Systematic Review of Health Disparities for Cardiovascular Diseases and Associated Factors among American Indian and Alaska Native Populations

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Abstract

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

Related collections

Most cited references 40

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The persistence of American Indian health disparities.

Roland S. G. Jones (2006)

Disparities in health status between American Indians and other groups in the United States have persisted throughout the 500 years since Europeans arrived in the Americas. Colonists, traders, missionaries, soldiers, physicians, and government officials have struggled to explain these disparities, invoking a wide range of possible causes. American Indians joined these debates, often suggesting different explanations. Europeans and Americans also struggled to respond to the disparities, sometimes working to relieve them, sometimes taking advantage of the ill health of American Indians. Economic and political interests have always affected both explanations of health disparities and responses to them, influencing which explanations were emphasized and which interventions were pursued. Tensions also appear in ongoing debates about the contributions of genetic and socioeconomic forces to the pervasive health disparities. Understanding how these economic and political forces have operated historically can explain both the persistence of the health disparities and the controversies that surround them.

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Rising tide of cardiovascular disease in American Indians. The Strong Heart Study.

B V Howard, E Lee, L D Cowan … (1999)

Although cardiovascular disease (CVD) used to be rare among American Indians, Indian Health Service data suggest that CVD mortality rates vary greatly among American Indian communities and appear to be increasing. The Strong Heart Study was initiated to investigate CVD and its risk factors in American Indians in 13 communities in Arizona, Oklahoma, and South/North Dakota. A total of 4549 participants (1846 men and 2703 women 45 to 74 years old) who were seen at the baseline (1989 to 1991) examination were subjected to surveillance (average 4.2 years, 1991 to 1995), and 88% of those remaining alive underwent a second examination (1993 to 1995). The medical records of all participants were exhaustively reviewed to ascertain nonfatal cardiovascular events that occurred since the baseline examination or to definitively determine cause of death. CVD morbidity and mortality rates were higher in men than in women and were similar in the 3 geographic areas. Coronary heart disease (CHD) incidence rates among American Indian men and women were almost 2-fold higher than those in the Atherosclerosis Risk in Communities Study. Significant independent predictors of CVD in women were diabetes, age, obesity (inverse), LDL cholesterol, albuminuria, triglycerides, and hypertension. In men, diabetes, age, LDL cholesterol, albuminuria, and hypertension were independent predictors of CVD. At present, CHD rates in American Indians exceed rates in other US populations and may more often be fatal. Unlike other ethnic groups, American Indians appear to have an increasing incidence of CHD, possibly related to the high prevalence of diabetes. In the general US population, the rising prevalence of obesity and diabetes may reverse the decline in CVD death rates. Therefore, aggressive programs to control diabetes and its risk factors are needed.

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Prehypertension and cardiovascular disease risk in the Women's Health Initiative.

Russell L. Margolis, Nanette K. Wenger, … (2007)

Prehypertension is common and is associated with increased vascular mortality. The extent to which it increases risk of nonfatal myocardial infarction, stroke, and congestive heart failure is less clear. We determined the prevalence of prehypertension, its association with other coronary risk factors, and the risk for incident cardiovascular disease events in 60,785 postmenopausal women during 7.7 years of follow-up using Cox regression models that included covariates as time-dependent variables. Prehypertension was present at baseline in 39.5%, 32.1%, 42.6%, 38.7%, and 40.3% of white, black, Hispanic, American Indian, and Asian women, respectively (P<0.0001 across ethnic groups). Age, body mass index, and prevalence of diabetes mellitus and hypercholesterolemia increased across blood pressure categories, whereas smoking decreased (all P<0.0001). Compared with normotensive women (referent), adjusted hazard ratios for women with prehypertension were 1.58 (95% confidence interval [CI], 1.12 to 2.21) for cardiovascular death, 1.76 (95% CI, 1.40 to 2.22) for myocardial infarction, 1.93 (95% CI, 1.49 to 2.50) for stroke, 1.36 (95% CI, 1.05 to 1.77) for hospitalized heart failure, and 1.66 (95% CI, 1.44 to 1.92) for any cardiovascular event. Hazard ratios for the composite outcome with prehypertension did not differ between ethnic groups (P=0.71 for interaction), although the numbers of events among Hispanic and Asian women were small. Prehypertension is common and was associated with increased risk of myocardial infarction, stroke, heart failure, and cardiovascular death in white and nonwhite postmenopausal women. Risk factor clustering was conspicuous, emphasizing the need for trials evaluating the efficacy of global cardiovascular risk reduction through primordial prevention.

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Author and article information

Contributors

Hamid Reza Baradaran: Role: Editor

Journal

Journal ID (nlm-ta): PLoS One

Journal ID (iso-abbrev): PLoS ONE

Journal ID (publisher-id): plos

Journal ID (pmc): plosone

Title: PLoS ONE

Publisher: Public Library of Science (San Francisco, USA )

ISSN (Electronic): 1932-6203

Publication date Collection: 2014

Publication date (Electronic): 15 January 2014

Volume: 9

Issue: 1

Electronic Location Identifier: e80973

Affiliations

[1 ]Lankenau Medical Center, Wynnewood, Pennsylvania, United States of America

[2 ]Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, United States of America

Iran University of Medical Sciences, Iran (Islamic Republic of)

Author notes

* E-mail: ahartnelson@ 123456partners.org

Competing Interests: The authors have declared that no competing interests exist.

Conceived and designed the experiments: RNH SS. Analyzed the data: RNH. Wrote the paper: RNH.

Article

Publisher ID: PONE-D-13-21077

DOI: 10.1371/journal.pone.0080973

PMC ID: 3893081

PubMed ID: 24454685

SO-VID: 3a7ebc86-486d-42d2-a62c-b72ad0c8e0c4

License:

This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

History

Date received : 22 May 2013

Date accepted : 8 October 2013

Page count

Pages: 9

Funding

The authors have no support or funding to report.

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