AHA: Increased Diabetes, CVD Risk for American Indians, Alaskan Natives

Diabetes prevalence is tripled among American Indian and Alaskan Native populations compared with white Americans, leading to disproportionately high rates of cardiovascular disease, according to a new statement from the American Heart Association (AHA). Highlighting reasons for this discrepancy, the authors draw attention to historical marginalization, barriers to healthcare access, and environmental exposures.

“COVID-19 has worsened disparities in racial and ethnic minority groups,” writing committee chair Khadijah Breathett, MD (University of Arizona, Tucson), told TCTMD in an email. “Major contributors include structural inequalities in the prevention and treatment of cardiovascular disease among racial and ethnic minorities. It is an opportune time to educate healthcare professionals and the general public on understudied populations with the highest rates of heart disease, American Indians and Alaska Natives. We hope that this statement will increase awareness and lead to action in fighting cardiovascular disease.”

Published online yesterday ahead of print in Circulation, the paper reviews the available data on the American Indian and Alaskan Native people, whose ethnicity is commonly misclassified yet who, based on self-identification, make up about 1.7% of the US population.

Compared with white individuals (8%), the age-adjusted prevalence of diabetes in American Indians is three times higher (24%). However, their rates vary across the country—reaching as high as 72% in women and 65% in men aged 45-74 in the Southwestern United States.

“Urgent work is needed to prevent diabetes in this population, increase awareness, and achieve control of diabetes,” Breathett said. “Community interventions such as those conducted by Strong Heart Study and Stop Atherosclerosis in Native Diabetics Study have been particularly effective.”

While their LDL-cholesterol levels are generally lower, American Indians tend to have greater rates of hypertension and obesity than white individuals. Interestingly, inflammation might play a greater role in the development of cardiovascular disease among both American Indians and Alaskan Natives, for whom C-reactive protein has shown to be elevated in some studies. Specific studies of cardiovascular risk factors in Alaskan Natives have been lacking, the authors write.

They also point to several behavioral risk factors that might be working against these populations. Namely, 31.8% of American Indians and Alaskan Natives smoke compared with 16.5% of both black and white Americans. Also, only 14.7% of American Indians and Alaskan Natives meet the current recommended physical activity levels.

Socioeconomic and environmental factors also play key roles. About one-quarter of American Indian and Alaskan Native populations live below the federal poverty line, with major implications for health, and underinsurance is rampant: 19.3% reported no health insurance coverage in 2017. Lastly, American Indians and Alaskan Natives are disproportionately affected by exposure to toxic metals like arsenic and cadmium in groundwater, which has shown to increase CVD risk.

Traditional risk factors are interwoven with social determinants of health such as discrimination, underinsurance, reduced wealth, and toxic-metal exposure from ground water. Khadijah Breathett

“Traditional risk factors are interwoven with social determinants of health such as discrimination, underinsurance, reduced wealth, and toxic-metal exposure from ground water,” Breathett explained. “Cardiovascular health equity will remain unattainable unless social determinants of health are concretely targeted by healthcare professionals, hospital administrators, policymakers, community stakeholders, and individuals. COVID-19 has highlighted how social determinants of health devastate racial and ethnic minority populations. We should use history and our current situation to implement strategies that support health equity.”

She added that a particular challenge in these populations is underreporting. “It is difficult to fix a problem that has not been fully assessed,” Breathett said.

The authors call for increased mitigation programs to reduce the risk of diabetes through physical activity and weight loss, risk factor control, smoking cessation, and toxic-metal remediation specifically in these populations. “Intervening at multiple levels of structural and intermediary social determinants of health will also reduce and ultimately eliminate inequities faced by American Indians and Alaska Natives,” they write. “The use of community-based interventions could increase implementation of CVD guidelines-based care and eventually eliminate existing social determinants of health.”

Establishing and promoting these programs, Breathett said means making them a dedicated focus for research and implementation science. “This involves rapidly implementing evidence-based solutions to the barriers in cardiovascular health equity, methodical evaluation of the process, titration of the solution until equity is achieved. Multiple guides exist to make this happen. We need patients, healthcare professionals, health administrators, policymakers, and community stakeholders to work together to eliminate social determinants of health. This requires investments of time, capital, and talent.”

In a viewpoint published yesterday on the AHA’s Center for Health Metrics and Evaluation website in tandem with the statement, Chiadi Ndumele, MD, PhD (Johns Hopkins University, Baltimore, MD), stresses the need for culturally appropriate, community-based interventions.

He suggests promoting interventions that 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.”