Eileen M. Stuart?Shor|Kathy Berra|Mercy Kamau|Shiriki Kumanyika
Behavioral Strategies for Cardiovascular Risk Reduction in Diverse and Underserved Racial/Ethnic Groups
Beth Israel Deaconess Medical Center|Stanford University|University of Massachusetts Boston|University of Pennsylvania|Beth Israel Deaconess Medical Center|Stanford University|University of Massachusetts Boston|University of Pennsylvania|Beth Israel Deaconess Medical Center|Stanford University|University of Massachusetts Boston|University of Pennsylvania|Beth Israel Deaconess Medical Center|Stanford University|University of Massachusetts Boston|University of Pennsylvania
homecirculationvol 125 1behavioral strategies cardiovascular risk reduction diverse underserved racialethnic groups free accessresearch articlepdfepubaboutview pdfview epubsections toolsadd favoritesdownload citationstrack citationspermissions shareshare onfacebooktwitterlinked inmendeleyreddit jump tofree accessresearch articlepdfepubbehavioral strategies cardiovascular risk reduction diverse underserved racialethnic groups eileen stuartshor kathy berra mercy w kamau shiriki k kumanyika eileen stuartshoreileen stuartshor university massachusetts boston college nursing health sciences ems mwk beth israel deaconess medical center boston ems stanford university school medicine palo alto ca kab university pennsylvania perelman school medicine philadelphia skk search papers author kathy berrakathy berra university massachusetts boston college nursing health sciences ems mwk beth israel deaconess medical center boston ems stanford university school medicine palo alto ca kab university pennsylvania perelman school medicine philadelphia skk search papers author mercy w kamaumercy w kamau university massachusetts boston college nursing health sciences ems mwk beth israel deaconess medical center boston ems stanford university school medicine palo alto ca kab university pennsylvania perelman school medicine philadelphia skk search papers author shiriki k kumanyikashiriki k kumanyika university massachusetts boston college nursing health sciences ems mwk beth israel deaconess medical center boston ems stanford university school medicine palo alto ca kab university pennsylvania perelman school medicine philadelphia skk search papers author originally published3 jan 2012httpsdoiorg101161circulationaha110968495circulation 2012125171184introductioncardiovascular disease cvd leading cause death disability united states across racialethnic groups1 much burden cvd morbidity mortality associated modifiable lifestyle risk factors disproportionate share burden cvd metabolicvascular risk factors falls racial ethnic communities result constellation social environmental biological systems factors12 disparities clearly evident black compared white americans1 available data racialethnic minority populations indicate disparities certain cvd risk factors outcomes13despite widespread awareness among clinicians primary secondary cvd prevention goals potential improving clinical outcomes integrating lifestyle risk reduction interventions practice application interventions far optimal4 therapeutic goals primary secondary prevention well established last 3 decades56table 1 derived american heart association aha scientific statements primordial4 primary5 secondary6 risk reduction diet lifestyle recommendations7 delineates targeted goals risk reduction strategies across spectrum prevention primary prevention seeks avoid first occurrence cvd among individuals risk smoking cessation management blood pressure bp lipids glucose weight control dietary physical activity counseling5 secondary prevention aims intensive comprehensive management risk factors established cvd associated improved survival reduction recurrent events6 secondary prevention benchmarks lipid management lower primary prevention bp smoking dietary physical activity goals result growing recognition subclinical disease develops many years various levels risk necessity broaden focus cvd prevention include primordial prevention avoidance adverse levels risk factors first place recognized4 including primordial prevention risk reduction paradigm necessitates promoting health behaviors associated decreased cvd morbidity across lifespan population focustable 1 established metrics strategies prevention cardiovascular disease adultstargeted risk factorideal cv health definition primordial prevention goalsprimary prevention goalssecondary prevention goalsstrategysmokingnever quit 12 mo agocomplete cessation exposure environmental tobacco smokecomplete cessation exposure environmental tobacco smokeask tobacco use every visitadvise every tobacco user quitassess smokers willingness quitassist smoker making plan quitting provide counselingarrange followup referral andor pharmacotherapyurge avoidance environmental exposuredietary pattern45 components primary metricsan overall healthy eating patternan overall healthy eating patternbalance calorie intake physical activity achieve maintain healthy body weightfruits vegetables 45 cupsdconsume diet rich vegetables fruitsfish 2 35oz servings per week preferably oily fishchoose wholegrain highfiber foodsfiberrich whole grains 11 g fiber per 10 g carbohydrate 3 1ozequivalent servings per dayconsume fish especially oily fish least twice weeksodium 1500 mgdlimit intake saturated fat 7 energy trans fat 1 energy cholesterol to300 mgdsugarsweetened beverages 450 kcal 36 ozwkminimize intake beverages foods added sugarssecondary metricschoose prepare foods little saltavoidance trans fat saturated fatconsume alcohol moderation allnuts legumes seeds 4 servings per weekwhen eating food prepared outside home follow aha diet lifestyle recommendationsprocessed meats 0 2 servings per weeksaturated fat 7 total energy intakephysical activity150 minwk moderate intensity 75 minwk vigorous intensity combinationat least 30 min moderateintensity physical activity preferably days week30 min 7 dwk minimum 5 dwkfor patients assess risk physical activity ry andor exercise test guide prescriptionfor high risk patients consult physician initiating vigorous exercise programfor patients encourage 30 60 min moderateintensity aerobic activity brisk walking days week supplemented flexibility training increase daily lifestyle activitiesencourage resistance training least 2 per weekbody mass index25 kgm2achieve maintain desirable weight body mass index 185249 kgm2 body mass index 25 kgm2 waist circumference iliac crest level 40 inches men 35 inches womenbody mass index 185 249 kgm2assess body mass index andor waist circumference visit consistently encourage weight maintenancereduction appropriate balance physical activity caloric intake formal behavioral programs indicated maintainachieve body mass index 185 249 kgm2waist circumference 40 inches men 35 inches womenif waist circumference measured horizontally iliac crest 35 inches women 40 inches men initiate lifestyle changes consider treatment strategies metabolic syndrome indicatedfor overweightobese persons reduce body weight 10 first year therapyblood pressure1208014090 mm hg 13085 mm hg renal insufficiency heart failure present 13080 mm hg diabetes mellitus present14090 mm hg or13080 mm hg patient diabetes mellitus chronic kidney diseasefor patients initiate maintain lifestyle modificationweight control increased physical activity alcohol moderation sodium reduction emphasis increased consumption fresh fruits vegetables lowfat dairy productsfor patients blood pressure 14090 mm hg 13080 mm hg individuals chronic kidney disease diabetes mellitus tolerated add blood pressure medication treating initially blockers andor angiotensinconverting enzyme inhibitors addition drugs thiazides needed achieve goal blood pressurecholesterol200 mgdlprimary goal ldlc 160 mgdl 1 risk factor present ldlc 130 mgdl 2 risk factors present 10y chd risk 20 ldlc 100 mgdl 2 risk factors present 10y chd risk 20 patient diabetes mellitusldlc 100 mgdl triglycerides mtequ200 mgdl nonhdlc 130 mgdlfor patients start dietary therapy reduce intake saturated fats 7 total calories transfatty acids cholesterol 200 mgd adding plant stanolsterols 2 gd viscous fiber 10 gd lower ldlc promote daily physical activity weight management encourage increased consumption omega3 fatty acids form fish capsule form 1 gd risk reductionsecondary goals ldlc goal range triglycerides 200 mgdl use nonhdlc secondary goal nonhdlc 190 mgdl 1 risk factor nonhdlc 160 mgdl 2 risk factors 10y chd risk 20 nonhdlc 130 mgdl diabetics 2 risk factors 10y chd risk 20for lipid management assess fasting lipid profile patients within 24 h hospitalization acute cardiovascular coronary event hospitalized patients initiate lipidlowering medication recommended discharge according following schedule ldlc 100 mgdl baseline ldlc mtequ100 mgdl initiate ldllowering drug therapy ontreatment ldlc mtequ100 mgdl intensify ldllowering drug therapy may require ldllowering drug combination baseline ldlc 70100 mgdl reasonable treat ldlc 70 mgdl triglycerides 200499 mgdl nonhdlc 130 mgdl reduction nonhdlc 100 mgdl reasonable therapeutic options reduce nonhdlc intense ldlclowering therapy niacin ldlclowering therapy fibrate therapy ldlclowering therapy triglycerides 500 mgdl therapeutic options prevent pancreatitis fibrate niacin ldllowering therapy treating ldlc goal triglyceridelowering therapy achieve nonhdlc 130 mgdl possibleother targets therapy triglycerides 150 mgdl hdlc 40 mgdl men 50 mgdl womentype 2 diabetes mellitusfasting plasma glucose 100 mgdlnormal fasting plasma glucose 110 mgdl nearnormal hemoglobin a1c 7hemoglobin a1c 7firststep therapy vigorous modification risk factors eg physical activity weight management blood pressure control cholesterol management recommended abovesecondstep therapy usually oral hypoglycemic drugs sulfonylureas andor metformin ancillary use acarbose thiazolidinedionesthirdstep therapy insulin treat risk factors aggressively eg change bp goal 13080 mm hg ldlc goal 100 mgdl coordinate diabetic care patients primary care physician endocrinologistcv indicates cardiovascular ldlc lowdensity lipoprotein cholesterol chd coronary heart disease hdlc highdensity lipoprotein cholesterol information adapted american heart association guidelines primordial prevention4 primary prevention5 secondary prevention6 diet lifestyle recommendations7the need effective prevention strategies especially urgent racialethnic minority communities prevalence risk factors high control risk factors remains low review examines evidencebased strategies facilitate integration established lifestyle risk reduction interventions diverse underserved racialethnic groups offers practical approaches achieve primary secondary prevention populations focusing behavioral strategies target individual implemented clinician point service definition limited scope article effective broadbased policies affect tobacco control nutrition physical activity access care48 strategies increase guideline concordant delivery pharmacological interventional cardiovascular care combined cliniciandelivered individualbased behavioral interventions important however thorough examination impact policies beyond scope articlethis article provides brief overview disparities cvd health status lifestyle risk factors health care successful cvd risk reduction strategies targeted lifestyle behaviors described focus research demonstrates benefit racialethnic minorities general issues related cultural competence cultural tailoring also discussedbackgroundracialethnic minority populationsus health statistics typically use categories based race african american black white american indianalaska native aian asian americans native hawaiians pacific islanders separate people report hispanic ethnicity eg mexican american hispanic versus nonhispanic black nonhispanic white9 need separate consideration asian10 pacific islander11 populations recognized given heterogeneity cvd risk profiles demographic characteristics within broader categories thus use single asianpacific islander category decreasing many data available black americans recently mexican americans racialethnic minorities11 addition heterogeneity demographic cultural variables cvd risk factors broader ethnic minority categories generally data reported aggregate categories may misleading generalities data single subgroup imprecise example puerto ricans may different cvd risk profiles compared mexican cuban americans asians india pakistan may different cvd risk profiles compared china japan110this article focuses raceethnicity designations identify groups known suffer disproportionate burden cvd acknowledges heterogeneity within groups limitations socially constructed categories1 recognize race ethnicity complex concepts elude simple discrete categorization many factors including environment access care lifestyle patterns perhaps ancestry influence health individuals socially constructed racialethnic categories1213 biological differences glucose lipid metabolism metabolism several cardiac medications racialethnic groups reported may contribute poorer outcomes1415 summarized racialethnic differences cvd risk also vary sex9disparities cvd health statushypertension leading preventable cause premature death united states major contributor disparate burden cvd borne racialethnic minorities particularly black americans diagnosed high bp racialethnic minorities less likely achieve adequate control likely experience endorgan damage111617 although data available black americans high rates hypertension noted american indians18 asian american populations19 mexican americans lower rates hypertension compared racialethnic subgroups although may function undetected disease true prevalence diagnosed least likely controlled11an estimated 47 americans 20 years age total blood cholesterol levels 200 mgdl11 mexican american women men higher rates dyslipidemia 51 49 respectively white counterparts less likely aware11 controlled20 although black american men women less likely experience dyslipidemia 40 42 respectively11 identified less likely controlled11 prescribed lipidlowering therapy21 white counterparts data awareness treatment control hispanics mexican americans asian americans including asian subgroups aian available needed1addressing obesity diabetes mellitus also critical reducing overall cvd risk addressed aha statements2224 downward shifts population levels cholesterol bp smoking account nearly half decline agestandardized cvd deaths past 4 decades however increasing obesity type 2 diabetes mellitus offset trend contribute persistent national cvd stroke burden425 black women mexican american men11 likely body mass index 25 kgm2 80 75 respectively aian populations likely diagnosed diabetes mellitus 15 high prevalence noted black mexican american women 13 black men 13 native hawaiians pacific islanders26 12 compared white men women 7 particular concern relation global risk prevalence 2 cvd risk factors highest among black americans aian 49 47 respectively although information hispaniclatinos asian americans native hawaiians pacific islanders less complete blacks whites mexican americans1the recently released american heart association aha science advisory cvd asian americans points need collect data heterogeneous racialethnic group10 authors note rapid growth asian american population recently subgroups asian americans included national health surveys particular importance thresholds certain risk factors asian descent populations may differ typical definitions27 studies suggest asians lower body mass index compared whites may similar proportion body fat28 lower thresholds defining obesity identified1029 information relevance clinical care asians higher rates diabetes mellitus would expected based body mass index levels30 issue may apply measures high waist circumference wellestablished risk factor insulin resistance type 2 diabetes mellitus31the value preventing controlling cv factors well established disparities presented substantial thus strategies effectively reduce risk highrisk groups critical importancedisparities cvd lifestyle risk factorscigarette smoking continues leading cause preventable morbidity mortality united states32 overall prevalence active smokers among american adults 21 men likely smoke women 23 18 respectively among racialethnic groups aian highest prevalence 24 black americans whites similar rates 21 22 respectively hispanics asians lowest rates 16 10 respectively1132 black americans suffer higher burden health consequences smoking particularly lung cancer cardiovascular disease despite fact smoking prevalence similar whites3334 black hispanic smokers less likely whites asked smoking habits offered tobaccocessation interventions3536 despite fact higher health consequences cigarette use37 studies included native americans despite high smoking ratesregular physical activity essential promote maintain health however current estimates indicate 33 americans meet current physical activity recommendations11 lack physical activity associated preventable morbidity mortality38 differences levels physical activity observed raceethnicity american indians blacks likely report engaging vigorous activity 68 66 respectively white respondents asians native hawaiians pacific islanders 57 60 61 respectively11 although reported using different metric hispanics also relatively inactive 25 report regular leisuretime physical activity11 increasing physical activity important intervention target primary secondary prevention cvd associated reductions bp lipid profiles blood sugar weight well maintaining healthy weight sustaining weight loss achieved38 makes imperative implement successful strategies improve health behaviors diverse groupsa framework addressing disparities health caredespite plethora studies documenting racialethnic disparities cardiovascular health national goal eliminating health disparities disparities persist institute medicine seminal report unequal treatment confronting racial ethnic disparities healthcare much raise public consciousness disparities health care proposed framework conceptualizing sources disparities2 defined disparities racialethnic differences explained underlying condition patient preferences institute medicine suggested understanding addressing institutional systems provider clinical encounter patientlevel variables lead differences quality healthcare received minorities critical finding effective solutionsthe robert wood johnson foundation initiative finding answers disparities research change39 builds institute medicine work work acknowledges social determinants health including poverty education access care significant barriers equitable care4041 must addressed eliminate disparities42 factors may beyond scope control providers39 initiative proposes framework providers healthcare organizations understand disparities solutions posits positive interactions patients providers system acknowledges individual characteristics community values societal norms lead improved processes care turn lead improved outcomes43behavioral interventions prevent cvd reduce cardiovascular riskas noted previously although considerable published data support effectiveness primary secondary prevention cvd risk factors reducing allcause cardiovascular morbidity mortality across racialethnic populations584445 achievement risk reduction optimal particularly racialethnic minority populations achieving cvd risk reduction ultimately reducing death disability cardiovascular diseases require specific strategies lifestyle change adherence medical therapies across racialethnic populations311interventions target smoking cessationa complex constellation biological social environmental psychological factors influences smoking prevalence dependence tobacco uniform characterization predicts initiation degree dependence37 compelling racialethnic group differences smoking behaviors make culturally tailored smokingcessation interventions priority blacks likely hispanics whites 69 29 22 respectively smoke mentholated cigarettes shown enhance smoking initiation inhibit quitting3346 black americans smoke fewer cigarettes per day however favored brands higher tar nicotine also make attempts quit per year less likely quit successfully compared nonhispanic white smokers33344750 hispanic americans less likely heavy smokers compared nonhispanic whites also less likely receive smokingcessation advice culturallylinguistically tailored services pharmacotherapy interventions4951 low quit rates52 little reported smoking preferences behaviors influence cultural practices relation smoking aian populations although highest prevalence active smoking low quit rates3352 data smoking behavior needed understudied aian asian native hawaiians pacific islanders populations52robles colleagues53 systematically reviewed smokingcessation pharmacotherapies diverse populations concluded pharmacotherapy including nicotine replacement gum patch nasal spray andor sustained release bupropion effective achieving smoking cessation racialethnic populations majority studies done blacks data less available aian hispanic asian populations53 quit rates pharmacotherapy attenuated blacks smoked within 30 minutes awakening smoked menthol cigarettes higher levels salivary cotinine individuals may need higher doses pharmacotherapy even light smokers another consideration quit rates attenuated 6 months thus booster sessions important sustained change53 one prospective observational study n1782 evaluated effectiveness nicotine replacement patch cessation rates among 5 major racialethnic groups using medicaid claims data survey response rate 58 although statistically significant betweengroup differences 30day cessation rates p014 trend asians 18 better quit rates whites blacks aian 10 12 9 respectively54 studies combination suggest smokingcessation pharmacotherapy may beneficial individuals racialethnic minority populations betweengroup differences persistcombining culturallylinguistically tailored cognitivebehavioral counseling tobaccocessation medication found increase rates smoking cessation minority populations studies combined counseling intervention 8 brief cognitivebehavioralmotivational counseling sessions either person telephonically combination sustainedrelease bupropion47 transdermal nicotine patch55 yielded 6month quite rates 21 17 respectively blacks combining openlabel bupropion nicotine patch individual counseling 8week intervention resulted impressive overall quit rate 53 note intervention effective 3 racialethnic groups included study however black americans benefitted lesser extent hispanics whites 38 41 60 respectively56the use clear direct advice healthcare providers stop smoking continues single influential way achieve smoking cessation patient populations provider education linked systemwide change cessation rates improve555759 adding smoking status vital sign clinic assessment process increased proportion providers asked smoking status advised patients quit arranged followup59 clinicwide initiatives including culturallylinguistically tailored behaviorchange stagespecific providerdelivered cessation advice techniques signed contracts waiting room posters cessation written information followup letters postintervention behavioral counseling electronic tracking medication cost reimbursement associated greater reduction smoking across racialethnic groups60 overall given significant disparities smoking prevalence cessation rates smokingrelated morbidity mortality experienced racialethnic populations encouraging note smokingcessation interventions effective underserved populations remains incumbent clinicians use bestpractice strategiesbehavioral strategies improve physical activity hearthealthy nutritionlifestyle behaviors including physical activity dietary habits influenced complex constellation personal environmental factors cultural norms values beliefs practices contribute shaping behavior important considerations effective interventions modify diet exercise behaviors diverse underserved racialethnic groups61 considerable interpersonal variation exists within racialethnic subgroup thus personally tailored interventions within cultural context appear successful61 environmental factors lack access healthy affordable food safe affordable places exercise exert significant influence h