Approximately 5.2 million American Indians and Alaska Natives (AI/ANs) reside in the United States (US), making up 1.7% of the total population1; however, the prevalence of cardiovascular disease (CVD) in this population is 2 times higher than the US population prevalence.2 More AI/ANs die of or experience disability each year from CVD than from any other cause.3 The excess burden of CVD in this population is attributable partially to the alarming increase in type 2 diabetes. Before World War II, diabetes was uncommon among AI/ANs; however, now, an estimated 12.4% of this population has diabetes, compared with 6% of non-AI/AN populations in the United States.4 In the Strong Heart Study, a landmark longitudinal study examining cardiovascular risk factors among 13 tribes in Arizona, Oklahoma, North Dakota, and South Dakota, diabetes was the strongest determinant of CVD among all risk factors examined, with 56% of cardiovascular events in men and 78% of events in women occurring in individuals with diabetes.2 The prevalence of metabolic syndrome, a cluster of risk factors for both CVD and diabetes that greatly increases the likelihood of development of either or both these diseases, is estimated to be around 35% in AI/ANs.5,6 There is documented higher prevalence of many modifiable risk factors associated with CVD in this population, including smoking, adverse patterns of dietary intake, sedentary lifestyles, obesity, substance abuse, and lack of access to healthcare, to name a few.4,7 Undeniably, the cardiometabolic risk experienced in this population is complex—an interaction of genetic and potentially modifiable behavioral and environmental factors.
Unfortunately, the rate of decline of CVD mortality among AI/ANs has been relatively slow since 1972, with almost no decline in the past 2 decades. This is starkly contrasted with the substantial declines in CVD mortality reported for the total US population since the early 1970s. In the early 1970s, CVD death rates for AI/ANs were 21% lower than those for the total US population; by the late 1990s, however, they were 20% higher.3 In addition to the disproportionate prevalence of CVD in this population, AI/ANs also succumb to CVD at younger ages than other racial and ethnic groups in the United States; more than one-third of CVD deaths occur before the age of 65 years.8
If clinicians and researchers are to successfully address the factors responsible for the cardiovascular disparities in this population, we must be aware and knowledgeable about a few important facts. First, Native Americans are often mistakenly viewed as a single ethnic minority population; however, they are a culturally and politically diverse population of AI/ANs representing 566 federally recognized tribes and numerous tribes and communities that are not federally recognized.9 American Indians and Alaska Natives are 1 of 5 racial/ethnic groups identified by the US Office of Management and Budget; the term AI/AN refers to individuals having origins in any of the original peoples of North and South America, including Central America, who maintain cultural identification through tribal affiliations or community recognition.10 Given this very broad definition, we must recognize that CVD prevention programs that are effective for one tribe, or regionally or culturally similar tribes, cannot simply be expected to be applicable to all Native individuals without first making them culturally relevant to that group. In addition, we must understand that tribes who are federally recognized tend to have greater healthcare resources, largely through the Indian Health Service (IHS), than those who are not. However, even those individuals who are eligible to obtain healthcare through IHS often report no usual source of healthcare or health insurance, in part because most AI/ANs live in urban areas away from medical facilities funded by IHS.7 For others, the nearest IHS facility may not offer comprehensive, preventive services. Access to healthcare is certainly a factor that must be addressed to reduce health disparities in this population.
Second, understanding the history of AI/ANs since first contact with Europeans may shed some light on contemporary cardiovascular health disparities experienced by Native communities. American Indians and Alaska Natives share a legacy of trauma and grief resulting, in part, from federally mandated relocation efforts, which began in the 17th century and continued through the mid-19th century and the forced assimilation efforts involving compulsory boarding schools for Native youth that continued through the early 20th century.11 The drastic shift away from traditional patterns of physical activity and diet that resulted from forced assimilation continues to contribute to the increasing rates of diabetes and CVD in this population.12
One of the 4 overarching goals of Healthy People 2020 is to achieve health equity, eliminate disparities, and improve the health of all groups.13 In 2011, building upon the Affordable Care Act, the US Department of Health and Human Services issued the first-ever Action Plan to Reduce Racial and Ethnic Health Disparities to collectively address the health disparities that continue to persist in the communities we serve, as well as in our data collection and research.14 In this plan, there are 5 overarching goals with subsequent strategies and actions that relate to the AI/AN population. One key recommendation relevant to cardiovascular nurses and our interdisciplinary teams is to develop, implement, and evaluate interventions to prevent CVD and associated risk factors in underserved populations. This will involve conducting and supporting research to inform disparities-reduction initiatives, which will require expanding research capacity for health disparities research, including faculty-initiated health disparities research programs.14 Although we recognize that AI/ANs experience excess cardiovascular morbidity and mortality compared with the general US population,3 they remain significantly underrepresented in health-related research. The Preventive Cardiovascular Nurses Association and American Heart Association (AHA) members are well positioned to be leaders in the development of culturally relevant health promotion interventions to address the cardiovascular health disparities experienced by AI/ANs. For example, in 2010, the AHA Southwest Affiliate launched a culturally tailored AI/AN awareness campaign called “Go Red for Women Storytellers” in which volunteer storytellers brought together American Indians in their communities to share how CVD had impacted them personally.15 There are far more opportunities like this for collaboration with AI/AN communities to promote cardiovascular health. Given the numerous cultural and political distinctions among regionally diverse tribes and the ultimate goal to establish sustainable cardiovascular health promotion programs in these communities, when possible, clinicians and researchers should build on preexisting relationships between regional universities, tribes and Native communities, and organizations like the Preventive Cardiovascular Nurses Association and AHA. Cardiovascular nurses will play a leading role in reaching out to these communities, partnering to design culturally relevant cardiovascular health promotion programs, and ultimately, reducing the cardiovascular disparities experienced in the AI/AN population.
1. US Census Bureau. The American Indian and Alaska Native population: 2010. US Census Bureau. US Department of Commerce. http://2010.census.gov/2010census/
. Published January 2012. Accessed May 19, 2012.
2. Howard BV, Lee ET, Cowan LD, et al.. Rising tide of cardiovascular disease in American Indians: the Strong Heart Study. Circulation. 1999; 99 (18): 2389–2395.
3. Indian Health Service. Trends in Indian health—2002–2003 edition. US Department of Health and Human Services. http://www.ihs.gov/NonMedicalPrograms/IHS_stats/index.cfm?module=hqPub&option=t00
. Published October 2009. Accessed May 19, 2012.
4. Steele CB, Cardinez CJ, Richardson LC, Tom-Orme L, Shaw KM. Surveillance for health behaviors of American Indians and Alaska Natives—findings from the behavioral risk factor surveillance system, 2000–2006. Cancer. 2008; 113 (Suppl 5): 1131–1141.
5. Resnick HE, Jones K, Ruotolo G, et al.. Insulin resistance, the metabolic syndrome, and risk of incident cardiovascular disease in nondiabetic American Indians: the Strong Heart Study. Diabetes Care. 2003; 26 (3): 861–867.
6. Schumacher C, Ferucci ED, Lanier AP, et al.. Metabolic syndrome: prevalence among American Indian and Alaska Native people living in the southwestern United States and in Alaska. Metab Syndr Relat Disord. 2008; 6 (4): 267–273.
7. Zuckerman S, Haley J, Roubideaux Y, Lillie-Blanton M. Health service access, use, and insurance coverage among American Indians/Alaska Natives and whites: what role does the Indian Health Service play? Am J Public Health. 2004; 94 (1): 53–59.
8. Oh S, Croft J, Greenlund K. Disparities
in premature deaths from heart disease—50 states and the District of Columbia—2001. MMWR Morb Mortal Wkly Rep. 2004; 53 (6): 121–125.
9. Indian Health Service. IHS fact sheets: IHS year 2012 profile. US Department of Health and Human Services. http://www.ihs.gov/PublicAffairs/IHSBrochure/Profile.asp
. Published January 2012. Accessed May 28, 2012.
10. Office of Management and Budget. The 1997 revisions to the standards for the classification of federal data on race and ethnicity. White House.gov. http://www.whitehouse.gov/omb/fedreg_1997standards
. Published October 30, 1997. Accessed May 19, 2012.
11. Caldwell JY, Davis JD, Du Bois B, et al.. Culturally competent research with American Indians and Alaska Natives: findings and recommendations of the first symposium of the work group on American Indian research and program evaluation methodology. Am Indian Alsk Native Ment Health Res. 2005; 12 (1): 1–21.
12. Jones DS. The persistence of American Indian health disparities
. Am J Public Health. 2006; 96 (12): 2122–2134.
13. US Department of Health and Human Services. Healthy People 2020. Healthy People.gov. http://www.healthypeople.gov/2020/topicsobjectives2020/default.aspx
. Published December 2, 2010. Accessed May 19, 2012.
14. US Department of Health and Human Services. HHS action plan to reduce racial and ethnic disparities
: a nation free of disparities
in health and health care. US Department of Health and Human Services. National Partnership for Action. http://minorityhealth.hhs.gov/npa/templates/content.aspx?lvl=1&lvlid=33&ID=285
. Published April 2011. Accessed May 19, 2012.
15. American Heart Association. Diversity report—defining moments. American Heart Association. http://www.heart.org/idc/groups/heart-public/@wcm/.../ucm_427469.pdf
. Published April 2011. Accessed May 19, 2012.