Dorothy A. Rhoades

LDL Cholesterol as a Strong Predictor of Coronary Heart Disease in Diabetic Individuals With Insulin Resistance and Low LDL The Strong Heart Study

Diabetes has been shown to increase the risk of coronary heart disease in all populations studied. However, there is a lack of information on the relative importance of diabetes-associated risk factors for cardiovascular disease (CVD), especially the role of lipid levels, because low density lipoprotein (LDL) cholesterol often is not elevated in diabetic individuals. The objective of this analysis was to evaluate CVD risk factors in a large cohort of diabetic individuals and to compare the importance of dyslipidemia (ie, elevated triglycerides and low levels of high density lipoprotein [HDL] cholesterol) and LDL cholesterol in determining CVD risk in diabetic individuals. The Strong Heart Study assesses coronary heart disease and its risk factors in American Indians in Arizona, Oklahoma, and South/North Dakota. The baseline clinical examinations (July 1989 to January 1992) consisted of a personal interview, physical examination, and drawing of blood samples for 4549 study participants (2034 with diabetes), 45 to 74 years of age. Follow-up averaged 4.8 years. Fatal and nonfatal CVD events were confirmed by standardized record review. Participants with diabetes, compared with those with normal glucose tolerance, had lower LDL cholesterol levels but significantly elevated triglyceride levels, lower HDL cholesterol levels, and smaller LDL particle size. Significant independent predictors of CVD in those with diabetes included age, albuminuria, LDL cholesterol, HDL cholesterol (inverse), fibrinogen, and percent body fat (inverse). A 10-mg/dL increase in LDL cholesterol was associated with a 12% increase in CVD risk. Thus, even at concentrations well below the National Cholesterol Education Program target of 130 mg/dL, LDL cholesterol is a strong independent predictor of coronary heart disease in individuals with diabetes, even when components of diabetic dyslipidemia are present. These results support recent recommendations for aggressive control of LDL cholesterol in diabetic individuals, with a target level of <100 mg/dL.

Changes in Cardiovascular Disease Risk Factors among American Indians: The Strong Heart Study

PURPOSE This study describes changes in cardiovascular disease (CVD) risk factors in older American Indians over a 4-year period. METHODS The Strong Heart Study, a longitudinal population-based study of CVD and CVD risk factors among American Indians aged 45-74 years, measured CVD risk factors among 3638 members of 13 tribes in three geographic areas during examinations in 1989 to 1991 and 1993 to 1995. RESULTS Changes in mean low-density lipoprotein (LDL) cholesterol and the prevalence of elevated LDL cholesterol were inconsistent. Mean high- density lipoprotein (HDL) cholesterol decreased, and the prevalence of low HDL cholesterol increased throughout. Mean systolic blood pressure and hypertension rates increased in nearly all center-sex groups, and hypertension awareness and treatment improved. Smoking rates decreased but remained higher than national rates except among Arizona women. Mean weight and percentage body fat decreased in nearly all center-sex groups but the prevalence of obesity did not change significantly in any group. Diabetes and albuminuria prevalence rates increased throughout the study population. The prevalence of alcohol use decreased, but binge drinking remained common in those who continued to drink. CONCLUSIONS Improvements in management and prevention of hypertension, diabetes, renal disease, and obesity, and programs to further reduce smoking and alcohol abuse, are urgently needed.

Racial Misclassification and Disparities in Cardiovascular Disease Among American Indians and Alaska Natives

Background—National vital event data suggest that cardiovascular disease (CVD) mortality rates are lower for American Indians and Alaska Natives (AIAN) than for the general US population, but these data are disproportionately flawed for AIAN because of racial misclassification. Methods and Results—Vital event data adjusted for racial misclassification and published by the Indian Health Service were used to compare trends in CVD mortality from 1989 to 1991 to 1996 to 1998 between AIAN, US all-races, and US white populations. Without misclassification accounted for, AIAN initially had the lowest mortality rates from major CVD, but by the end of the study, their rates were the highest. Adjustment for misclassification revealed an early and rapidly growing disparity between CVD mortality rates among AIAN compared with rates in the US all-races and white populations. By 1996 to 1998, the age- and misclassification-adjusted number of CVD deaths per 100 000 among AIAN was 195.9 compared with age-adjusted rates of 166.1 and 159.1 for US all races and whites, respectively. The annual percent change in CVD mortality for AIAN was 0.5 compared with −1.8 in the other groups. Regardless of racial misclassification, the most striking and widening disparities were found for middle-aged AIAN, but CVD mortality among AIAN ≥65 years of age was lower than in the other populations. Conclusions—A previously underrecognized disparity in CVD mortality exists for AIAN, particularly among middle-aged adults. Moreover, these disparities are increasing. Efforts to reduce CVD mortality in AIAN must begin before the onset of middle age.

Discovering the full spectrum of cardiovascular disease: Minority Health Summit 2003: report of the Outcomes Writing Group.

The US population is exceptionally rich in cultural diversity, and that diversity is increasing rapidly. Nearly 33% of the US population self-identifies as a member of a racial or an ethnic minority.1 Trends in US Census data for the past 30 years point to the continual increase in the number of diverse groups. Roughly 1 million immigrants enter the United States each year; by 2000, there were 32 million immigrants. Some regions are extraordinarily diverse: For example, in Los Angeles County, Calif, 140 nationalities have been documented. In terms of future population trends, Latinos, Asians, and their subgroups will at least double, if not triple, in population size by the year 2050.2 Likewise, people of predominantly African descent and Native Americans will show marginal increases in population size. The number of individuals who claim membership in at least 2 ethnic groups will increase 10% by 2050, and racial/ethnic minorities will constitute 50% of the US population. The aging of the “baby boom” population segment of the United States, which is defined as people born between 1946 and 1964, will create increasing numbers of cases of cardiovascular diseases (CVD) and escalating demand for screening and treatment services. A broad (eg, World Health Organization) definition of health as physical, mental, and social well-being must guide advocacy efforts to define policy and programmatic strategies to eliminate racial/ethnic disparities in CVD because healthcare practices and policies do not sufficiently address racial/ethnic disparities in health status.3 In fact, most of the determinants of health status fall outside the healthcare sector. This point is graphically demonstrated in the framework for a comprehensive public health strategy presented in A Public Health Action Plan to Prevent Heart Disease and Stroke, released in April 2003. The purpose of this article is to set an advocacy and action agenda for research and service efforts with regard to disparities in CVD. In endeavoring to systematically explore and delineate these efforts, the authors use 3 categories of prevention: primary, secondary, and tertiary.4 It should be recognized, however, that these efforts extend well beyond the clinical encounter to embrace a variety of regulatory, policy, and practice changes in sectors outside health care and even health services. Primary prevention strategies are those that ameliorate the root causes of disease before its development, those that are mainly population based. Secondary prevention aims at detecting disease or disease precursors early, when intervention is most effective. Tertiary prevention involves aggressive treatment and rehabilitation strategies, which halt or slow disease progression, restore function, and limit disability. The categories are used only as a way of organizing a fairly complex body of material and are to some extent not mutually exclusive and overlapping. A number of overarching issues or needs may be identified that cut across these prevention categories and that must be addressed in concert with categorically specific approaches to eliminate disparities:

Aging and the Prevalence of Cardiovascular Disease Risk Factors in Older American Indians: The Strong Heart Study

OBJECTIVES: To describe longitudinal changes in the prevalence of major cardiovascular disease (CVD) risk factors in aging American Indians.

Characteristics Associated with Reservation Travel Among Urban Native American Outpatients

The objectives of this study were to ascertain the extent of, and health-related characteristics associated with, travel to reservations in a low-income, urban American Indian and Alaska Native (AI/AN) population. We surveyed more than 500 AI/AN adults at a primary care clinic. Measures included time spent visiting a reservation during the past year, and sociodemographic, cultural, and clinical characteristics. More than half (52%) of the patients had not traveled, 34% had traveled up to 30 days, and 14% had spent more than 30 days traveling to reservations. Multivariate ordinal regression revealed that a strong Native American cultural identification, presence of lung disease, absence of thyroid and mental problems, and greater dissatisfaction with care were independently associated with more travel to reservations (p ≤ 0.05). This research begins to augment the paucity of information on such travel and its relationship to health status and use of health services among urban AI/ANs.

National Health Data and Older American Indians and Alaska Natives

The population of older American Indians and Alaska Natives (AI/ANs) is growing rapidly, but few population-based reports of the health of older AI/ANs exist. The objective was to assess the representation of older AI/ANs in population based health data sets. Health- and aging-related population-based data sets were reviewed for inclusion of AI/AN adults. Data sets were identified using online searches of the Inter-University Consortium for Political and Social Research and the National Archive of Computerized Data on Aging, and federal health care and research agencies. Unweighted sample sizes of AI/ANs were collected for each study by age group. Of 190 data sets reviewed, only 25 (13%) contained at least 100 AI/ANs ages 65 years or older, and less than 5% contained 500 or more. Older AI/ANs are underrepresented in national data sets. Concerted efforts to improve data collection regarding the health and health care needs of this population are needed.

Traumatic brain injury and mental health among two American Indian populations.

ObjectivesDescribes prevalence of traumatic brain injury (TBI) and associated neuropsychiatric problems among two American Indian (AI) communities. DesignAnalysis of cross-sectional epidemiological data. SettingA Southwest (SW) and 2 Northern Plains (NP) AI reservations. ParticipantsAI tribal members (N = 2687; 394 with history of TBI and 2293 noninjured comparisons) aged 15 to 54. Outcome measuresMood or anxiety disorders present more than 1 year after injury. ResultsPrevalences were high (>20% in males; >10% in females) in these populations. Associations between TBI and disorders meeting Diagnostic and Statistical Manual of Mental Disorder, Fourth Edition criteria were strong in the SW community (adjusted odds ratio [OR] = 2.4; 95% confidence interval [CI] = 1.5–3.8), less so in the NP community (adjusted OR = 1.4; 95% CI = 0.9–2.2). ConclusionsTBI is prevalent among AIs and is associated with increased OR of neuropsychiatric difficulties. This association may vary between tribes, though no interaction effect was found. AIs with TBI may require more thorough psychiatric screening to promote healthier outcomes.

The Public Health Foundation of Health Services for American Indians & Alaska Natives

The integration of public health practices with federal health care for American Indians and Alaska Natives (AI/ANs) largely derives from three major factors: the sovereign nature of AI/AN tribes, the sociocultural characteristics exhibited by the tribes, and that AI/ANs are distinct populations residing in defined geographic areas. The earliest services consisted of smallpox vaccination to a few AI/AN groups, a purely public health endeavor. Later, emphasis on public health was codified in the Snyder Act of 1921, which provided for, among other things, conservation of the health of AI/AN persons. Attention to the community was greatly expanded with the 1955 transfer of the Indian Health Service from the US Department of the Interior to the Public Health Service and has continued with the assumption of program operations by many tribes themselves. We trace developments in integration of community and public health practices in the provision of federal health care services for AI/AN persons and discuss recent trends.

Hypertension in older urban Native-American primary care patients.

OBJECTIVES: To examine hypertension and its management in a population of older urban American Indians and Alaska Natives (AI/ANs).