among women. Self-reported data on hypertension diagnosis from the Behavioral Risk Factor Surveillance System can be used to obtain unbiased state-level estimates of blood pressure and uncontrolled hypertension as benchmarks for priority setting and for designing and evaluating intervention programs.

Cardiovascular risk factors among Native American women Inter-Tribal Heart Project participants

OBJECTIVE

To examine cardiovascular disease risk factors among adult Native American women Inter-Tribal Heart Project participants.

DESIGN

A secondary analysis used controllable risk factors identified by the American Heart Association as the framework to examine cardiovascular disease risk factors in this population.

SETTING

Three Native American Reservations in Minnesota and Wisconsin.

PARTICIPANTS

866 adult Native American women who participated in the Inter-Tribal Heart Project cardiovascular health research study.

MAIN OUTCOME MEASURES

Descriptive, correlational, bivariate, and multivariate analysis provided findings on cardiovascular disease risk factors in this population.

RESULTS

Cardiovascular disease risk factors are high among this population. For every additional risk factor, the odds of self-reported cardiovascular disease increases 1.2 times (95% confidence interval: 1.1-1.3). Participants who self-reported cardiovascular disease were older, less educated, employed less, and reported more Indian ancestry (higher blood quantum) and had higher prevalence rates of diabetes, higher systolic blood pressure, and body mass index in comparison to women who self-reported an absence of cardiovascular disease.

CONCLUSIONS

A key to decreasing cardiovascular disease lies in preventing and controlling cardiovascular disease risk factors with concerted efforts specific to the culture and life ways of the Native American woman.

Awareness and use of home- and community-based long-term care by rural American Indian and white elderly with co-morbid diabetes

The purposes of this study were to determine if there are any differences in awareness and utilization of available home- and community-based long-term care (HCBLTC) between rural American Indian and white elderly with co-morbid diabetes, and to examine how they learned about HCBLTC programs. Survey data were analyzed from 62 American Indians and 64 whites aged 65 years or older living in the community. The American Indian respondents were more likely to be aware of and to have used HCBLTC programs compared to their white counterparts. The most common way that the American Indian participants learned about HCBLTC programs was through health care referrals, while the most common way for whites was through friends.