AHA: Diabetes plays major role in increased CVD risk in American Indians, Alaska Natives
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The rate of diabetes is nearly three times higher in American Indians and Alaska Natives compared with white Americans, which increases their risk for CVD, according to an American Heart Association scientific statement.
The most important CHD risk factor in American Indians is diabetes, which is three times more prevalent in this patient population compared with white Americans, according to the statement. Diabetes also affects cardiac function and structure, which increases the risk for arrhythmias and HF in American Indians, the authors wrote.
“It is an opportune time to educate health care professionals and the general public on understudied populations with the highest rates of heart disease: American Indians and Alaska Natives,” Khadijah Breathett, MD, MS, FAHA, assistant professor of medicine in the division of cardiology at the University of Arizona in Tucson, advanced heart failure and transplant cardiologist at Banner – University Medical Center in Tucson and chair of the writing committee, told Healio. “We hope that this statement will increase awareness and lead to action in fighting cardiovascular disease.”
CVD prevalence
CVD is the leading cause of death for American Indians and Alaska Natives, with rates high in these younger populations, according to the statement published in Circulation. In addition, the population of American Indians and Alaska Natives has increased by 39% from 2000 to 2010. Although there are currently 5.2 million people in the U.S. who self-identify as American Indian and Alaska Native, they are often misclassified by race.
Data from the Strong Heart Study helped in the development of a CHD risk calculator for American Indians in 2006. This featured significant predictors such as sex, age, LDL, diabetes, smoking, hypertension and albuminuria.
The risk factors for CHD in American Indians also increase the rates of stroke. Although diabetes and age remain important predictors, others include ratio of HDL/LDL, hypertension, smoking, history of left ventricular hypertrophy or CHD, waist circumference, parental history of stroke, renal function and alcohol consumption.
Inflammatory processes may play a major role in CVD in American Indians and Alaska Natives, according to the scientific statement. Some studies have shown elevations in inflammatory markers including C-reactive protein in American Indians and Alaska Natives. These elevations can show prognostic importance in American Indians and Alaska Natives with obesity regarding CVD development.
Few analyses focus on CVD risk factors in Alaska Natives, according to the scientific statement. Findings from the Genetics of Coronary Artery Disease in Alaska Natives (GOCADAN) study determined that strong correlates of CVD were hypertension, sex, albuminuria, diabetes, low HDL, high LDL and high apolipoprotein B.
Behavioral risk factors including cigarette smoking, alcohol use and physical inactivity also increase CVD risk in American Indians and Alaska Natives.
CVD risk assessment in Alaska Natives and American Indians can be improved with further understanding of genetics and demographics, especially since these patient populations develop CVD earlier than white Americans. Studies like the Strong Heart Study and GOCADAN are assessing the genetic role of CVD in these patients.
“In the era of precision medicine, it is particularly important to study the impact of genetics, epigenetics and behavioral factors on the risk of CVD in American Indians and Alaska Natives,” Breathett and colleagues wrote. “Future research needs to examine the heterogeneity in demographic risk factors and CVD across tribal nations to really highlight the disparities within the American Indian and Alaska Native populations.”
American Indians and Alaska Natives both face inequalities related to several health outcomes, which are influenced by exclusionary governmental policies, broken treaties and structural discrimination. There are also discrepancies in social determinants of health in both of these patient populations. These include educational attainment, poverty, wealth inequality and lack of health insurance.
Environmental chemical exposure including toxic metals disproportionally affect American Indians and Alaska Natives. Exposure to arsenic and cadmium can increase the risk for CHD, in addition to the incidence of LV hypertrophy, peripheral artery disease and diabetes. These populations can be exposed to toxic metals by groundwater contamination, for example.
“We hope that patients, health care professionals and policymakers recognize these risk factors and consider what steps can be taken to prevent risk factors and achieve risk factor control,” Breathett said in an interview.
Guidelines for treatment, prevention
CVD prevention and treatment guidelines should be followed by all populations regardless of race and ethnicity, according to the scientific statement. Implementation of these guidelines may be more successful in American Indians and Alaska Natives through community-based interventions. Several programs have been developed that focus on diabetes, BP control, CVD and stroke risk factors, and general disease management. Shared decision-making can also make an impact in these patient populations.
“The process of shared decision-making has been long-standing among American Indians and Alaska Natives, who participate in community talking circles in which each individual in the group has the right to provide uninterrupted perspectives,” Breathett and colleagues wrote. “Talking circles have been instrumental in providing diabetes mellitus education and empowering the American Indian and Alaska Native community to manage diabetes mellitus.”
Breathett also said reporting data on American Indians and Alaska Natives is important.
“Data are vastly underreported among American Indians and Alaska Natives,” Breathett told Healio. “It is important to obtain patient identification of race and ethnicity in order to better understand health of this population; however, care should be individualized. It is important for health care professionals to individualize patient’s needs and match them to the appropriate resources such as community-based interventions.” – by Darlene Dobkowski
For more information:
Khadijah Breathett, MD, MS, FAHA, can be reached at kbreathett@shc.arizona.edu; Twitter: @kbreathettmd.
Disclosures: Breathett reports she received research grants from the AHA, NIH and the University of Arizona to study disparities in HF. Please see the study for all other authors’ relevant financial disclosures.
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