Heart Health in Tribal Nations

You see them every February: campaigns for American Heart Month reminding us that cardiovascular disease (CVD) is the leading cause of death in the U.S. Riding alongside Valentine’s Day ads, we’re told to check our blood pressure, start a fitness routine, and eat healthier. That one person dies from heart disease every 33 seconds. What isn’t called out as much: that heart health is worse among Native Americans – with CVD mortality rates 20% higher among Native Americans.

Death comes earlier too, unfortunately. 36% of CVD deaths occur before age 65 for Native patients, compared to 14.7% for White patients with CVD. The differences are especially concerning for Alaska Native people. Heart disease deaths are 30% higher for Alaska Natives age 25 to 44 – and 40% higher for patients age 45 to 54.

Why such stark differences? And what can we do?

Heart Health Risk Factors

Cardiovascular disease is an umbrella term that covers every type of disease affecting the heart or blood vessels – including coronary heart disease. Factors influencing heart health for Native Americans include:

  • Stress. Historical trauma, discrimination, racism, and other stressors can affect heart health. Native American poverty rates are at 26.2 percent, nearly double that of the rest of the United States.
  • Sex. Native men have higher rates of CVD than women, according to the Strong Heart Study, which explored cardiovascular disease in Native Americans.
  • Genetics. The Strong study also found that heritability pattern contributes to 20% to 50% of the phenotype of CVD risk factors such as obesity, dyslipidemia, hypertension, and diabetes mellitus.
  • Clinical discrimination. 23% of Native patients reported experiencing discrimination in clinical settings; 15% have avoided seeking care for themselves or family members due to anticipated discrimination.
  • Environmental poisoning. Nuclear testing, high levels of air pollution, and exposure to toxic metals in Tribal nations is linked to a dramatic increase in cancer, heart disease, and stroke.
  • Food Insecurity. 1 in 4 Native Americans is food insecure.  A new study suggests that food insecurity is linked to cardiovascular disease.
  • Diabetes. Diabetes mellitus is a strong risk factor, with rates approaching 24% in Native Americans – that’s compared to 8% in White patients. The Strong study found almost all women and more than half the men with diabetes had heart disease.
  • Hypertension. High blood pressure is strongly linked to CVD risk, with one study finding Native adults were 10% more likely than White adults to have high blood pressure.
  • Smoking. Native Americans cigarette use is nearly double that of White and Black smokers, according to the 2016 National Health Interview Survey from the Centers for Disease Control and Prevention (CDC).
  • Obesity. The obesity epidemic is rampant across all U.S. populations, but Native communities are leading the rest – with obesity rates than span 30% to 40%.

The good news is that healthcare teams and Native patients have the power to radically reduce cardiovascular disease rates. There’s a common saying that “Family history and genetics load the gun but lifestyle pulls the trigger.” Smart practices address both.

Telemedicine Access

When a patient walks into most hospitals across the United States, they can count on access to blood testing, electrocardiograms, echocardiograms, and coronary angiograms. But underfunded Indian Health Service facilities may not always offer cardiology services beyond echocardiography and treadmill testing. This means patients either skip testing or travel hours for an appointment. But while some services must be done in person, such as coronary bypass, telemedicine can connect patients to a cardiologist’s care right from their community.

Smoking Cessation Programs

An estimated 56% of Native smokers report the desire to quit smoking. The problem: once again, Native people can have a harder time accessing a commercial tobacco cessation service. Telemedicine may not be much help here, because so many programs fail to differentiate between ceremonial tobacco use and recreational smoking. The most effective option here: culturally adapted programs that involve Tribal leadership. Young leaders can be especially persuasive in stopping smoking in the younger generation.

Diabetes and Hypertension Management

Several programs tailored to Native communities have had great success in addressing risk factors. The Special Diabetes Program for Indians offers a Healthy Heart program and a Diabetes Prevention Program; the Native-CHART project (Native-Controlling Hypertension and Risk Through Technology) works to help Native patients lower their blood pressure and reduce their risk of stroke. The REACH program (Racial and Ethnic Approaches to Community Health), developed by the CDC, blends community empowerment, cultural intelligence, and clinical treatment.

Cultural Approaches

Sweat lodge ceremonies, talking circles, and community-driven programs are effective ways to help Native CVD patients learn more about their condition and make lifestyle changes, such as increasing physical activity. Shared decision making and talking circles can allow each person to provide uninterrupted perspectives, ensuring everyone feels heard and respected –  and that health decisions are framed in a cultural context. 

Woman-Centric Programs

The Division for Heart Disease and Stroke Prevention (DHDSP) is emphasizing heart health in women this year – precisely because so many women don’t realize CVD is the leading cause of death for women, don’t recognize symptoms, and struggle to get a diagnosis. The result is preventable conditions and delayed treatment for cardiac events, such as heart attacks. Healthcare providers can help educate their patients at wellness visits and connect them to educational resources on prevention, diagnosis, and lifestyle changes. 


Smarter Practices, Healthier Hearts

While social determinants of health can’t be solved overnight, building culturally relevant heart health plans for all ages is a great start to reducing CVD inequities on Tribal lands. Cardiovascular disease is a community problem, and it takes community-based interventions to change the roots of cardiac disease.

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