Making The Connection: The Health of Black Women Cardiovascular Disease, Hypertension

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Making The ConnectionThe Health of Black
WomenCardiovascular Disease, Hypertension
Diabetes

• Philip M. Bonaparte. M.D.
• Chief Medical Officer
• Horizon NJ Health
• June 11, 2007

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What Is Cardiovascular Disease?

• CVD is a chronic health condition that affects
  the heart and the blood vessels.
• It includes
• Coronary Heart Disease
• Stroke
• Hypertension
• Rheumatic Heart Disease
• Facts about women and cardiovascular disease
• American Heart Association
• http//www.americanheart.org/presenter.jhtml?ident
  ifier2876

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Cardiovascular Disease in the US

• Nearly 80 million Americans have cardiovascular
  disease.
• Cardiovascular disease is the cause of more that
  6 million
• hospitalizations.
• AHA Statistical Update. Heart Diease and
  Stroke Statistics-2007 Update
• Circulation. 2007 115e69-e171
• 2007 American Heart Assocaition,
  Inc.

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Cost of CVD in the US, 2007
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Prevalence of CVD Among Women in the US

• CVD kills half a million women a year
• Its the leading cause of premature death among
  American women of all racial and ethnic groups
• Black women have the highest rate of CVD deaths
• Risk factors for heart disease and stroke are
  more common among women in ethnic minorities and
  those with lower socioeconomic status
• Centers for Disease Control and
  Prevention

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Prevalence of CVD Among Women in the US (contd)

• Women know more about their risks and symptoms of
  heart disease than of stroke
• Many women are unclear about the best ways to
  prevent CVD, such as the role of aspirin,
  hormones and supplements in prevention or the
  best diet for heart health
• Centers for Disease Control and
  Prevention

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Prevalence of CVD Among Women (contd)

• CVD is responsible for 39 of all female deaths
• In 2003, CVD claimed the lives of 483,842 females
  vs. 267, 902 deaths caused by all forms of
  cancer
• 38 of women compared to 25 of men will die
  within a year of a heart attack
• American Heart Association

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Prevalence of CVD Among Women (contd)

• Heart disease is often perceived as an older
  woman's disease
• Leading cause of death among women aged 65 years
  and older
• Third leading cause of death among women aged
  2544 years of age
• The 2nd leading cause of death among women aged
  4564 years
• In 2002, ageadjusted death rates for heart
  disease were higher among Black women (169.7 per
  100,000) than among White women (131.2 per
  100,000)
• 
  

Centers for Disease Control and Prevention
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Death Rates Diseases of Heart Per 100,000 Women
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Heart Disease Number One Killer Among Women

• Awareness Good News
• The percentage of women who spontaneously
  identified heart disease as the number one killer
  of women increased from 30 in 1997 to 46 in
  2003
• Perception Bad News
• Only 13 of the women surveyed in 2003 perceived
  heart disease as their greatest health problem
• Although this is an increase from the 7 in 1997,
  it reflects an attitude that heart disease is
  "not my problem"

American Heart Association Survey
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National Institutes of Health Report on CHD

• Heart disease deaths in women declined by nearly
  17,000 between 2003 and 2004, the last year
  statistics were available
• Experts quick to warn that the decline in death
  reflects mostly improvements in treatment and not
  a large drop in new cases of heart disease among
  women
• Rising obesity rates and other worrisome health
  trends, however, threaten to undo recent progress
  against heart disease

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National Institutes of Health Report on CHD

• Coronary heart disease is still the leading cause
  of death in both women and men

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CVD Risk Factors

• Family History
• Race
• Increasing Age
• Hx heart attack or stroke
• Diabetes Mellitus
• JAMA 2005 293 1868-74

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Additional Risk Factors Lifestyle Habits

• Smoking
• Physical inactivity
• Obesity and overweight
• Stress
• Low literacy level

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Cardiovascular Risk Factor Trends Among US
Adults Aged 20-74
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Risk Factor Differences Between Men and Women

• More women than men will have a second heart
  attack within 6 years after their 1st heart
  attack
• Women with diabetes are 3-4 times more likely
  than men to develop heart disease
• Diabetes doubles the risk of a second heart
  attack in women

National, Heart, Lung and Blood Institute The
Healthy Heart Handbook for Women, 2003
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Racial Disparity in Cardiovascular Disease

• Heart Disease is the leading cause of death among
  African American, Hispanic and Native American
  women.
• The prevalence of CVD in black women is 44.7
  compared to 32.4 in white women
• The rate of high blood pressure for black women
  age 20 and older is 45.4
• 33.9 of black women are inactive compared to
  21.6 of white women
• 77.2 of black women 20 and older are overweight
  or obese
• Women and Heart Disease An Atlas of Racial and
  Ethnic Disparities in Mortality, Second Edition.
  Morgantown, WV Office for Social Environment and
  Health Research, West Virginia University, 2000.

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African Americans With CVD

• Hospitalization for total heart disease and acute
  myocardial infraction
• Greater in men
• Greater and more congestive heart failure and
  stroke for women
• For Medicare enrollees, CHF hospitalization
• Higher in Blacks, Hispanics and American
  Indians/Alaska Natives than among Whites
• Stroke hospitalization was highest in Blacks

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Additional Contributing Factors

• Disparate use of invasive treatment options for
  patients who presented with Medicaid when
  compared to those with private pay,such as
  diagnostic cardiac catherization, percutaneous
  transluminal coronary angioplasty, coronary
  artery bypass graft surgery revascularization
• Several researchers have documented the disparity
  in the amount and quality of healthcare a person
  receives based on socioeconomic conditions
• Viswanath et al. found the source of health
  messages that a person encounters through their
  environment has relevance in the level and
  quality of information recall
• Viswanath, K., Steele, W.R., Finnegan, J.R.
  (2006). Social capital and health Civic
  engagement, community size, and recall of health
  messages. American Journal of Public Health, 96,
  1456-1461.

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Guidelines and Recommendations to Reduce CVD

• Lifestyle Interventions
• Urge women to seek a healthy weight
• Increase physical activity
• Stop or drink alcohol in moderation
• Eat less salt and sodium
• Stop smoking
• Drug Therapy Interventions
• Lower blood pressure
• Lower lipids
• Manage diabetes
• Use aspirin
• Circulation 2007. March 20
  115(11)1481-501

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High Blood Pressure

• More than 40 of adult African-Americans have
  hypertension
• An earlier onset rate and more severe in this
  group than in Caucasian and other racial or
  ethnic populations
• African-Americans are also at a higher risk for
  complications from HBP
• 80 higher death rate associated with stroke
• 50 higher rate associated with heart attack
• 320 higher death rate associated with end-stage
  kidney disease due to hypertension.
• Good news lowering blood pressure (BP) over time
  will help
• provide decreases of between 35 and 50 with
  these complications

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Misperceptions about Hypertension (HBP)

• Affects nearly 1 in 4 adults (60 million) in the
  United States
• About half do not know they have HBP, because it
  is associated with few symptoms
• More prevalent among African-Americans than other
  ethnic groups
• Despite encouraging progress in management and
  control, further lifestyle changes are needed to
  better manage HBP and risks for heart disease,
  stroke and kidney disease

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Factors Contributing to the Disparity

• Inadequate access to care
• Denial of life saving therapies
• Substandard level of medical care
• Sedentary lifestyles
• National Heart Lung and Blood Institute
• Imrproving Cardiovascular Health in African
  Americans
• http//www.nhlbi.nih.gov/health/public/heart/other
  /chdblack/

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Hypertension Education Foundation (HEF)

• Survey of 1,245 American adults, age 45 who
  have been diagnosed with hypertension show
• Misconceptions about elevated blood pressure
  persist in the African-American community
• More than one out of 10 (13) African-American
  respondents believe that HBP is not as much of a
  problem for older adults, because higher pressure
  is needed to get blood to the brain and kidneys
• Nearly one-quarter (22) believe that
  hypertension means a person is tense or anxious
• One third (35) did not identify 120/80 mmHg as
  optimal blood pressure

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Education is Key for HBP Management

• Peoples understandingor misunderstandingof
  high blood pressure is a key factor in how
  patients try to manage it
• Effective treatment of hypertension is one of the
  most dramatic examples of successful disease
  prevention
• Survey suggests that we still have room to
  improve its management within the
  African-American community

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Not So Good News for AA w/ HBP

• 75 with a body mass index (BMI) of more than
  gt30kg/m²
• 40 of African-Americans surveyed have diabetes
• 36 currently smoke
• 46 are not exercising regularly
• Greater efforts to modify eating (finding food
  lower in fat/sodium) and exercise habits will
  clearly provide a benefit in this population

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Target for Treatment

• Since African-Americans are disparately afflicted
  by hypertension and related complications, such
  as kidney disease and stroke, it is especially
  important to target efforts for treating this
  population
• Overwhelming evidence shows
• Treatment will prevent the ravages of
  hypertension in African Americans
• Therefore being African American is not the real
  problem, it is untreated hypertension

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Diabetes

• Most common chronic childhood disease
• Your generation will be the first to have a lower
  life expectancy than your parents
• 1 in 3 children will develop diabetes in their
  lifetime
• Diabetes disproportionately affects ethnic and
  racial minorities
• In NJ, non-Hispanic blacks have the highest rate
  of diabetes,followed by Hispanics and
  non-Hispanic whites
• 1 in 2 Latino children will develop diabetesin
  their lifetime
• African Americans are 1.6 times more likely to
  havediabetes than non-Latino whites and have a
  higherincidence of and greater disability from
  diabetescomplications such as kidney failure,
  visualimpairment and amputations

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Long Term Complications Associated With
Diabetes

• Eye disease - 1 cause of blindness
• Kidney damage - 1 cause of kidney failure
• Heart disease- high blood pressure, high
  cholesterol, strokes, heart attacks
• 70 of all people with diabetes die from a
  cardiovascular incident
• Nerve damage - feet and legs, possible amputation
• Dental disease - gum infections

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Diabetes

• Incidence of obesity,high cholesterol,high
  blood pressure,type 2 diabetes,sleep apnea
  andasthma are on the rise
• People at high risk for type 2 diabetes,
  including African Americans, can prevent or delay
  diabetes with modest weight loss and regular
  exercise

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Gestational Diabetes

• Occurs when your blood glucose or blood sugar is
  too high during pregnancy.
• Out of every 100 pregnant women in the US, three
  to eight get gestational diabetes.
• National Diabetes Information Clearinghouse
• National Institute of Diabetes and Digestive and
  Kidney Diseases

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Risk for Gestational Diabetes

• Having a family member with diabetes
• African American, American Indian, Asian
  American, Hispanic/Latino, or Pacific Islander
• 25 years old or older
• Overweight
• Previous history of gestational diabetes
• Previous child weighing more than 9 pounds
• National Diabetes Information Clearinghouse
• National Institute of Diabetes and Digestive and
  Kidney Diseases

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Can Gestational Diabetes Affect a Newborn?

• May be born very large or with extra fat
• May have low blood glucose after birth
• May have breathing problems
• May increase need for cesarean section
• National Diabetes Information Clearinghouse
• National Institute of Diabetes and Digestive and
  Kidney Diseases

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Gestational Diabetes Among African American And
Latina Women

• In a study of Kieffer et.al. of approximately
  1200 women ranging in age from 14 to 47 years,
• 47 of African American women and 37 of Latinas
  were overweight or obese, and 53 of African
  American women and 38 of Latinas gained weight
  during pregnancy
• The prevalence of GDM was 5.4 among Latinas and
  3.9 among African American women.
• After adjusting for other risk factors, Latinas
  were 2.5 times more likely than African Americans
  to develop GDM.
• Obesity and Gestational Diabetes Among
  African-American Women and Latinas in Detroit
  Implications for Disparities in Womens Health.
  JAMWA. 200156181-187.

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Kieffer et al. Study Conclusions

• Overweight, obesity, and GDM increase the risks
  of pregnancy, labor, delivery, and postpartum
  complications congenital anomalies fetal
  macrosomia preterm birth and perinatal
  mortality.
• As many as 50 of women with GDM will develop
  Type 2 diabetes within 5 years postpartum- with
  obesity and retains pregnancy weight gain as
  major risk factors.
• Obesity and Gestational Diabetes Among
  African-American Women and Latinas in Detroit
  Implications for Disparities in Womens Health.
  JAMWA. 200156181-187.

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Kieffer et al. Study Conclusions-contd

• A major focus of prenatal care research includes
  the prevention of low birth weight and
  encouraging weight gain in pregnancy. There is
  less attention given to obesity and diabetes
  during pregnancy.
• If more attention is paid to dietary
  modifications, increased physical activity, and
  breastfeeding to reduce pregnancy weight gain the
  rising prevalence of intrauterine exposure to GDM
  among infants and early-onset Type 2 diabetes.
• Obesity and Gestational Diabetes Among
  African-American Women and Latinas in Detroit
  Implications for Disparities in Womens Health.
  JAMWA. 200156181-187.

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Obesity A Threat

• There are ominous signs that obesity could
  undermine the positive trends found in the report
  
• About one-third of U.S. women are obese, giving
  them a prime risk factor for heart disease
• A major federal health survey (1999 to 2004)
  showed a 29 rate for adult hypertension, which
  was up from 23 a decade before

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Cause For Concern

• Obesity and hypertension, both major heart
  disease risk factors, could soon undo the
  improvements seen in the last few years 
• The consequences
• Chronic disease takes time to get bad
• Obesity, over time, will affect blood pressure,
  heart disease and other areas

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Obesity In Pregnancy

• An obese, expectant mother nearly doubles the
  risk of having a premature baby or a baby born
  with birth defects, as compared to a woman who
  maintains a normal weight
• Obesity increases the health risks to the mother
  for her entire life
• Pregnant, obese women more likely to have
  increased rates of gestational diabetes, high
  blood pressure and toxemia they are also more
  likely to be hospitalized during pregnancy
• When women gain more than the recommended amount
  of weight during pregnancy, they are more likely
  to be obese one year after giving birth, as
  compared with women who gain within the
  recommended range.
• One study found AA women were four times more
  likely to be obese
• National Institutes of Health

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Awareness Is Key

• Researchers compared the findings of the national
  survey of 1,000 women to previous survey results
  dating back to 1997, when the American Heart
  Association launched the "Go Red for Women"
  campaign to educate women about heart disease and
  stroke
• Though they are at greater risk for
  cardiovascular disease, minority women in the US
  know less about this serious health issue than
  white women

American Heart Association
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Awareness And Prevention

• There is still the challenge to reduce ethnic
  disparities and maximize knowledge among all
  racial and ethnic groups
• Awareness is linked to preventive action
• Data suggest one potential way to reduce
  disparities in health outcomes in the U.S.
• Through more targeted efforts to raise awareness
  among racial and ethnic minorities who are least
  aware of heart disease and stroke and also at
  greatest risk

American Heart Association/survey
(January/February issue of the Journal of Women's
Health)
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QUESTIONS???
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Contact InformationPhilip M. Bonaparte,
MD210 Silvia St.West Trenton, NJ
08628phil_bonaparte_at_horizonnjhealth.com(609)
538-0700 x5186