Hypertension-related mortality and morbidity in the southeast

Practice Notes: Strategies in Health Education

The Practice Notes section is intended to keep readers informed about health education practice around the country. It is an attempt to spread the word about exemplary strategies, initiatives, and programs and share success in overcoming obstacles or challenges. Periodically, articles presenting perspectives on practice-related issues are also included in Practice Notes.

Epidemiology of Diabetes

The incidence of diabetes mellitus, particularly type 2 diabetes, is increasing dramatically in the United States and in other Westernized, industrialized societies because of increasing obesity, sedentary lifestyle, and population aging. There are currently 20 million persons with diabetes in the United States, of whom more than 5 million remain undiagnosed. The diabetic population consumes a disproportionate share of health care resources because of both microvascular and macrovascular complications. Diabetes is a major cause of new-onset blindness, end-stage renal disease, and nontraumatic amputation in the United States. Cardiovascular disease accounts for up to 80% of premature excess mortality in diabetic patients. Strategies to lessen the disease burden in these patients include hygienic measures (diet and exercise) as well as rigorous treatment of hypertension, dyslipidemia, and hyperglycemia.

Implementation of the fit body and soul, a church-based life style program for diabetes prevention in high-risk African Americans: a feasibility study

PURPOSE

The purpose of this study was to determine the effects of a behavioral faith-based diabetes prevention program called the Fit Body and Soul program in a semi-urban African-American church using a community-based participatory approach.

METHODS

The 12-session Fit Body and Soul program was modified from the group lifestyle balance intervention that was modified from the successful National Institute of Health (NIH) funded Diabetes Prevention Program. The Fit Body and Soul program was implemented in a semi-urban African-American church community. Based on the results of physical examinations and increased body mass index (BMI > or = 25), 40 adult members of the church were identified as being at high risk for diabetes. Four church ministers, after receiving Fit Body and Soul program training for 2 days, served as study interventionists. The primary objective was weight loss of at least 5% by the end of the 12-session Fit Body and Soul intervention.

RESULTS

Screening of church participants was conducted at the Gospel Water Branch Baptist Church in Augusta, Georgia. A total of 40 individuals having a BMI > or = 25 were selected. Of the 40, a total of 35 (87.5%) attended at least 10 sessions and provided information required for the study. Of the 35, a total of 48% lost at least 5% of baseline weight, 26% lost 7% or more, and 14% lost >10% of baseline weight.

CONCLUSIONS

This pilot trial suggests that carrying out a larger Fit Body and Soul study in a faith-based setting, using behavioral lifestyle interventions, in the context of a diabetes prevention program for African American communities is feasible, as is the possibility that subjects in that larger study will achieve a clinically significant degree of weight loss.

The Impact of Lifestyle Behavior on Hypertension Awareness, Treatment, and Control in a Southeastern Population

BACKGROUND

We were interested in determining the rates of hypertension awareness, treatment, and control in individuals living in the southeastern United States and evaluating the impact of lifestyle behaviors on these rates.

METHODS

This is a cross-sectional survey of a sample of community dwellers in the greater Columbia, South Carolina area. The survey was developed from validated community-based survey questionnaires to evaluate demographic and social history (age, gender, race-ethnicity, income, and education), hypertension history (diagnosis and treatment), and lifestyle behavior (servings of fruits and vegetables [FV] and physical activity [PA] duration and frequency), as well as blood pressure measurement.

RESULTS

A total of 763 people (mean +/- standard error age 52.4 +/- 0.7 years; 68% women, 53% African American) agreed to be screened. Of all participants with hypertension (438 [58%]), 82% were aware of their illness and 79% were on treatment. Of all hypertensive participants, 39% had their hypertension controlled below 140/90 mm Hg at the time of the survey. Only 11% reported consuming five or more FV per day and 18% reported PA five or more times per week. African-Americans consumed less FV (P < 0.001) and performed less PA (P < 0.001). Those consuming more FV and exercising more frequently had lower hypertension prevalence and tended to have better control rates.

CONCLUSIONS

In a sample of southeastern residents, the control rate was suboptimal despite a relatively high rate of treatment. Low levels of FV consumption and PA were noted especially in African-American patients and may explain this rate.

Systemic Hypertension: An Endemic, Epidemic, and a Pandemic

Disease epidemics have influenced world history throughout time. Although disease patterns such as the plague and smallpox historically have been infectious in nature, chronic diseases such as cardiovascular disease, stroke, congestive heart failure, and end-stage renal disease have become the new global epidemics. The effects of these conditions affect nearly all populations of the world. Although high blood pressure has been implicated as the common link of these pandemic patterns only for less than half a century, the impact of hypertension treatment and control has become a documented population-based response with the greatest potential for global impact. For example, an estimated 45% of the deaths among African-American men could be prevented with treatment of high blood pressure to goal level. However, population demographics and risk factors predict a worsening effect as the populations of the world increase in age, racial disparities in access to medical care widen, and comorbid conditions such as obesity and metabolic syndrome continue to increase at epidemic rates. The economic impact of hypertension-related conditions, end-stage renal disease, and congestive heart failure is staggering, such that health care delivery systems will fail if the current trends are not changed. Hospitalization rates of hypertension-related conditions are increasing along with an aging population. The number of at-risk individuals in the population also is increasing. As the definition of hypertension changes with lower levels of blood pressure, the proportion of the population considered to have hypertension increases substantially. These trends and disease patterns clearly identify the essential need to implement population and clinical strategies for high blood pressure prevention, treatment, and control.

Aging and eating in the rural, southern United States: beliefs about salt and its effect on health

This paper draws upon qualitative research conducted among older adults in the rural, southern United States in which they articulated their beliefs and experiences with nutrition and foods, and lay models of the connection of diet with chronic disease. Salt emerged as a focus of contention. The goals of the paper are to (1) present the culturally constructed meaning of salt, (2) contrast the cultural meaning with biomedical views, and (3) discuss how these findings can be applied to health education and better doctor-patient communication. Data were collected in two rural communities characterized by high rates of poverty and a high proportion of minority residents. A total of 116 African American, Native American and white adults aged 60 years and older participated in 55 in-depth interviews or seven focus groups. A systematic analysis of text showed that salt was a highly contested component of food. While valued for its role in traditional foods and cuisine, it also held negative connotations because of biomedical links to chronic diseases prevalent in the population. We suggest that attempts to control salt intake are made difficult by the changes in taste perceptions that accompany aging. Respondents' articulation of salt's role in health and disease shows cross-over among different chronic diseases and a lay interpretation of blood as the medium through which salt affects disease. These older adults' narratives demonstrate their attempts to reconcile the important role of traditional foods in their identity as Southerners with their attempts to meet medical recommendations for healthy eating.

Stroke in patients with diabetes and hypertension

Stroke is major public health problem leading to increased morbidity and mortality. Modifiable risk factors for stroke include hypertension, diabetes, atrial fibrillation, dyslipidemia, smoking, and alcohol abuse. Among these risk factors, diabetes and hypertension are rapidly growing epidemics leading to a substantial increase in cardiovascular disease and stroke. In this review, the authors discuss the risk factors for stroke with emphasis on the diabetic and hypertensive population, highlighting the interventions that have been shown to decrease stroke risk in this patient population.

Pediatric Stroke Belt

BACKGROUND AND PURPOSE

Numerous studies have demonstrated higher stroke mortality rates in adults residing in the Southeastern United States (the "Stroke Belt"). If the Stroke Belt is solely caused by regional differences in atherosclerotic stroke risk factors, it should not apply to children.

METHODS

For the years 1979 to 1998, we determined rates of death from stroke in children <20 years of age based on death certificates, and compared age-adjusted stroke mortality rates in 11 Stroke Belt states versus other US states. For comparison, the same methods were applied to adults.

RESULTS

Children in Stroke Belt states have an increased risk of death from stroke compared with children in other states (relative risk [RR], 1.21; 95% CI, 1.12 to 1.29). The greater risk in Stroke Belt states was apparent for ischemic and hemorrhagic stroke, for all age groups and both sexes, and persisted after adjustment for ethnicity. The geographic disparity in children was similar in magnitude to that in adults.

CONCLUSIONS

Similar to adults, children in Stroke Belt states have a higher risk of death from stroke than children in other US states. Stroke risk factors that are applicable to both children and adults should be considered in attempts to explain this geographic variation.

Short-term, intermediate-term, and long-term mortality in patients hospitalized for stroke

Cerebrovascular disease is the third leading cause of death and the primary cause of long-term disability in the United States. Although the risk factors for stroke have been well defined, less is known about stroke mortality over varying time periods within the same cohort of patients. The purpose of this study is to define rates of short-term, intermediate-term, and long-term stroke mortality among patients experiencing a first-ever hemorrhagic or ischemic stroke between 1994 and 1998. Patients were identified from the Patient Treatment Files of the Department of Veterans Affairs (VA). We included all patients who were discharged from a VA inpatient facility with a diagnosis of acute stroke. Patients were excluded from the study if they had an admission within the previous 5 years for stroke or hemiplegia. We obtained information on the patient's age, gender, and coexisting illnesses. Unadjusted and adjusted 30-day mortality rates were computed using Kaplan-Meier analyses and Cox proportional hazards regression models. The survival-dependent Cox proportional hazards regression models were run for 31-90 days and 91-365 days from the index admission date, for patients who had survived to the start of each of these time periods. Separate models were run for ischemic (n = 34,866 patients) and hemorrhagic (n = 5,442 patients) strokes. Unadjusted 30-day mortality was 8.2 and 20.5% for ischemic and hemorrhagic strokes, respectively. The adjusted 30-day mortality rate was 7.4 and 18.8% for ischemic and hemorrhagic strokes, respectively. For ischemic stroke, age 65 years and older was associated with an increased risk for short-term, intermediate-term, and long-term mortality, while chronic heart failure was associated with an increased risk for short-term and long-term mortality. For hemorrhagic stroke, age 75 years and older, malignancy, and chronic heart failure were associated with increased mortality during all three time periods. Thirty-day mortality is over two times greater following hemorrhagic stroke vs. ischemic stroke. For patients who survive 30 days after an ischemic stroke, the risk factor that remains significantly associated with long-term mortality, which may be improved with appropriate process of care, is chronic heart failure. For patients with a hemorrhagic stroke, variables that remain significantly associated with increased short-term and long-term mortality include malignant neoplasm and chronic heart failure. Information on stroke mortality is important for patients, physicians, and researchers. In addition to stroke treatment, clinicians must be able to provide families of stroke victims with appropriate prognostic information. Further work is needed to assess the impact of actual care patterns, for the above identified risk factors, on stroke prognosis over varying time periods.

Lower extremity nontraumatic amputation among veterans with peripheral arterial disease: is race an independent factor?

OBJECTIVES

To determine if race/ethnicity is independently associated with an increased risk for nontraumatic lower extremity amputation versus lower extremity bypass revascularization among patients with peripheral arterial disease (PAD).

METHODS

Data were analyzed from the National VA Surgical Quality Improvement Program (NSQIP) and from the Veterans Affairs Patient Treatment File (PTF). Race/ethnicity was defined as non-Hispanic white, black, or Hispanic. Variables that were univariately associated (P < or = 0.05) with the outcome of amputation were placed into a multiple logistic regression model to determine independent predictors for the dependent variable, lower extremity amputation versus lower extremity bypass revascularization.

RESULTS

Three thousand eighty-five lower extremity amputations and 8409 lower extremity bypass operations were identified. Among all cases included, there were 416 Hispanic patients (3.6%), 2337 black patients (20.3%), and 8741 non-Hispanic white patients (76.1%). Among all variables within the model, Hispanic and black race were each associated with a greater risk for amputation than a history of rest pain/gangrene (Hispanic race 1.4, 95% CI 1.1, 1.9; black race 1.5, 95% CI 1.4, 1.7; rest pain/gangrene 1.1, 95% CI 1.0, 1.3). The final model had a c statistic of 0.83.

CONCLUSION

Hispanic race and black race were independent risk factors for lower extremity amputation in patients with PAD. Although the burden of certain atherosclerotic risk factors (eg, diabetes and hypertension) is higher in minority patients, the impact of this burden does not account for the increased risk for the outcome of lower extremity amputation in these two populations. Further research is needed to better understand the reason(s) why race/ethnicity is independently associated with poor outcomes in PAD.

Mortality from multiple sclerosis and exposure to residential and occupational solar radiation: a case-control study based on death certificates

OBJECTIVES

To explore whether mortality from multiple sclerosis is negatively associated with exposure to sunlight.

METHODS

Two case-control studies based on death certificates were conducted for mortality from multiple sclerosis and non-melanoma skin cancer (as a positive control) to examine associations with residential and occupational exposure to sunlight. Cases were all deaths from multiple sclerosis between 1984 and 1995 in 24 states of the United States. Controls, which were age frequency matched to a series of cases, excluded cancer and certain neurological deaths. The effects of occupational exposure to sunlight were assessed among subjects with usual occupations requiring substantial activity, so as to exclude those whose indoor jobs resulted from disabilities subsequent to the onset of the disease. Multiple logistic regression analyses were applied, with adjustment for age, sex, race, and socioeconomic status.

RESULTS

Unlike mortality from skin cancer, mortality from multiple sclerosis was negatively associated with residential exposure to sunlight (odds ratio (OR)=0.53 (multiple sclerosis) and OR=1.24 (skin cancer)). Odds ratios for the highest occupational exposure to sunlight were 0.74 (95% confidence interval (95% CI) 0.61 to 0.89) for mortality from multiple sclerosis, compared with 1.21 (1.09 to 1.34) for mortality from non-melanoma skin cancer. The OR was 0.24 for the combined effect of the highest levels of residential and occupational exposure to sunlight on multiple sclerosis, compared with an OR of 1.38 for skin cancer.

CONCLUSIONS

In this exploratory study, mortality from multiple sclerosis, unlike mortality from skin cancer, was negatively associated with both residential and occupational exposure to sunlight.

Impact of nativity and race on "Stroke Belt" mortality

The southeastern region of the United States has been recognized for 6 decades as an area of excess cerebrovascular mortality rates. While the reasons for the disease variation remain an enigma, South Carolina has consistently been the forerunner of the "Stroke Belt." To determine the effects of nativity (birthplace) on stroke mortality rates in South Carolina, proportional mortality ratios (PMRs) were calculated for stroke deaths in South Carolina during 1980-1996 according to birthplace and stratified by gender, race, age, and educational status. The analyses revealed a graded risk of stroke by birthplace, with the highest PMRs (95% CI) among individuals born in South Carolina (104.8 [103.4 to 106.3]), intermediate PMRs in those born in the Southeast other than South Carolina (92.5 [90.2 to 94.9]), and lowest PMRs for those born outside the Southeast (77.4 [74.9 to 80.1]). The lower stroke PMRs for individuals born outside the Southeast were more striking in blacks (51.8 [45.2 to 59.3]) than in whites (84.9 [82.0 to 88.0]) and for men (73.3 [69.5 to 77.3]) than women (83.5 [79.9 to 87.3]). The findings, particularly in blacks, were not explainable by gender, differences in age, and/or markers of educational and socioeconomic status. These findings suggest that nativity is a significant risk marker for the geographic variation in stroke mortality. Moreover, the regional disparities for nativity and subsequent stroke mortality appear to be greater in blacks than in whites and for men than for women. An understanding of factors linking birthplace to risk for cerebrovascular mortality could facilitate efforts directed at stroke prevention.

The geographic variation in stroke incidence in two areas of the southeastern stroke belt: the Anderson and Pee Dee Stroke Study

BACKGROUND AND PURPOSE

South Carolina and the southeastern United States have maintained the highest stroke mortality in the country. The Anderson and Pee Dee Stroke Study is an assessment of cerebrovascular disease incidence in 2 geographically defined communities in the stroke belt.

METHODS

Strokes were identified in the Anderson and Pee Dee areas of South Carolina. All hospitalized and out-of-hospital deaths occurring during 1990 among the residents of these 2 areas were included. Strokes were classified by an independent panel of neurologists using a standard protocol that included specific criteria for stroke and subtypes.

RESULTS

The overall age-adjusted stroke incidence rates (per 100 000 population) were significantly higher in the Pee Dee population (293.1) compared with Anderson (211.2). The geographic differences were more dramatic in the younger age groups of 35 to 64 years. Likewise, incidence rates for blacks were nearly twice the rates for whites. The rates in the Pee Dee were higher than the rates from other studies in the United States and other parts of the world. Although the stroke subtypes did not vary between the 2 regions, race-sex differences were identified.

CONCLUSIONS

High stroke incidence and disease rates persist for all 4 race-sex groups in the Southeast and reflect similar risks as mortality rates. However, geographic variability in stroke rates suggests that the pattern of disease in the region is not so much a "belt" of increased stroke in contiguous areas but rather more a "necklace" of different levels of risk. These results should be useful in the identification of factors associated with this geographic enigma.