Cover Story | Caught Between Two Worlds: Cardiovascular Care in American Indians and Alaska Natives
Cardiovascular disease is the leading cause of death among American Indians and Alaska Natives. This should not be surprising, given it is also the leading cause of death in the U.S. But the cardiovascular disease that takes the lives of people who are American Indian or Alaska Native is somewhat nuanced and requires a tailored focus.
This month, as we observe Indigenous Peoples' Day and look to observe National Native American Heritage Month in November, Cardiology spoke with clinician experts on American Indian and Alaska Native cardiovascular health and health care in an effort to better understand the challenges facing these unique patient populations.
Distinct Populations, Distinct Challenges
In a future article,
we'll look at the
care of Hawaiian Natives and
American Indians and Alaska Natives represent about 1.7% of the U.S. population, or about 5.2 million people, and they are more likely to die from treatable conditions than White Americans. While some progress has been made in raising awareness and reducing risk factors, mortality rates from cardiovascular disease are 20% higher among American Indians and Alaska Natives compared with the general population, and death comes earlier.
Fully 36% of American Indians with cardiovascular disease die before age 65, vs. 14.7% of non‐Hispanic Whites and 31.5% of Blacks.1 Mortality from heart disease was 30% and 40% higher in Alaska Natives, compared with Whites, who are ages 25 to 44 and 45 to 54, respectively. Notably, the rate was 20% lower in Alaska Natives 75 years and older.2
Diabetes rates are also high – and the main driver of heart disease that occurs in about 12% of American Indians and Alaska Natives, although this is thought to be underreported by 21%. In American Indians, the rate of diabetes varies by region and sex, reaching as high as 72% of women and 65% of men ages 45 and 74 years living in the Southwestern U.S.
The Strong Heart Study, a longitudinal study of cardiovascular disease in American Indians, found a close connection between coronary heart disease and diabetes, with nearly all women and more than half of men with diabetes having heart disease.
Stroke is the sixth leading cause of death for American Indians and Alaska Natives. Although rates are declining, they remain highest in adults younger than 45 years.
Until recently, it was tempting to lump the health disparities of American Indians and Alaskan Natives together with other racial or ethnic populations, including Hispanic/Latinx and Blacks; however, conflating their issues is an oversimplification that has made it more difficult to address disparities specific to the American Indian and Alaska Native communities.
"This is an underserved population that shoulders a disproportionate burden of cardiovascular disease, like other minority groups, but with barriers and facilitators to care that are very different from other underserved populations, making it important we understand how to tailor care to their cultural and personalized needs," says Elizabeth A. Jackson, MD, MPH, FACC, a cardiologist and health system researcher at the University of Alabama, Birmingham. She helped to write a Scientific Statement from the American Heart Association (AHA) on the cardiovascular health of American Indians and Alaska Natives that published in June.2
Cardiologist Eric Brody, MD, FACC, currently a staff cardiologist at Southern Arizona Veteran's Administration Healthcare System, echoes Jackson's sentiments, noting that some of the cardiovascular issues facing Native Americans are similar with those everyone else in the U.S. faces. But some are unique to their situation and require unique solutions.
Among the major issues: access to health care, poverty, substance abuse and other socioeconomic issues often common among those living in geographically rural areas. In terms of access to care, transportation to health care can be a challenge and roughly 20% of American Indians have no health insurance, with the remainder split between public and private health insurance.
Poverty rates are also high, with 26% living below the poverty level in 2017 alone, compared with 11% for White Americans. For some tribes and nations, this rate reaches to 40% or higher.
Substance abuse, which has hit many rural areas hard, coupled with the constant strains of cultural dislocation and trauma, as well as discrimination and microaggressions, is another unique issue to American Indian and Alaskan Native communities and can't be overlooked, according to Dena Wilson, MD, FACC, cardiology clinical consultant for the Indian Health Service (IHS).
"When communities deal with poverty, alcohol/drug abuse, racism, violence and trauma on a daily basis, there is no time to recover. People function in a constant mode of stress, which as we know is detrimental to heart health, and health in general," she says. "There are many individuals who live on the reservation surrounded by the community and culture, yet because of substance abuse they have lost that connection."
Risk Factor Profile For Cardiovascular Disease
All the usual culprits are fingered as factors that contributed to an increased prevalence of diabetes from a traditionally lower rate – poor diet, lack of physical activity, genetic susceptibility, and so forth.
However, added to this list are environmental contaminants. Multiple studies have shown higher levels of air pollution and metals exposure in American Indians compared with other groups, including other rural groups.7 The Strong Heart Study found in American Indians with diabetes, exposure to toxic metals increased rates of heart disease and stroke over 20 years.2
But some of the issue revolves around the unique culture of the tribe, or more to the point, the disruption of the connection with land and tribe.
Hypertension: Common in American Indians, frequently along with diabetes, and strong independent predictor of cardiovascular disease risk.
Renal function: High prevalence of renal disease in American Indians, resulting from high diabetes rate, and a unique risk factor for predicting coronary heart disease. Microalbuminuria or macroalbuminuria was present in 20% to 48% of the Strong Heart Study participants, with the rates being significantly higher for older age, diabetes or hypertension.
Obesity: High prevalence in American Indians, ranging from 30% to 40%, with higher rates in different states.
Smoking: At nearly 32%, the estimated prevalence of smoking in American Indians and Alaska Natives is nearly double the rates in Whites and Blacks.
Physical Inactivity: Only 15% of American Indian and Alaska Native adults meet current recommendations for physical activity.
"Heart disease has been the major cause of death in the general U.S. population forever, but historically it wasn't the #1 cause of death in Native American people," says Brody, who has provided health care to Native Americans in rural and urban settings for 24 years, including 15 years with the IHS as a commissioned officer and as a civil servant. "This is one of the reasons it is important to understand [these factors] better."
Discrimination should not be disregarded either. In a 2019 report, almost one in four American Indians (23%) reported experiencing discrimination in clinical encounters, while 15% avoided seeking health care for themselves or family members due to anticipated discrimination.8
All Health Care is "Local"
To make things more complicated, just as lumping American Indians and Alaska Natives into the broader category of "underserved minorities" is imprecise, it is equally inaccurate to lump all American Indians and Alaska Natives together.
American Indians and Alaskan Natives live in all regions of the U.S., often under very different circumstances.
The largest proportion reside in the West (40.7%), followed by the South (32.8%), Midwest (16.8%) and the Northeast (9.7%). Approximately 22% live on state- or federally-recognized tribal lands. They also have distinct differences in culture, lifestyle, socioeconomic status and health care access, and genetic backgrounds.
"It's very simplistic to assume the needs of Native Americans living on the reservation in North Dakota are the same as those living in urban areas in other parts of the country. There are important differences, not just in geography and culture. We also see differences in pathogenicity," says Jackson.
Diabetes provides a good case study of geographical disparities. Diabetes is the most important risk factor for coronary heart disease in American Indians and Alaska Natives, with a 2- or 3-fold higher age-adjusted prevalence compared with non-Hispanic Whites.2,3 But these rates vary dramatically by region. In some regions (for example, Alaska and the Western states), rates don't differ much from those seen in the general population.
The Pima Indians of Arizona, on the other hand, have the highest documented rates of diabetes in the world. In 2006, the prevalence of type 2 diabetes in adults >20 years was 38%.4 In those over 55 years, the rates were 67.4% in men and 82.2% in women.
This same study illustrates the important impact of environmental circumstances that may be amenable to intervention: the prevalence of diabetes among the Pima Indians of Mexico in 2006 was only 6.9%, similar with that of non-Pima Mexicans (2.6%).4
To provide some context, only 21 cases of diabetes were identified among the Pima Indians living in the Sonoran Desert in a 1940 study.5
The overall prevalence of diabetes in U.S. adults in 2012 was 11.7%. From 1990 to 1998, the total number of young American Indians and Alaska Natives (<34 years) with diagnosed diabetes increased by 71%.6
"The causes of this increase in diabetes in native populations are probably multifactorial. But there is clearly a need to do more research around genetics and epigenetics to better understand the impact of changed lifestyles on these groups. Unfortunately, there have been very few interventional studies conducted in this population," says Jackson.
Reducing Diabetes Prevalence
Diabetes prevention is a substantial achievement by the IHS, with a slowing in the prevalence of diabetes. Wilson says the quality of the preventive care in IHS is "really excellent" and she is focusing on how to expand that quality and reach to rural areas. One focus of her efforts is telemedicine as a means of expanding care.
The Special Diabetes Program for Indians (SDPI), established by Congress in 1997, has contributed to this success. With $150 million per year in grants, the SDPI provides funding to 301 programs for American Indians and Alaskan Natives in 35 states. Data from a 2014 Report to Congress is illustrative of the many programs facilitated by the grant funds.12
Much of the success can be attributed to culturally-centered interventions for health promotion that are driven by the community.
Most importantly, diabetes prevalence appears to be falling.13 After increasing significantly from 2006 to 2013 (annual percent change, 1.1%; p<0.01) in the active IHS population, the prevalence of adults with diabetes overall has decreased from 2013 to 2017 (annual percent change, −1.3%; p<0.01). This represented the first known decrease in diabetes prevalence in this population.
Other positive findings attributed at least in part to the SDPI include a decreased incidence in end-stage renal disease, better renal function and blood pressure control, more referrals for tobacco cessation counseling, less diabetic maculopathy, and a greater use of ACE inhibitors and ARBs in the population.
The program has also been shown to positively impact health in other ways – from 2014 to 2018, there was a significant increase in the proportion of American Indians and Alaska Natives who received annual dental exams and received the hepatitis B vaccine series.
Given the success the SDPI has had in addressing diabetes, there is an effort afoot to use SDPI-funded programs to mitigate the high risk of severe complications from COVID-19 in American Indians and Alaska Natives.
An offshoot, the Special Diabetes Program for Indians Healthy Heart (SDPI-HH) Demonstration Project is an intensive case management intervention to reduce cardiovascular risk among American Indians and Alaska Natives with diabetes. Participants reported improvements in key behavioral cardiovascular disease risk factors, which have been backed up by measured improvements in blood pressure and lipid levels.
The professional cardiology societies currently recommend that established guidelines for cardiovascular disease prevention should be followed in all populations, including American Indians and Alaska Natives, irrespective of race and ethnicity.
Culture As a Cure
Culture could be the missing prescription when it comes to improving cardiovascular health among American Indians and Alaska Natives. In addition to relying on modern medicine, clinicians in the IHS have been focused on also finding ways for communities and patients to reconnect with culture.
A 2016 review showed that resilience – a marker associated with cardiovascular health among minorities – is accessed through cultural knowledge and practice.2 Greater tribal cultural spirituality was linked to better mental health among American Indians, while prevention interventions that meshed with cultural activities had greater efficacy than those that were not culturally specific.2
Some experts have called for a "strengths-based approach" to improving health among American Indians and Alaska Natives.10 This requires strengthening tribal identity and traditions in ways that offer holistic approaches to improving both physical and mental health in their community.
One small example of this is the Talking Circle. Community Talking Circles allow each member a chance to express their perspectives and thoughts uninterrupted. They've been used in both reservation and urban settings to provide diabetes education and empower individuals to manage their diabetes better.11
"When you see the interesting approaches that are being taken in the communities where investigators are working to adapt interventions to really fit the needs of the community but also the ways in which the communities work together, it makes you realize how all health care really is local," says Jackson.
It's a common misconception to assume that Native peoples living traditional lives on their Native land are healthy eaters and lead healthier lives. Indeed, it was generally assumed until somewhat recently that Alaska Natives were protected against cardiovascular disease by lifestyle factors.
However, a comprehensive review in 2003 found little evidence to support this idea.7 Instead it appears cardiovascular disease incidence has been increasing among Alaska Natives at least since the 1980s.
The majority of Alaska Natives live in small villages or remote regional hubs such as Nome, Dillingham and Bethel. They eat healthy foods like salmon. But they also hunt seal and eat a distinct version of ice cream called akutaq, which is made from reindeer fat or tallow, seal oil, freshly fallen snow or water, fresh berries, and sometimes ground fish.
Iqmik, a smokeless tobacco product widely used by Alaska Natives, is reported to have a higher nicotine content than traditional cigarettes.
Alaska Natives living in rural communities still consume a large number and variety of subsistence foods (salmon and other fish, moose, caribou, and a wide variety of plant foods). Yet they also report consuming purchased staples and sugared beverages, and many no longer live strict subsistence lives, where hunting and gathering are daily activities.9
For clinicians treating American Indians and Alaska Natives outside IHS facilities, Wilson suggests connecting to the Tribal community.
"Understand the beauty of the culture and people. Yes, there are many negatives that affect rural and isolated communities but there are also so many strengths such as the support of the community. Incorporating the culture and community into health care will help improve outcomes."
The Indian Health Service
The IHS is an agency within the Department of Health and Human Services (HHS) tasked with providing federal health care to American Indians and Alaska Natives.
The agency grew out of a recognition that members of federally-recognized tribes required specialized, culturally-responsive care.
IHS is one of two HHS agencies that provide direct health care (the other being the National Institutes of Health). Some, but not all, of IHS employees are U.S. Public Health Services (USHPS) uniformed officers.
All federally recognized American Indian and Alaska Natives are entitled to health care, provided either through IHS-run hospitals and clinics or tribal contracts to provide health care service. As of January 2020, they serve 2.56 million of the nation's estimated 5.2 million American Indians and Alaska Natives.
Members of 573 federally recognized American Indian and Alaska Native Tribes and their descendants are eligible for services provided by the IHS, with services administered through a system of 12 area offices and 170 IHS and tribally managed service units.
There are long-standing issues with funding. The IHS budget for 2020 was $6.0 billion, up from $5.8 billion in 2019. In 2019, IHS expenditure per user population was $4,078, or about half of the per user expenditure for Medicaid ($8,109), and well below that spent by the Veterans Health Administration and Medicare at $10,692, and $13,185, respectively.12
But even when an American Indian or Alaskan Native falls into the "covered" category, it's a complicated and fragmented system. For the remaining American Indian or Alaskan Native population not covered by IHS – just over half of the total population – underinsurance is an issue.
"If you are a member of a federally-recognized tribe and you live on the reservation or if you are in an urban setting and go to an IHS facility, you're covered. But if you aren't covered under the IHS, or if you live off the reservation and go to a non-IHS facility, you're just like everyone else who doesn't have insurance," explains Brody.
Even within the system, there is no guarantee that tertiary care will be provided. "You'll get emergency care and care for your colds and sore throats, but they may not provide you with a coronary bypass unless you can pay for it," he adds.
"Cardiology services within the Indian Health Service are limited," says Wilson. Other than herself, she thinks IHS employs only two other cardiologists in the country. Advanced diagnostics are not available usually, just echocardiography and treadmill testing, so most facilities refer patients to private cardiologists.
"Through my involvement with ACC and what I saw in practice, I've become more involved in the administrative side of medicine to focus on system-wide improvements that will increase and improve the quality of care we can provide. There are several avenues in which we can partner with outside organizations to provide quality specialty care to our patients."
Community, Culture and Cardiology
Leaving the reservation is not the easy solution. In 2010, fully 78% of American Indians and Alaska Natives lived outside reservations and communities, with 71% living in urban areas.
"I wish I could verbalize the feeling of what it is like to be away from your culture. There's a wound that, even to this day, I struggle with. I was granted a great skillset in becoming a cardiologist, but there is a disconnect with my community and culture that I still feel every day," says Wilson, chief medical officer for the Phoenix Area Indian Health Service, and possibly the only female Native cardiologist in the country.
Wilson's personal story is inspiring.
She grew up on the Pine Ridge Indian Reservation in South Dakota and is a member of the Oglala Sioux Tribe.
Raised by a single mother who was a social worker, her early experiences accompanying her mother on hospital trips inspired her to be a physician.
"Growing up on a reservation and not having any mentors or really any clue for how to go about getting into medicine, it was quite a struggle. The opportunities afforded to me were not the same as those afforded others. But my mom and I figured it all out – how to take the MCAT and apply, and eventually all the doors opened for me."
But her work is in Arizona and her family and tribe in South Dakota (and unlike for many other minority or religious groups, it doesn't work to just join a local tribe).
"It's still a challenge for me to be away from my tribe and culture and I don't have the magic formula for how to make it work for other Native people. It's different for everyone. I think my drive for knowledge so I could help my Native people was the most influential factor in my success."
Understanding the needs of our diverse patient population is instrumental in meeting them where they are and helping them achieve their best outcomes.
Think Cultural Health is a free cultural competency training program, offering nine hours of CME/CE credit, from the Office of Minority Health within the Department of Health and Human Services.
The ACC is committed to exploring the social determinants of health across the diversity of patient populations to meet its Mission of transforming cardiovascular care and improving heart health.
Interested in sharing your story as an indigenous patient? As a health care professional providing care to these patients? Contact email@example.com.
ACC's Diversity and Inclusion Resource Center provides a range of tools to help health care professionals enhance and build their awareness and skills for working with a diverse patient population.
This article was authored by Debra L. Beck, MSc.
- Disparities in Premature Deaths from Heart Disease - 50 States and the District of Columbia, 2001. Available here. Accessed Sept. 22, 2020.
- Breathett K, Sims M, Gross M, et al. Cardiovascular health in American Indians and Alaska Natives: A Scientific Statement from the American Heart Association. Circulation 2020;141(25).
- Cholerton B, Omidpanah A, Verney SP, et al. Type 2 diabetes and later cognitive function in older American Indians: The Strong Heart Study. Int J Geriatr Psychiatry 2019;34:1050-7.
- Schulz LO, Bennett PH, Ravussin E, et al. Effects of traditional and western environments on prevalence of type 2 diabetes in Pima Indians in Mexico and the U.S. Diabetes Care 2006;29:1866-71.
- Satterfield D. Health promotion and diabetes prevention in American Indian and Alaska Native Communities - Traditional Foods Project, 2008–2014. MMWR Suppl 2016;65.
- Acton KJ, Ríos Burrows N, Moore K, et al. Trends in diabetes prevalence among American Indian and Alaska Native children, adolescents, and young adults. Am J Public Health 2002;92:1485-90.
- Deen JF, Adams AK, Fretts A, et al. Cardiovascular disease in American Indian and Alaska Native youth: unique risk factors and areas of scholarly need. J Am Heart Assoc 6:e007576.
- Findling MG, Casey LS, Fryberg SA, et al. Discrimination in the United States: Experiences of Native Americans. Health Serv Res 2019;54(S2):1431-41.
- Ballew C, Tzilkowski AR, Hamrick K, Nobmann ED. The contribution of subsistence foods to the total diet of Alaska Natives in 13 rural communities. Ecol Food Nutr 2006;45:1-26.
- Bylander J. For healthier native youth, look to their strengths. Health Affairs 2020;39:[Epub June 1, 2020] Available here. Accessed Sept. 15, 2020.
- Mendenhall TJ, Seal KL, Greencrow BA, Let al. The Family Education Diabetes Series: improving health in an urban-dwelling American Indian community. Qual Health Res 2012;22:1524-34.
- IHS Profile Fact Sheet. Available here. Accessed Sept.15, 2020.
- Bullock A, Sheff K, Hora I, et al. BMJ Open Diab Res Care 2020;8:e001218.
Clinical Topics: Cardiovascular Care Team, Prevention, Smoking
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