Chiadi E. Ndumele, M.D., Ph.D., M.H.S., Robert E. Meyerhoff Assistant Professor, Department of Medicine, Johns Hopkins University
High rates of diabetes and other risk factors have contributed to increased prevalence of cardiovascular disease among American Indians and Alaska Natives over the past 50 years, according to a scientific statement.
The statement, published today in the American Heart Association journal Circulation, summarizes population-level risk factors and intervention strategies to improve heart health in the two populations. It’s based on a review of scientific evidence, Centers for Disease Control and Prevention data and the association’s annual Heart Disease and Stroke Statistics Report.
American Indians have a three-fold higher age-adjusted prevalence of diabetes compared with whites; prevalence varies by region and is as high as 72% in women and 65% in men ages 45 to 74 in the Southwestern United States.
Other clinical risk factors leading to the higher rates of cardiovascular disease among American Indians and Alaska Natives include: abnormal cholesterol levels, hypertension, obesity and renal disease (which is directly related to the high prevalence of diabetes). Sex and age are also important risk factors in this population.
According to the statement, American Indian and Alaska Native men have higher rates of cardiovascular disease than women, and these populations develop cardiovascular diseases at earlier ages than whites.
- The prevalence of smoking among American Indians and Alaska Natives (31.8%) is nearly double that of blacks (16.5%) and whites (16.5%).
- In contrast to other racial/ethnic groups, smoking rates in American Indians and Alaska Natives haven’t decreased significantly over the past 20 years.
- Only 14.7% of American Indians and Alaska Natives meet physical activity recommendations, a number that has been mostly stagnant between 1998 and 2017.
Additional contributors to health disparities among American Indians and Alaska Natives are socioeconomic factors, environmental factors and historical experiences:
- Across the country, one quarter of these populations live below the federal poverty line, which has implications for social and physical environmental risk exposure as well as family and community well-being.
- There is generally less optimal access to routine health care in these populations.
- Some subpopulations are disproportionately exposed to toxic metals, such as arsenic, through groundwater contamination.
- Historical experiences include epidemic infectious disease, removal and restriction to reservations, and forced assimilation and urbanization.
American Indian and Alaska Native populations are often not sufficiently included in national health surveys because of small population size, but enhanced surveillance would provide a more detailed picture of their heart disease risk factors. This would increase awareness about the health challenges these populations face, which could help healthcare and public health stakeholders improve health and work toward health equity.
Implications for intervention
To better prevent and treat cardiovascular disease in American Indians and Alaska Natives, it’s imperative to control risk factors and implement community-based interventions that address social determinants of health — especially among those with diabetes.
Interventions may include incorporating culturally-centered solutions driven by indigenous concepts of wellness, equipping communities with the capacity and infrastructure to implement changes and promoting shared decision making.
In addition, interventions that consider the historical trauma that has contributed to health disparities among indigenous peoples can help address their structural and social determinants of health.