Elsevier

Annals of Epidemiology

Volume 12, Issue 2, February 2002, Pages 97-106
Annals of Epidemiology

Original article
Changes in Cardiovascular Disease Risk Factors among American Indians: The Strong Heart Study

https://doi.org/10.1016/S1047-2797(01)00270-8Get rights and content

Abstract

PURPOSE: This study describes changes in cardiovascular disease (CVD) risk factors in older American Indians over a 4-year period.

METHODS: The Strong Heart Study, a longitudinal population-based study of CVD and CVD risk factors among American Indians aged 45–74 years, measured CVD risk factors among 3638 members of 13 tribes in three geographic areas during examinations in 1989 to 1991 and 1993 to 1995.

RESULTS: Changes in mean low-density lipoprotein (LDL) cholesterol and the prevalence of elevated LDL cholesterol were inconsistent. Mean high- density lipoprotein (HDL) cholesterol decreased, and the prevalence of low HDL cholesterol increased throughout. Mean systolic blood pressure and hypertension rates increased in nearly all center-sex groups, and hypertension awareness and treatment improved. Smoking rates decreased but remained higher than national rates except among Arizona women. Mean weight and percentage body fat decreased in nearly all center-sex groups but the prevalence of obesity did not change significantly in any group. Diabetes and albuminuria prevalence rates increased throughout the study population. The prevalence of alcohol use decreased, but binge drinking remained common in those who continued to drink.

CONCLUSIONS: Improvements in management and prevention of hypertension, diabetes, renal disease, and obesity, and programs to further reduce smoking and alcohol abuse, are urgently needed.

Introduction

Mortality from cardiovascular disease (CVD) in the United States has been steadily declining in recent decades, and this improvement is attributable in part to decreased prevalence of major cardiovascular risk factors (1). However, recent reports suggest that both mortality rates and incidence rates are rising among American Indians (2) Cardiovascular mortality rates among American Indians aged 45 to 74 years were as high or higher than corresponding state rates in 1984–1988 (3). Furthermore, several studies report rapid and alarming increases in the prevalence of cardiovascular risk factors among American Indian communities 4, 5, 6, 7.

To our knowledge, longitudinal trends in the prevalence of CVD risk factors in a diverse population of American Indians have never been examined. Previously, we described the prevalence of major CVD risk factors among the Strong Heart Study (SHS) cohort of American Indian adults aged 45 to 74 years (8). We now report changes in these risk factors after 4 years of follow up.

Section snippets

Study Population

The eligible population for the first SHS examination in-cluded individuals aged 45 to 74 years between 1989 and 1991 who resided in their tribal communities and were members of the following tribes: Akimel O'odham/PeePosh/Tohono O'odham of central Arizona in the Gila River, Salt River, and Ak-Chin Indian communities; the seven Tribes of southwestern Oklahoma (Apache, Caddo, Comanche, Delaware, Ft. Sill Apache, Kiowa, and Wichita); the Oglala and Cheyenne River Sioux of South Dakota, and the

Results

Baseline age, income, lipid concentrations, and prevalence rates of hypertension, smoking, alcohol use, obesity, diabetes, and proteinuria among the 3638 survivors who came to the follow-up examination were compared with those among the 496 survivors (238 men and 258 women) who did not. Only two significant differences were found: surviving women who came to the follow-up examination had lower mean total cholesterol than those who did not (5.3 mg/dl); and the prevalence of smoking was lower

Discussion

This is the largest longitudinal study to assess changes in CVD and its risk factors in a diverse group of adult American Indians. Although some changes over the 4 years of follow up represented improvements in CVD risk factors, several adverse changes occurred that will likely increase morbidity and mortality from CVD in this cohort.

Unfavorable changes in the lipoprotein profile of this population included increases in LDL cholesterol for women and decreases in HDL cholesterol for both men and

Summary

The rapid increases in the prevalence rates of the strongest CVD risk factors, especially diabetes, highlight the urgent need for community-based and clinical efforts to combat the epidemics of chronic diseases in Indian communities. Primary prevention of obesity starting in childhood by healthful eating and increased physical activity is essential because obesity is a risk factor for both CVD and diabetes (37). Physical activity is also protective against the development of diabetes and

Selected Abbreviations and Acronyms

BMI = body mass index

CVD = cardiovascular disease

DBP = diastolic blood pressure

HDL = high-density lipoprotein

HTN = hypertension

IGT = impaired glucose tolerance

JNC-V = Fifth Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure

LDL = low-density lipoprotein

NGT = normal glucose tolerance

NHANES = National Health and Nutrition Examination Survey

SBP = systolic blood pressure

SHS = Strong Heart Study

SD/ND = South Dakota/North Dakota

Acknowledgements

This study was conducted by cooperative agreements U01-HL41642, U01-HL41652 and U01-HL41654 from the National Heart, Lung, and Blood Institute. The authors acknowledge the assistance and cooperation of the participating tribes and the Indian Health Service facilities that serve those tribes. The authors also thank the study participants, the Directors of SHS clinics, Betty Jarvis, Martha Stoddart, Beverly Price, Marcia O'Leary, Dr. Tauqeer Ali, Alan Crawford and their staffs, LaVonne Looking

References (42)

  • MMWR Morb Mortal Wkly Rep

    (1994)
  • T.K. Welty et al.

    Cardiovascular disease risk factors among American Indians. The Strong Heart Study

    Am J Epidemiol

    (1995)
  • E.T. Lee et al.

    The Strong Heart Study. A study of cardiovascular disease in American Indiansdesign and methods

    Am J Epidemiol

    (1990)
  • The Fifth Report of the Joint National Committee on Detection, Evaluation and Treatment of High Blood Pressure

    (1993)
  • Diabetes MellitusReport of a WHO Study Group

    (1985)
  • R.J. Kuczmarski et al.

    Varying body mass index cutoff points to describe overweight prevalence among U.S. AdultsNHANES III (1988 to 1994)

    Obes Res

    (1997)
  • B.V. Howard et al.

    Coronary heart disease prevalence and its relation to risk factors in American Indians. The Strong Heart Study

    Am J Epidemiol

    (1995)
  • Howard BV, Lee ET, Cowan LD, et al. LDL cholesterol is a strong predictor of coronary heart disease in diabetic...
  • M.M. Burnette et al.

    Smoking cessation, weight gain, and changes in cardiovascular risk factors during menopausethe Healthy Women Study

    Am J Public Health

    (1998)
  • C. Couillard et al.

    Associations between 12 year changes in body fatness and lipoprotein-lipid levels in men and women of the Quebec Family Study

    Int J Obes Relat Metab Disord

    (1996)
  • A.R. Folsom et al.

    Plasma fibrinogen and other cardiovascular risk factors in urban American Indian smokers

    Ethn Dis

    (1993)
  • Cited by (88)

    • Cancer mortality in a population-based cohort of American Indians – The strong heart study

      2021, Cancer Epidemiology
      Citation Excerpt :

      Again, our study may have limited power to detect residual differences by center. Regional differences in cancer mortality in other AI studies [12,28] are often attributed to differences in smoking [12,29,30]. We could not assess other factors such as access to care that may contribute to regional differences [31,32].

    • Culturally-tailored text-messaging intervention for smoking cessation in rural American Indian communities: Rationale, design, and methods

      2019, Contemporary Clinical Trials Communications
      Citation Excerpt :

      Lifetime cigarette smoking prevalence in American Indian (AI) and Alaska Native (AN) communities are among the highest in the United States (U.S.) [1–6].

    • Disparities in Smoking-Related Mortality Among American Indians/Alaska Natives

      2015, American Journal of Preventive Medicine
      Citation Excerpt :

      In addition to the racial difference in smoking prevalence between AI/ANs and whites, regional variations in smoking prevalence within the AI/AN population have also been reported, with an estimated prevalence as low as 21% in the Southwest and as high as 40% in the Northern Plains and Alaska.4 Additionally, over the last three decades, the prevalence of cigarette smoking has been rising in some tribal communities where prevalence had been historically low.5 Overall, smoking prevalence among AI/ANs has consistently remained high and this disparity in cigarette smoking represents the largest among the racial and ethnic minority groups in the U.S.2

    View all citing articles on Scopus
    View full text