CVD Prevention in American CVD Prevention in American Indian & Alaska Native Indian & Alaska Native

Communities:Communities:Opportunities and Challenges Opportunities and Challenges

for the 21for the 21stst CenturyCentury

Thomas K. Welty, MD, MPHThomas K. Welty, MD, MPHRetired USPHSRetired USPHS

Investigator,Investigator,Strong Heart StudyStrong Heart Study

Acknowledgments:

Drs. James Galloway, Lyle Best, Barbara Howard & Dorothy Rhoades

For sharing their slides

http://strongheart.ouhsc.edu/

National Health Lung and Blood Institute>

13 Strong Heart Study tribesSHS investigators & coordinators

SHS: WHAT WAS THE GOAL?SHS: WHAT WAS THE GOAL?

Is CVD an important public health Is CVD an important public health problem in Indian communities?problem in Indian communities?How does it compare with nonHow does it compare with non--Indian communities?Indian communities?Do the prevalences of risk factors Do the prevalences of risk factors differ? differ? Do the risk factors work the Do the risk factors work the same? same? Can this kind of research be done Can this kind of research be done in Indian country? in Indian country?

Strong Heart Study Population

Ak-ChinPhoenix

Salt River Indian Community

ARIZONA

Gila RiverIndianCommunity

Oklahoma City

AnandarkoLawton

OKLAHOMA

NORTH DAKOTA

SOUTH DAKOTA

Rapid CityPine Ridge

Oglala

Cheyenne RiverEagle Butte

Bismarck

Spirit Lake

Ak-Chin

4549 American Indians ages 45-74 years

Arizona: Pima/Maricopa/Papagoin the Gila River, Salt River, and Ak-Chin Indian communities

Oklahoma: Apache, Caddo, Comanche, Delaware, Fort Sill Apache, Kiowa, and Wichita

South/North Dakota: Oglala Sioux and Cheyenne River Sioux (SD) and the Spirit Lake Tribe in the Fort Totten area (ND)

Strong Heart Study1988-2003

• Community Mortality Study35–74-year-old men and womenDeaths between 1984 and 1994Medical record review of all possible CVD deaths

· Physical Examinations of Cohort1989-91, 1993-5 and 1998-9ECG, Cardiac and Carotid ECHOBP and other measurementsBlood, urine and DNA samplesMedical, diet and medication history

Strong Heart Study1988-2003

• Cohort SurveillanceYearly contactMedical record review for all cause and CVD Mortality and nonfatal CVD

• Family Study120 families of 30 members eachExamination similar to that of cohortGenetic mapping for CVD risk factors

Community InvolvementCommunity InvolvementThe Key to the Success of SHSThe Key to the Success of SHS

Study design and implementationStudy design and implementationAmerican Indian investigators and staffAmerican Indian investigators and staffParticipants referred for medical careParticipants referred for medical careData used for community health Data used for community health initiativesinitiativesEducation of community youthEducation of community youthParticipation in community health Participation in community health initiativesinitiatives

STRONG HEART STUDYSTRONG HEART STUDY

Heart disease Heart disease isis a major a major public health problem!!public health problem!!Some risk factors higher, Some risk factors higher, some lowersome lower--varies by regionvaries by regionStrength of risk factors differsStrength of risk factors differs“Cutting edge” medical “Cutting edge” medical research research cancan be done in be done in Indian country Indian country GOALS MET!!!

Lyle Best, MDLinda Cowan, PhDRichard Devereux, MDRichard Fabsitz, PhDJames M. Galloway, MDJeffrey Henderson, MDBarbara Howard, MDWm. James Howard, MDDavid Kaufman, PhDElisa Lee, PhDSandra Laston, PhD

The Strong Heart StudyInvestigators

Kari North, PhDJean MacCluer, PhDHelaine Resnick, PhDEverett Rhoades, MDMarie Russell, MDMaurice Sievers, MDJason Umans, MD, PhDThomas Welty, MDFawn Yeh, PhDJeunliang L. Yeh, PhDEllie Zephier, RD

Marcia O’Leary, BSNLillian BrownCherie KesslerDaniel KouglWendy Lawrence, BSNLavonne Looking ElkFrancine Red Willow, BSNTauqeer Ali, PhD

The Strong Heart StudyField Staff

Karen KimberlyLinda PoolawStephanie GomezBetty Jarvis, BSNBert LewisRosinna BrionesMary RybkaNanette Oram

CVD PreventionCVD Prevention

CVD Morbidity and MortalityCVD Morbidity and MortalityCVD Risk FactorsCVD Risk FactorsPrimordial PreventionPrimordial PreventionPrimary PreventionPrimary PreventionSecondary PreventionSecondary PreventionConclusionsConclusions

CVDCVDMORBIDITYMORBIDITY

ANDANDMORTALITYMORTALITY

SHS CVD MORBIDITYSHS CVD MORBIDITY

Cardiac and carotid artery echo studiesCardiac and carotid artery echo studiesEKGEKGReview of health care for heart disease Review of health care for heart disease and strokeand strokeMorbidity Committee:Morbidity Committee:Drs. R. Devereux, L. Best, M. Russell, Drs. R. Devereux, L. Best, M. Russell, R. R. RodehefferRodeheffer, J. , J. KizerKizer, J. Bella,, J. Bella,Stroke: Drs. D. Stroke: Drs. D. WiebersWiebers, J. , J. WhisnantWhisnant

Roman MJ, et al. Circulation 1998;98Roman MJ, et al. Circulation 1998;98

Carotid Atherosclerosis Carotid Atherosclerosis in American Indiansin American Indians

0

20

40

60

80

100

45-49 50-54 55-59 60-64 65-69 70-74 75-79Years

plaq

ue p

reva

lenc

e

ARIC SHS CHS

ARIC = Atherosclerosis at Risk StudySHS = Strong Heart StudyCHS = Cardiovascular Health Study

INCIDENCE OF CHDINCIDENCE OF CHDStrong Heart Study Strong Heart Study vsvs ARICARIC

0

4

8

12

16

20

Women Men

ARIC, Aged 45 to 64 SHS, Aged 45 - 64

CHD includes fatal and nonfatal events plus revascularizationFatal and Nonfatal Rates per 1000 person years. The Rising Tide of CVD in AI: The SHS, Circulation, 1999

Age and Misclassification-adjusted CVD Mortality Rates By Population

150

160

170

180

190

200

'92-'94 '94-'96

Year

Adj. AIANUS All RacesUS WhiteAIAN

D. Rhoades. Circulation 2005;111:1250-1256

Rat

e pe

r 100

,000

Native American Cardiac MortalityNative American Cardiac MortalityBy IHS Area, 1994 By IHS Area, 1994 -- 19961996

per 100,000; age-adjusted; Regional Differences in Indian Health - 1998-99; US All Races 138.3

156229.7

151.685.1

287206.4

129.3190.4

105.7163.6

145.9140.9137.5

Total All AreasAberdeen

AlaskaAlbuquerque

BemidjiBillings

CaliforniaNashville

NavajoOklahoma

PhoenixPortlandTucson

0 50 100 150 200 250 300

SHS MORTALITYSHS MORTALITY4549 participants (age 454549 participants (age 45--74 in 198974 in 1989--91) 91) 1691 (37%) deaths reviewed by May 20051691 (37%) deaths reviewed by May 2005530 (31%) died of CVD 530 (31%) died of CVD Each death reviewed by Dr. Each death reviewed by Dr. MauriMauri SieversSieversSecond review: Drs. E. Rhoades, D. Rhoades, Second review: Drs. E. Rhoades, D. Rhoades, J. Henderson, J. Galloway, T. WeltyJ. Henderson, J. Galloway, T. WeltyAdjudicate when the cause differs:Adjudicate when the cause differs:Dr. J. HowardDr. J. HowardStroke: Drs. D. Stroke: Drs. D. WiebersWiebers, J. , J. Whisnant Whisnant

Stroke in Native AmericansStroke in Native Americans

Limitations:Limitations:

Limited DataLimited DataWide Variations among TribesWide Variations among TribesRacial MisclassificationRacial MisclassificationStrong Heart Study analyses in progressStrong Heart Study analyses in progress

Stroke Mortality for American Indians Stroke Mortality for American Indians and Alaska Natives, 1992and Alaska Natives, 1992--9696

Total Alaska East Northern Plains

Pacific Coast

Southwest05

101520253035404550

Rates per 100,000, NCHS; age-adjusted and adjusted for racial misclassificationUS All-Races rate (1994) Rate significantly different from US rate*

**

*

CVD CVD RISKRISK

FACTORSFACTORS

Zephier, et al. Arch Peds & Adolescent Zephier, et al. Arch Peds & Adolescent Med In press 2005Med In press 2005

AMERICAN INDIAN CHILDHOOD AMERICAN INDIAN CHILDHOOD OBESITY AND OVERWEIGHT OBESITY AND OVERWEIGHT

Are high and increasingAre high and increasingAt age 5, 47% of boys and 40% of girls are At age 5, 47% of boys and 40% of girls are overweight; 24% of boys and girls are overweight; 24% of boys and girls are obese in the Northern Plainsobese in the Northern PlainsIncreasing over 7 % per decadeIncreasing over 7 % per decade

CVD RISK FACTORSCVD RISK FACTORSUS ALL RACES & AMERICAN INDIAN WOMEN AGES 45US ALL RACES & AMERICAN INDIAN WOMEN AGES 45--7474

NHANES III 1988NHANES III 1988--91; STRONG HEART STUDY 198991; STRONG HEART STUDY 1989--9191

CHOL>239=TOTAL CHOLESTEROL>=240MG/DL SMOKING=CURRENTLY SMOKING CIGARETTESHTN=SBP>=140 OR DBP>=90 OR TAKING ANTIHYPERTENSIVE MEDSOVERWT=BODY MASS INDEX>=27.3 BINGE=5 OR MORE DRINKS ON OCCASION IN LAST YEARWelty, et al Am J. Epidemiol 1995

3438

23

44

15

89

43

13

80

71

24

13

43

32

71

42

1416

28

45

66

46

25

0

10

20

30

40

50

60

70

80

90

CHOL>239 HTN SMOKING OVERWT DIABETES ALCOHOLBINGE

WOMEN 45-74 YEARS OF AGE

PER

CEN

T

US AZ INDIANS OK INDIANS SD/ND INDIANS

CVD RISK FACTORSCVD RISK FACTORSUS ALL RACES & AMERICAN INDIAN MEN AGES 45US ALL RACES & AMERICAN INDIAN MEN AGES 45--7474NHANES III 1988NHANES III 1988--91; STRONG HEART STUDY 198991; STRONG HEART STUDY 1989--9191

CHOL>239=TOTAL CHOLESTEROL>=240MG/DL SMOKING=CURRENTLY SMOKING CIGARETTESHTN=SBP>=140 OR DBP>=90 OR TAKING ANTIHYPERTENSIVE MEDSOVERWT=BODY MASS INDEX>=27.3 BINGE=5 OR MORE DRINKS ON OCCASION IN LAST YEARWelty, et al Am J. Epidemiol 1995

28

43

26

38

1115

5

44

30

67 65

51

9

47

37

65

3633

11

27

53 54

32

50

0

10

20

30

40

50

60

70

80

CHOL>239 HTN SMOKING OVERWT DIABETES ALCOHOLBINGE

MEN 45-74 YEARS OF AGE

PER

CEN

T

US AZ INDIANS OK INDIANS SD/ND INDIANS

Welty TK, et al Ann Epi 2002:12Welty TK, et al Ann Epi 2002:12

Changes in CVD Risk Factors:Changes in CVD Risk Factors:American Indians Over a 4 Year PeriodAmerican Indians Over a 4 Year Period

The Strong Heart StudyThe Strong Heart Study

Diabetes increased by 6 Diabetes increased by 6 -- 12% in all centers12% in all centers

Prevalence of HTN increased overall by 7 Prevalence of HTN increased overall by 7 -- 9%9%

Albuminuria increased by 5 Albuminuria increased by 5 -- 9% overall.9% overall.

Changes in LDL cholesterol inconsistentChanges in LDL cholesterol inconsistent

HDL decreased by more than 9%HDL decreased by more than 9%

Weight decreased for those with DM (mean 1.9 kg), Weight decreased for those with DM (mean 1.9 kg), increased for those with NGT (mean increase 1.4 kg) increased for those with NGT (mean increase 1.4 kg)

Smoking prevalence decreased significantly in women Smoking prevalence decreased significantly in women

Lee ET, et. al Diab Care 2002:25(1) Lee ET, et. al Diab Care 2002:25(1) Welty TK, et al Ann Epi 2002:12Welty TK, et al Ann Epi 2002:12

DIABETES INCIDENCEDIABETES INCIDENCEAmerican Indians Over a 4 Year PeriodAmerican Indians Over a 4 Year Period

The Strong Heart StudyThe Strong Heart StudyOverall 19.6% (4.9% per year)Overall 19.6% (4.9% per year)Those with impaired glucose tolerance (IGT) at Those with impaired glucose tolerance (IGT) at higher risk developing DM:higher risk developing DM:37.2% developed DM and gained 1.1 kg37.2% developed DM and gained 1.1 kg35.2 % remained in IGT category and their wt. 35.2 % remained in IGT category and their wt. did not changedid not change27.6% reverted to normal glucose tolerance and 27.6% reverted to normal glucose tolerance and they lost 1.0 kgthey lost 1.0 kg

DM and CVD among Native DM and CVD among Native AmericansAmericans

What can we do?What can we do?

ABCs OF CVD PREVENTIONABCs OF CVD PREVENTION

A = A healthier community = A = A healthier community = Primordial preventionPrimordial preventionB = Be healthy =B = Be healthy =Primary preventionPrimary preventionC = Control =C = Control =Secondary preventionSecondary prevention

ABCs FOR DIABETESABCs FOR DIABETES

A = A1c hemoglobin measures glucose A = A1c hemoglobin measures glucose controlcontrolB = Blood pressureB = Blood pressureC = CholesterolC = Cholesterol

A HEALTHIER COMMUNITY

“THE HEALTH OF AN INDIVIDUALIS DETERMINED BY THE HEALTH

OF THE FAMILY AND COMMUNITY”Warne D. Native Visions, KAET TV May 11, 2005

Primordial PreventionPrimordial Prevention•• Focus on our youthFocus on our youth•• Healthy school lunchesHealthy school lunches•• Get the soda pop out of schools and health care Get the soda pop out of schools and health care

facilitiesfacilities•• Get physical education back in schoolsGet physical education back in schools•• Environment conducive to walking or joggingEnvironment conducive to walking or jogging--dog dog

control, school facilities open to the communitycontrol, school facilities open to the community•• Just Move It ProgramJust Move It Program•• SmokeSmoke--free facilities/meetings/homesfree facilities/meetings/homes•• Tribal/community leaders & providers as role Tribal/community leaders & providers as role

modelsmodels--Sally Smith and Tex HallSally Smith and Tex Hall

“Acknowledging that obesity is epidemic “Acknowledging that obesity is epidemic among New York City schoolchildrenamong New York City schoolchildren,,

the NYC Education Department is: the NYC Education Department is:

-- reducing the fat content in thereducing the fat content in the800,000 meals it serves daily and 800,000 meals it serves daily and

-- banning candy, soda and other banning candy, soda and other sugary snacks from school vendingsugary snacks from school vendingmachines.”machines.”

BE HEALTHY

Prev Med supp Dec 2003 Prev Med supp Dec 2003

PATHWAYS STUDY OF PREVENTION OF PATHWAYS STUDY OF PREVENTION OF OBESITY IN AMERICAN INDIAN OBESITY IN AMERICAN INDIAN

CHILDRENCHILDREN

Feasibility 1993Feasibility 1993--96; Intervention 9696; Intervention 96--20002000SchoolSchool--based randomized trialbased randomized trial--41 schools41 schools1704 3d to 51704 3d to 5thth grade studentsgrade studentsImprovement in intervention schools:Improvement in intervention schools:Knowledge, attitudes, and behaviorsKnowledge, attitudes, and behaviorsHealthy foods in schoolsHealthy foods in schoolsParental involvementParental involvementPhysical activity at 3 of 4 sitesPhysical activity at 3 of 4 sitesNo difference in % body fatNo difference in % body fat

Promising Interventions for Promising Interventions for Childhood Obesity PreventionChildhood Obesity Prevention

Involve family, friends, and the entire Involve family, friends, and the entire community community –– primordial preventionprimordial preventionFurther research with preschool & head Further research with preschool & head start students and antenatal patientsstart students and antenatal patientsPathways curriculum available at Pathways curriculum available at http://http://hschsc..unmunm.edu/pathways.edu/pathways

Welty IHS Primary Care Provider 1989Welty IHS Primary Care Provider 1989

INDIAN SPECIFIC HEALTH RISK INDIAN SPECIFIC HEALTH RISK APPRAISALAPPRAISAL

Developed by AAIHS in 1988 in Developed by AAIHS in 1988 in collaboration with CDC and Carter Centercollaboration with CDC and Carter CenterProvided feed back to Strong Heart Study Provided feed back to Strong Heart Study participants on how to reduce health risksparticipants on how to reduce health risksNeeds to be updated, integrated with Needs to be updated, integrated with RPMS, and effectiveness evaluatedRPMS, and effectiveness evaluatedUseful for brief clinical interventions by Useful for brief clinical interventions by providersproviders

RISK FACTOR KNOWLEDGERISK FACTOR KNOWLEDGESTRONG HEART STUDYSTRONG HEART STUDY

Knowledge of 9 CVD risk factors ranged from 71 Knowledge of 9 CVD risk factors ranged from 71 to 90 % among 3226 participantsto 90 % among 3226 participantsThose with hypertension and diabetes more Those with hypertension and diabetes more likely to have knowledge of CVD risk factors. likely to have knowledge of CVD risk factors. Men, smokers, and those with less education Men, smokers, and those with less education had less knowledge. had less knowledge. Targeted educational programs needed to raise Targeted educational programs needed to raise awareness of CVD risk factors.awareness of CVD risk factors.Knowledge needs to lead to behavior change.Knowledge needs to lead to behavior change.

ScheweigmanScheweigman, et al, Submitted to Ethnicity & Disease 2005, et al, Submitted to Ethnicity & Disease 2005

Lee, et al. Poster 2005Lee, et al. Poster 2005

PREDICTION OF CHDPREDICTION OF CHDSTRONG HEART STUDY MODELSTRONG HEART STUDY MODEL

AgeAgeGenderGenderCholesterol (total, LDL, and HDL)Cholesterol (total, LDL, and HDL)DiabetesDiabetesHypertensionHypertensionSmokingSmokingAlbuminuriaAlbuminuria

Calculates risk of CHD in 10 years Calculates risk of CHD in 10 years Future integration into RPMSFuture integration into RPMS

The Diabetes Prevention Program:The Diabetes Prevention Program:Reduction in the incidence of Type 2 DM Reduction in the incidence of Type 2 DM

with lifestyle or metforminwith lifestyle or metformin

•• 3234 adults at high risk for diabetes 3234 adults at high risk for diabetes -- Randomized to 3 groups:Randomized to 3 groups:

Standard lifestyle recommendations + Standard lifestyle recommendations + placeboplaceboStandard lifestyle recommendations + Standard lifestyle recommendations + metformin (850 BID)metformin (850 BID)Intensive lifestyle modificationIntensive lifestyle modification

–– Goal: at least 7% weight reduction and Goal: at least 7% weight reduction and 150 minutes of exercise weekly150 minutes of exercise weekly

DPP Research Group, NEJM 346:393DPP Research Group, NEJM 346:393--403,2002403,2002

The Diabetes Prevention Program:The Diabetes Prevention Program:Reduction in the incidence of Type 2 DM Reduction in the incidence of Type 2 DM

with lifestyle or metforminwith lifestyle or metformin

Enrollment Criteria:Enrollment Criteria:•• BMI of 24 or greaterBMI of 24 or greater•• Fasting serum glucose of 95 to 125 mg/dLFasting serum glucose of 95 to 125 mg/dL•• Plasma glucose of 140 to 199 mg/dL two Plasma glucose of 140 to 199 mg/dL two

hours after oral glucose loadhours after oral glucose load

•• Average follow up of over 2.8 years Average follow up of over 2.8 years

DPP Research Group, NEJM 346:393DPP Research Group, NEJM 346:393--403,2002403,2002

The Diabetes Prevention Program:The Diabetes Prevention Program:Lifestyle InterventionLifestyle Intervention

•• 16 session core curriculum (over 24 weeks) 16 session core curriculum (over 24 weeks)

•• LongLong--term maintenance programterm maintenance program

•• Supervised by a case managerSupervised by a case manager

•• Access to lifestyle support staffAccess to lifestyle support staff

•• DietitianDietitian

•• Behavior counselorBehavior counselor

•• Exercise specialistExercise specialist

DPP Research Group, NEJM 346:393DPP Research Group, NEJM 346:393--403,2002403,2002

The Diabetes Prevention Program:The Diabetes Prevention Program:Lifestyle Intervention: Physical Activity ResultsLifestyle Intervention: Physical Activity Results

•• 74% of volunteers assigned to intensive lifestyle 74% of volunteers assigned to intensive lifestyle achieved the study goal of achieved the study goal of >> 150 minutes of 150 minutes of activity per week at 24 weeksactivity per week at 24 weeks

•• Promote physical activity addictionPromote physical activity addiction•• How can we achieve this in Native communities?How can we achieve this in Native communities?•• IHS standards for prediabetes releasedIHS standards for prediabetes released

DPP Research Group, NEJM 346:393DPP Research Group, NEJM 346:393--403,2002403,2002

0 1 2 3 4

0

10

20

30

40 Placebo (n=1082)Metformin (n=1073, p<0.001 vs. Plac)Lifestyle (n=1079, p<0.001 vs. Met , p<0.001 vs. Plac )

Percent developing diabetes

All participants

All participants

Years from randomization

Cum

ulat

ive

inci

denc

e (%

)

Risk reduction31% by metformin58% by lifestyle

The DPP Research Group, NEJM 346:393-403, 2002

SHS DIETARY STUDIESSHS DIETARY STUDIES

Phase I: 24 hour recall Phase I: 24 hour recall –– Higher intake of Higher intake of fats and cholesterol than NHANES, diets fats and cholesterol than NHANES, diets at high risk of increasing risk of chronic at high risk of increasing risk of chronic diseasediseasePhase II: 24 hour recallPhase II: 24 hour recall--Intake of most Intake of most vitamins lower than NHANESvitamins lower than NHANESHealthy foods need to be more available Healthy foods need to be more available and affordableand affordable

Zephier EM, et al. Prev. Med 1997Stang J, et al. Submitted JADA 2005

Primary Prevention of DM & Primary Prevention of DM & CVD Among Native AmericansCVD Among Native Americans

Community DevelopedCommunity DevelopedCommunity ImplementedCommunity ImplementedCommunity IntegratedCommunity IntegratedSupported by Providers and Public HealthSupported by Providers and Public HealthIndividual, Provider and Community FocusIndividual, Provider and Community Focus

SMOKING CESSATIONSMOKING CESSATIONAmerican Indians Over a 4 Year PeriodAmerican Indians Over a 4 Year Period

The Strong Heart StudyThe Strong Heart Study

•• 21 % of smokers quit, a high spontaneous 21 % of smokers quit, a high spontaneous cessation rate. cessation rate.

Usual quit rates:Usual quit rates:•• Spontaneous ~ 15% Spontaneous ~ 15% •• Post intervention ~ 15Post intervention ~ 15--25%. 25%. Older people, those who smoked less and Older people, those who smoked less and

started at an older age, and those with DM started at an older age, and those with DM more likely to quitmore likely to quit

Primary prevention is priorityPrimary prevention is priority

Henderson PN, et.al. Henderson PN, et.al. EthnEthn Dis. 2004;14(2)Dis. 2004;14(2)

CONTROL BP, LIPIDS, GLUCOSEIN PERSONS WITH DM OR CHD

SANDS: SANDS: STOP ANTHEROSCLEROSIS IN NATIVE STOP ANTHEROSCLEROSIS IN NATIVE

DIABETICSDIABETICS

Will lowering LDL cholesterol and blood Will lowering LDL cholesterol and blood pressure to lower targets than are currently pressure to lower targets than are currently recommended retard CVD?recommended retard CVD?

ControlControl InterventionInterventionLDL chol (mg/dl)LDL chol (mg/dl) <100<100 <70<70SBPSBP (mm)(mm) 130/80130/80 115/75115/75Ultrasound measures plaque in carotid arteryUltrasound measures plaque in carotid artery

Howard, et al Arterioscler Thromb Vasc Howard, et al Arterioscler Thromb Vasc Biol; 20: 2000Biol; 20: 2000

LDL CHOLESTEROL A STRONG LDL CHOLESTEROL A STRONG PREDICTOR OF CHD IN SHS PREDICTOR OF CHD IN SHS

PARTICIPANTS WITH DMPARTICIPANTS WITH DM

Mean LDL cholesterol levels lower Mean LDL cholesterol levels lower American Indians with diabetes than those American Indians with diabetes than those without.without.LDL cholesterol remains a strong CVD risk LDL cholesterol remains a strong CVD risk factor in persons with diabetes even at low factor in persons with diabetes even at low level. level.

Fonarow GC, et al Am J Cardiol. 2001 Fonarow GC, et al Am J Cardiol. 2001 Apr 1;87(7):819Apr 1;87(7):819--2222

Cumulative Impact of Four CV Cumulative Impact of Four CV Protective Medications Post MIProtective Medications Post MI

RelativeRelative--riskrisk 5yr CV event rate5yr CV event rate

None None ---- 20%20%

AspirinAspirin ▼▼25%25% 15%15%

Beta blockerBeta blocker ▼▼25%25% 11.3%11.3%

ACE inhibitorACE inhibitor ▼▼25%25% 8.4%8.4%

StatinStatin ▼▼30%30% 5.9%5.9%

Cumulative risk reduction if all four medications are used = 70%

Despite compelling Despite compelling scientific evidencescientific evidence

and national treatment guidelines for and national treatment guidelines for the prevention and treatment of the prevention and treatment of

diabetes & CVD, diabetes & CVD, prevention efforts continue to be prevention efforts continue to be

underutilized… underutilized…

What can we do?What can we do?

Cultural SensitivityCultural SensitivityCultural HumilityCultural HumilityCultural AppropriatenessCultural Appropriateness

We need the ability to translate this We need the ability to translate this excellent science into changes in excellent science into changes in community understanding, cultural community understanding, cultural perceptions and individual lifestyles. perceptions and individual lifestyles.

What MUST we do?

American Heart AssociationAmerican Heart AssociationIndian Health ServiceIndian Health Service

Get With Get With The Guidelines The Guidelines

ProgramProgram

EXPENSIVE HIGH TECHEXPENSIVE HIGH TECHLIFE SAVING TREATMENTLIFE SAVING TREATMENT

Coronary Artery Bypass SurgeryCoronary Artery Bypass SurgeryCardiac TransplantCardiac TransplantDialysis and Kidney TransplantDialysis and Kidney Transplant

Need for these interventions can be reduced Need for these interventions can be reduced by primordial, primary and secondary by primordial, primary and secondary prevention.prevention.

OVERCOME FATALISMOVERCOME FATALISM

FatalismFatalismI will get diabetesI will get diabetesCan do nothing about itCan do nothing about itCan’t prevent diabetesCan’t prevent diabetesTalking Circle Intervention reduced fatalism Talking Circle Intervention reduced fatalism compared to controlscompared to controlsDr. Felicia Hodge and Lorelei Decora, RN have Dr. Felicia Hodge and Lorelei Decora, RN have spearheaded this intervention.spearheaded this intervention.Both primary and secondary preventionBoth primary and secondary prevention

ABCs OF CVD PREVENTIONABCs OF CVD PREVENTION

A = A healthier community = A = A healthier community = Primordial preventionPrimordial preventionB = Be healthy =B = Be healthy =Primary preventionPrimary preventionC = Control =C = Control =Secondary preventionSecondary prevention

HIV/AIDS IN AFRICA SIMILARHIV/AIDS IN AFRICA SIMILARTO DM/CVD IN NATIVE PEOPLETO DM/CVD IN NATIVE PEOPLEBoth are devastating epidemicsBoth are devastating epidemicsBoth are preventable by behavior changeBoth are preventable by behavior changeBoth are chronic diseases Both are chronic diseases –– require lifelong RXrequire lifelong RXFor HIV/AIDS successful prevention has reduced For HIV/AIDS successful prevention has reduced HIV seroprevalence in Uganda from 30% to <10%HIV seroprevalence in Uganda from 30% to <10%A = Abstinence A = Abstinence B = Be Faithful B = Be Faithful C = CondomsC = Condoms

LEADERSHIP IS A KEY FACTORLEADERSHIP IS A KEY FACTOR

President President MuseveniMuseveni of Uganda since 1986 of Uganda since 1986 has played a key role in reducing HIV/AIDS has played a key role in reducing HIV/AIDS “When there is a lion in the village, you “When there is a lion in the village, you don’t whisper.” You shout to warn people.don’t whisper.” You shout to warn people.Which Tribe/Native community will be the Which Tribe/Native community will be the first to reduce obesity, DM and CVD? first to reduce obesity, DM and CVD? Can effective preventive solutions be Can effective preventive solutions be replicated in Native communities? replicated in Native communities?

RESOURCES FOR PREVENTIONRESOURCES FOR PREVENTION

Diabetes Prevention Grants for TribesDiabetes Prevention Grants for TribesFunding needed for CVD prevention Funding needed for CVD prevention –– Tex Hall, President of NCAI, supportiveTex Hall, President of NCAI, supportive

Tribal/community and provider coalitions are Tribal/community and provider coalitions are necessary to develop comprehensive preventive necessary to develop comprehensive preventive programs and obtain fundingprograms and obtain fundingInterventions tailored to common risk factorsInterventions tailored to common risk factorsPrevention researchPrevention research--CDC/NIH funds availableCDC/NIH funds available

CONCLUSIONSCONCLUSIONS

Research in Native communities has led to Research in Native communities has led to knowledge that helps to define health problems knowledge that helps to define health problems and to identify interventions that can lead to and to identify interventions that can lead to improved health.improved health.Translation of research findings into practical Translation of research findings into practical preventive and clinical interventions must preventive and clinical interventions must accelerate and receive financial support. accelerate and receive financial support. Individuals and communities must overcome Individuals and communities must overcome fatalism to succeed in reducing DM and CVD.fatalism to succeed in reducing DM and CVD.

CONCLUSIONS (CONT)CONCLUSIONS (CONT)Comprehensive, culturally appropriate, Comprehensive, culturally appropriate, preventive interventions for communities and preventive interventions for communities and families have the greatest chance of success.families have the greatest chance of success.Tribal/community, clinical, and national Tribal/community, clinical, and national leadership and governmental financial support leadership and governmental financial support are essential.are essential.Further research is needed to determine which Further research is needed to determine which preventive interventions are most effective.preventive interventions are most effective.Successful interventions need to be replicated.Successful interventions need to be replicated.Ongoing surveillance of obesity, DM, and CVD is Ongoing surveillance of obesity, DM, and CVD is essential to assess the impact of prevention.essential to assess the impact of prevention.

TOGETHER WE TOGETHER WE CAN DO ITCAN DO IT