Health Disparities in Native American Cardiovascular Health: From Science to Action

Healthy People 2020 defines health disparity as “a particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage”1. Health disparities in the U.S. have predominantly been identified across race, ethnic, geographic location and socioeconomic groups. The estimated cost of health inequalities including medical care expenditures and those related to premature death in minority populations is 1.2 trillion U.S. dollars2, 3. Although overall mortality rates in the U.S. have declined 20% between 1990 and 2016 4, 5, findings from the Global Burden of Disease Study suggest that such improvement to population health may not necessarily translate into longer years of healthy life. In a similar time period, the study showed a 7% increase in the gap between life expectancy and number of years in good health4. Importantly, recent data suggest persisting or increasing health disparities, particularly across geographic locations and racial subgroups5. For example, in 2005-2016 the life expectancy at birth was 81.3 and 74.7 years in Hawaii and Mississippi, respectively5, and 78.9 vs 75.5 among White and African American adults6. Not surprisingly, similar patterns of inequality are observed in cardiovascular disease, the leading cause of death in the United States. The highest number of years of potential life lost from stroke before age 75 is observed among African Americans, followed by Hispanics and Native Americans6. On the other hand, the prevalence of premature death due to cardiovascular disease - 36% - is highest among Native Americans, followed by African Americans (32%), and Hispanics (24%)2, 7. Yet, despite being disproportionally affected by poor cardiovascular health, Native Americans remain largely understudied, and little is known about cardiovascular disease outcomes and related risk factors in this vulnerable population

The American Heart Association’s scientific statement “Cardiovascular Health in American Indians & Alaska Natives”8 addresses this important gap in knowledge by reviewing evidence on risk factors for cardiovascular disease among American Indian and Alaska Native groups. The Statement also provides an overview of major social determinants of health, and community-based programs to reduce disease burden in this population. According to the AHA statement, diabetes is the leading risk factor for coronary heart disease, affecting nearly 1 in every 4 American Indians8. These data underscore the importance of primary prevention programs aimed at diabetes risk reduction in this population, particularly those living in Southwestern U.S., where the prevalence of diabetes is nearly three times greater than estimates for the overall American Indian population 8. These findings also highlight the need for interventions and strategies to prevent cardiovascular complications, the leading cause of diabetes-related morbidity and mortality in middle-aged and older adults. The AHA Statement also reports a high prevalence of sedentary behavior, with nearly 85% of American Indian and Alaska Native adults currently below the physical activity guidelines for Americans. Findings on diabetes and physical inactivity are consistent with observations in other U.S. minority populations 8. In a review of evidence from population-based studies investigating racial and ethnic disparities, Graham reported that diabetes and suboptimal physical activity were the top contributors to poor cardiovascular health among African Americans and Hispanics2 . On the other hand, American Indians are nearly two times more likely to smoke than African or White Americans8. While the number of U.S. individuals currently smoking has steadily declined in the last decades, cigarette smoking among American Indians has remained persistently high overtime. Future strategies to improve health outcomes should include smoke cessation programs specially tailored to the needs and characteristics of this population.

This 2020 AHA Scientific Statement increases awareness of a vulnerable population, shedding important light on key risk factors, determinants and programs that are crucial to improve poor cardiovascular health among American Indians. Although much remains to be investigated, this statement provides a clear starting point for public health researchers, clinicians and policy makers working toward closing longstanding health disparity gaps, thus improving health among all Americans.