uS$r- muJf\ Volume IV: '. rj- Cardiovascular and Cerebrovascular 9 )ioS Disease jm V. y Part 1 fcZS^lst Report of the Secretary's Task Force on Black & Minority Health U.S. Department of Health and Human Services U.S. NATIONAL LIBRARY OF MEDICINE Volume IV: Cardiovascular and Cerebrovascular Disease Part 1 Report of the Secretary's Task Force on Black & Minority Health U.S. Department of Health and Human Services January 1986 SECRETARY'S TASK FORCE ON BLACK AND MINORITY HEALTH MEMBERS Thomas E. Malone, Ph.D., Chairperson Katrina W. Johnson, Ph.D., Study Director Wendy Baldwin, Ph.D Betty Lou Dotson, J.D. Manning Feinleib, M.D., Dr.P.H. William T. Friedewald, M.D. Robert Graham, M.D. M. Gene Handelsraan Jane E. Henney, M.D. Donald R. Hopkins, M.D. Stephanie Lee-Miller Jaime Manzano J. Michael McGinnis, M.D. Mark Novitch, M.D. Clarice D. Reid, M.D. Everett R. Rhoades, M.D. William A. Robinson, M.D., M.P.H. James L. Scott Robert L. Trachtenberg T. Franklin Williams, M.D. 300 US2r in pt./ .^ ALTERNATES Shirley P. Bagley, M.S. Claudia Baquet, M.D., M. Howard M. Bennett Cheryl Damberg, M.P.H. Mary Ann Danello, Ph.D. Jacob Feldman, Ph.D. Marilyn Gaston, M.D. George Hardy, M.D. John H. Kelso P.H. James A. Kissko Robert C. Kreuzburg, M.D Barbara J. Lake Patricia L. Mackey, J.D. Delores Parron, Ph.D. Gerald H. Payne, M.D. Caroline I. Reuter Clay Simpson, Jr., Ph.D. Ronald J. Wylie u TABLE OF CONTENTS PART 1 Introduction to the Task Force Report ............ v Members of the Subcommittee on Cardiovascular and Cerebrovascular Diseases.....................ix Report of the Subcommittee ............... 1 PART 2 Supporting Papers 1. Shiriki K. Kumanyika, Daniel D. Savage: Ischemic Heart Disease Risk Factors in Black Americans ......... 229 2. Lucile L. Adams, Laurence 0. Watkins, Lewis H. Kuller, Daniel D. Savage, Richard Donahue, Ronald E. LaPorte: Relationship of Social Class to Coronary Disease Risk Factors in Blacks: Implications of Social Mobility for Risk Factor Change................285 3. Hector F. Myers: Coronary Heart Disease in Black Populations: Current Research, Treatment, and Prevention Needs ...... 303 4. Melford J. Henderson, Daniel D. Savage: Prevalence and Incidence of Ischemic Heart Disease in United States' Black and White Populations.............347 5. Helen P. Hazuda: Differences in Socioeconomic Status and Acculturation among Mexican Americans and Risk of Cardiovascular Disease ............... 367 6. Shiriki K. Kumanyika, Daniel D. Savage: Ischemic Heart Disease Risk Factors in Hispanic Americans ........ 393 7. Shiriki K. Kumanyika, Daniel D. Savage: Ischemic Heart Disease Risk Factors in Asian/Pacific Islander Americans . ... 415 8. Shiriki K. Kumanyika, Daniel D. Savage: Ischemic Heart Disease Risk Factors in American Indians and Alaska Natives....................445 9. Lewis H. Kuller: Stroke Report 477 INTRODUCTION TO THE TASK FORCE REPORT Background The Task Force on Black and Minority Health was established by Secretary of Health and Human Services Margaret M. Heckler in response to the striking differences in health status between many minority populations in the United States and the nonminority population. In January 1984, when Secretary Heckler released the annual report of the Nation's health, Health, United States, 1983, she noted that the health and longevity of all Americans have continued to improve, but the prospects for living full and healthy lives were not shared equally by many minority Americans. Mrs. Heckler called attention to the longstanding and persistent burden of death, disease, and disability experienced by those of Black, Hispanic, Native American, and Asian/Pacific Islander heritage in the United States. Among the most striking differentials are the gap of more than 5 years in life expectancy between Blacks and Whites and the infant mortality rate, which for Blacks has continued to be twice that of Whites. While the differences are particularly evident for Blacks, a group for whom information is most accurate, they are clear for Hispanics, Native Americans, and some groups of Asian/Pacific Islanders as well. By creating a special Secretarial Task Force to investigate this grave health discrepancy and by establishing an Office of Minority Health to implement the recommendations of the Task Force, Secretary Heckler has taken significant measures toward developing a coordinated strategy to improve the health status of all minority groups. Dr. Thomas E. Malone, Deputy Director of the National Institutes of Health, was appointed to head the Task Force and 18 senior DHHS executives whose programs affect minority health were selected to serve as primary members of the Task Force. While many DHHS programs significantly benefit minority groups, the formation of this Task Force was unique in that it was the first time that attention was given to an integrated, comprehensive study of minority health concerns. Charge Secretary Heckler charged the Task Force with the following duties: • Study the current health status of Blacks, Hispanics, Native Americans, and Asian/Pacific Islanders. • Review their ability to gain access to and utilize the health care system. • Assess factors contributing to the long-term disparities in health status between the minority and nonminority populations. v • Review existing DHHS research and service programs relative to minority health. • Recommend strategies to redirect Federal resources and programs to narrow the health differences between minorities and nonminorities. • Suggest strategies by which the public and private sectors can cooperate to bring about improvements in minority health. Approach After initial review of national data, the Task Force adopted a study approach based on the statistical technique of "excess deaths" to define the differences in minority health in relation to nonminority health. This method dramatically demonstrated the number of deaths among minorities that would not have occurred had mortality rates for minorities equalled those of nonminorities. The analysis of excess deaths revealed that six specific health areas accounted for more than 80 percent of the higher annual proportion of minority deaths. These areas are: • Cardiovascular and cerebrovascular diseases • Cancer • Chemical dependency • Diabetes • Homicide, suicide, and unintentional injuries • Infant mortality and low birthweight. Subcommittees were formed to explore why and to what extent these health differences occur and what DHHS can do to reduce the disparity. The subcommittees examined the most recent scientific data available in their specific areas and the physiological, cultural, and societal factors that might contribute to health problems in minority populations. The Task Force also investigated a number of issues that cut across specific health problem areas yet influence the overall health status of minority groups. Among those reviewed were demographic and social characteristics of Blacks, Hispanics, Native Americans, and Asian/Pacific Islanders; minority needs in health information and education; access to health care services by minorities; and an assessment of health professionals available to minority populations. Special analyses of mortality and morbidity data relevant to minority health also were developed for the use of Task Force. Reports on these issues appear in Volume II. Resources More than 40 scientific papers were commissioned to provide recent data and supplementary information to the Task Force and its subcommittees. Much material from the commissioned papers was incorporated into the subcommittee reports; others accompany the full text of the subcommittee reports. VI An inventory of DHHS program efforts in minority health was compiled by the Task Force. It includes descriptions of health care, prevention, and research programs sponsored by DHHS that affect minority populations. This is the first such compilation demonstrating the extensive efforts oriented toward minority health within DHHS. An index listing agencies and program titles appears in Volume I. Volume VIII contains more detailed program descriptions as well as telephone numbers of the offices responsible for the administration of these programs. To supplement its knowledge of minority health issues, the Task Force communicated with individuals and organizations outside the Federal system. Experts in special problem areas such as data analysis, nutrition, or intervention activities presented up-to-date information to the Task Force or the subcommittees. An Hispanic consultant group provided inform- ation on health issues affecting Hispanics. A summary of Hispanic health concerns appears in Volume VIII along with an annotated bibliography of selected Hispanic health issues. Papers developed by an Asian/Pacific Islander consultant group accompany the report of the Subcommittee on Data Development appearing in Volume II. A nationwide survey of organizations and individuals concerned with minority health issues was conducted. The survey requested opinions about factors influencing health status of minorities, examples of success- ful programs and suggestions for ways DHHS might better address minority health needs. A summary of responses and a complete listing of the organizations participating in the survey is included in Volume VIII. Task Force Report Volume I, the Executive Summary, includes recommendations for department-wide activities to improve minority health status. The recommendations emphasize activities through which DHHS might redirect its resources toward narrowing the disparity between minorities and nonminorities and suggest opportunities for cooperation with nonfederal structures to bring about improvements in minority health. Volume I also contains summaries of the information and data compiled by the Task Force to account for the health status disparity. Volumes II through VIII contain the complete text of the reports prepared by subcommittees and working groups. They provide extensive background information and data analyses that support the findings and intervention strategies proposed by the subcommittees. The reports are excellent reviews of research and should be regarded as state-of-the-art knowledge on problem areas in minority health. Many of the papers commissioned by the Task Force subcommittees accompany the subcommittee report. They should be extremely useful to those who wish to become familiar in greater depth with selected aspects of the issues that the Task Force analyzed. vn The full Task Force report consists of the following volumes: Volume I: Executive Summary Volume II: Crosscutting Issues in Minority Health: Perspectives on National Health Data for Minorities Minority Access to Health Care Health Education and Information Minority and other Health Professionals Serving Minority Communities Volume III: Cancer Volume IV: Cardiovascular and Cerebrovascular Diseases Volume V: Homicide, Suicide, and Unintentional Injuries Volume VI: Infant Mortality and Low Birthweight Volume VII: Chemical Dependency Diabetes Volume VIII: Hispanic Health Issues Survey of the Non-Federal Community Inventory of DHHS Program Efforts in Minority Health vm SUBCOMMITTEE ON CARDIOVASCULAR AND CEREBROVASCULAR DISEASES CHAIR William T. Friedewald, M.D. Director Division of Epidemiology and Clinical Applications National Heart, Lung, and Blood Institute National Institutes of Health MEMBERS Howard Bennett, esq. Associate Deputy Director Office of Management and Policy Office for Civil Rights Allan L. Forbes, M.D. Director Office of Nutrition and Food Sciences Center for Food Safety and Applied Nutrition Food and Drug Administration Gerald H. Payne, M.D. Chief Prevention and Demonstration Research Branch Division of Epidemiology and Clinical Applications National Heart, Lung, & Blood Institute National Institutes of Health Daniel D. Savage, M.D., Ph.D. Medical Officer National Center for Health Statistics Mark Novitch, M.D. Formerly: Deputy Commissioner Food and Drug Administration Ronald J. Wylie, esq. Special Assistant to the Administrator Health Care Financing Administration Paul A. Nutting, M.D. Director Office of Primary Care Studies Health Resources and Services Administration T. Franklin Williams, M.D. Director National Institute on Aging National Institutes of Health IX ALTERNATES Shirley P. Bagley, M.S. Assistant Director for Special Programs National Institute on Aging National Institutes of Health Mary Ann Danello, Ph.D. Special Assistant to the Commissioner for Science Food and Drug Administration Lynn A. Larsen, Ph.D. Associate Director for Program Development Center for Food Safety and Applied Nutrition Food and Drug Administration CONSULTANT WRITERS Laurence 0. Watkins, M.D., M.P.H. Assistant Professor of Medicine Section of Cardiology Department of Medicine Medical College of Georgia Hector F. Myers, Ph.D. Associate Professor of Psychology Department of Psychology University of California at Los Angeles STAFF Elisabeth Pitt, M.A. Program Analyst Clinical Applications and Prevention Program Division of Epidemiology & Clinical Applications National Heart, Lung, 6c Blood Institute National Institutes of Health Marilyn Kunzweiler, M.P.H. Presidential Management Intern Division of Epidemiology & Clinical Applications National Heart, Lung, & Blood Institute National Institutes of Health x Report of the Subcommittee On Cardiovascular and Cerebrovascular Diseases In Black and Minority Populations All tables and figures from the American Heart Journal reprinted with permission bv C.V. Mosbv Company. All material copyrighted by the American Heart Association reprinted by permission of the American Heart Association. Reproduced with permission from the Annual Review of Public Health, vol. 2, ® 1981, by Annual Reviews, Inc. Archives of Environmental Health, vol. 19, August 1969. Reprinted with permission of the Helen Dwight Reid Educational Foundation. Published by Heldref Publications, 4000 Albemarle Street, N.W., Washington, D.C. 20016. The table from Journal of Chronic Diseases, vol. 17, by Gordon T. Garcia- Palmieri MR, Kagan A, et al.," Differences in coronary heart disease in Framingham, Honolulu, and Puerto Rico," 1974, reprinted with permission, Pergamon Press, Ltd. REPORT OF THE SUBCOMMITTEE ON CARDIOVASCULAR AND CEREBROVASCULAR DISEASES CONTENTS ACKNOWLEDGEMENTS xvn INTRODUCTION CARDIOVASCULAR AND CEREBROVASCULAR DISEASES IN BLACK AMERICANS Introduction Coronary Heart Disease Mortality Morbidity Incidence Cohort Studies Sudden Death . Acute Myocardial Infarction Hypertension .... Blood Pressure Levels and Prevalence of Hypertension Trends in Blood Pressure Levels and Prevalence Awareness of Blood Pressure Status, Treatment, & Control Trends in Awareness, Treatment, and Control Stroke ..... Mortality ..... Morbidity ..... Hypertensive End-Stage Renal Disease Introduction .... Morbidity ..... Incidence ..... Mortality ..... Explanations for Differences Introduction ..... Biologic and/or Physiologic Variables Coronary Heart Disease Introduction .... Age, Sex, and Family History Hypertension .... Blood Lipids and Lipoproteins Total Blood Cholesterol High-Density Lipoprotein Cholesterol Cigarette Smoking . Diabetes Mellitus . Electrocardiographic Abnormality Obesity ..... Conclusion: Multiple Risk Factors Hypertension .... Introduction .... Inadequacy of Genetic Explanations BP Distributions in African & Other Black Populations Differential Sensitivity to Dietary Electrolytes? Correlates of Hypertension Incidence: Implications for Primary Prevention xm Stroke ..... Hypertension .... Cholesterol and Cigarette Smoking Conclusion .... Hypertensive End-Stage Renal Disease Conclusion ..... The Role of Hypertension in Black CVD Mortality and Morbidity Racial Trends in Hypertension-Related Mortality: Role of Hypertension Treatment Socioeconomic Factors ...... Social Epidemiology ...... Coronary Heart Disease ..... Social Epidemiology ..... Socioeconomic Status and Biological Risk Factors Hypertension ....... Social Epidemiology ..... Psychosocial Stress Hypothesis Social Class and Hypertension-Related Mortality Stroke ........ Links with Socioeconomic Factors . Hypertensive End-Stage Renal Disease Links with Socioeconomic Factors . Behavioral and/or Cultural Factors Introduction Coronary Heart Disease Health Beliefs/Knowledge Risk Factors Diet and Cardiovascular Disease Cardiovascular Health Education Health Practices ...... Dietary Practices ..... Physical Activity ..... Cigarette Smoking ..... Health Care Seeking Behavior Hypertension ....... Health Beliefs/Knowledge .... Hypertension as a Health Problem Causes of Hypertension .... Health Practices ...... Dietary Practices and Primary Prevention Health Care Seeking Behavior Nonadherence to Antihypertensive Therapy Determinants of Adherence Effective Intervention Models . Access to and Utilization of the Health Care System Introduction ....... Health Care for Coronary Heart Disease Data on Office Visits ..... Hospitalization ...... Prognosis After Myocardial Infarction . 30 30 30 30 30 31 31 31 32 32 33 33 34 35 35 36 37 37 37 38 38 38 38 38 38 39 39 40 40 40 40 41 42 42 42 42 43 43 43 44 44 45 46 47 47 49 49 50 50 xiv Hospitalization for Chronic Coronary Heart Disease Coronary Arteriography and Coronary Bypass Surgery Health Care for Hypertension ..... Data on Visits to Physicians .... Awareness, Treatment, and Control Status Perceptions of Access and Impact on Medical Care Use Effect of Decreasing Public Support for Health Services 54 Black Physician Manpower . . . . . .54 50 51 52 52 52 53 CARDIOVASCULAR AND CEREBROVASCULAR DISEASE IN HISPANIC, ASIAN/PACIFIC ISLANDER, AND NATIVE AMERICANS Introduction .... .57 CARDIOVASCULAR AND CEREBROVASCULAR DISEASES IN HISPANIC AMERICANS Introduction Coronary Heart Disease Mortality Morbidity Stroke Mortality Hypertension Explanations for Differences Biologic and/or Physiologic Variables Risk Factors .... Lipids and Lipoproteins Hypertension .... Diabetes Mellitus . Obesity ..... Cigarette Smoking . Socioeconomic and Sociocultural Factors Socioeconomic Factors Sociocultural Factors Behavioral and Sociocultural Factors Introduction .... Exercise ..... Access to and Utilization of the Health Care System 59 60 60 61 62 62 62 64 65 65 66 67 67 68 69 70 70 71 71 71 72 72 CARDIOVASCULAR AND CEREBROVASCULAR DISEASES IN ASIAN/PACIFIC ISLANDER AMERICANS Introduction Coronary Heart Disease Mortality Morbidity Stroke Mortality Morbidity Explanations for Differences .... Biologic and/or Physiologic Variables in Japanese Hypertension ...... Cholesterol ...... Smoking ....... 73 74 . 74 77 77 77 78 78 Americans 79 79 80 . 81 XV Overall Impact of Risk factors on CHD in Japanese Americans 81 Biologic and/or Physiologic Variables in Chinese Americans 82 Biologic and/or Physiologic Variables in Filipino Americans 84 Hypertension ......... 84 Smoking .......... 84 CARDIOVASCULAR AND CEREBROVASCULAR DISEASES IN NATIVE AMERICANS Introduction ..... Coronary Heart Disease Mortality ..... Morbidity ..... Explanations for Differences Biologic and/or Physiologic Variables Hypertension .... Blood Lipids and Lipoproteins Diabetes and Obesity . Cigarette Smoking and Alcohol Use Socioeconomic and Sociocultural Factors 87 88 88 89 89 90 90 91 92 92 92 TABLES AND FIGURES Black Americans Hispanic Americans Asian/Pacific Islander Americans Native Americans 96 152 156 186 RECOMMENDATIONS Research Issues ...... Information and Education .... Access and Utilization .... Capacity Building in the Non-Federal Sector Financing ...... Health Professions' Development . Leadership ...... Data Issues ...... REFERENCES Black Americans (1. - 215.) Hispanic Americans (300. - 350.) Asian/Pacific Islander Americans (400. - 426.) Native Americans (500. - 524.) 191 197 198 199 199 199 200 200 203 219 223 225 xvi ACKNOWLEDGEMENTS This report is the result of dedicated work done by the consultant writers, position paper authors, members of the Subcommittee, their alternates, National Heart, Lung, and Blood Institute staff, and the support staff from the DHHS Task Force on Black and Minority Health. In particular, I would like to thank: Laurence 0. Watkins for his extensive and competent report on Black Americans Hector F. Myers for his well-crafted reports on Hispanic Americans, Asian/Pacific Islander Americans, and Native Americans, despite the scant data available to him; Daniel D. Savage for his coordination efforts; Elisabeth Pitt for her untiring, comprehensive, and competent editorial work in shepherding this report through its numerous stages, especially for her detailed work with its multiple authors; Gerald H. Payne for his occasional representation of this Subcommittee at Task Force meetings, and for providing invaluable editorial advice. This report drew heavily not only from the literature, but also from several manuscripts (position papers), commissioned by the Task Force for the Subcommittee, to the authors of which we are indebted. They are: Luc He L. Adams, Laurence 0. Watkins, Lewis H. Kuller, Daniel D. Savage, Richard Donahue, Ronald E. LaPorte Helen P. Hazuda Melford Henderson and Daniel D. Savage Lewis H. Kuller Shiriki K. Kumanyika and Daniel D. Savage Hector F. Myers xvn In addition we wish to thank the following authors of papers, (commissioned for other Task Force Subcommittees) that this report used as resource materials: John K. Davidson E.S. Helena Yu, C.F. Chang, W.T. Liu, and S.H. Kan Finally, gratitude is due to the many dedicated support staff on the Task Force who, despite other deadlines, managed to assist us in producing this report. William T. Friedewald, M.D. Director Division of Epidemiology and Clinical Applications NHLBI, NIH xvm INTRODUCTION The arteriosclerotic diseases, particularly coronary heart disease and cerebrovascular disease, specifically stroke, cause more deaths, disability, and economic loss in the United States than any other group of acute or chronic diseases [Figure 1, Table 1]. They are also the leading cause of days lost from work.(l) Despite the fact that cardiovascular disease is a major killer in the United States, the data on the impact of cardiovascular diseases in minority populations are relatively sparse compared to those available on the white population. In recent years, the practice of collecting nationwide data by white and non-white categories is being replaced by data collection according to more specific minority categories.(2) In these minority groups, the most ample data on cardiovascular diseases are available for Blacks. The data on Hispanic populations, Asians, and Native Americans are less ample. Thus, though it is possible to examine some information on cardiovascular morbidity, mortality, prevalence and incidence rates, and their determinants in the white population, it is less feasible to obtain similar reliable data on cardiovascular diseases in specific minorities. This report addresses the chronic cardiovascular diseases: 1. coronary heart disease, 2. hypertension, 3. stroke, and 4. end-stage renal disease related to hypertension (only for Blacks). The report consists of several parts, each devoted to a minority group: 1. Black Americans, 2. Hispanic Americans, 3. Asian/Pacific Islander Americans, and 4. Native Americans. 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P- O CD Co CD 3 £ Cfl V. CD Mi Ml ^ 0 M Co 3 3 P- 3 p- P1 h-1 3 rt CD tr OO o 0 3 n CD 3 CD CD 3 -5 3 3 n 3 P- 0 CD 3 3 p- p- Co n 0 M. M ON CD W Cfl CD Cfl CD cr M t*-! P» 3 CD CD V. rt 3 00 JTJ M cH? 3 C3 ** 13 p-3 Mi 3 p-rt Co p' P-r-> S On CD 0 Mi 0 3 CD CD Cfl B VJ rt tr to Co y-\ CD 0 •S CD p1 MD Mi h( cr rt to CD Co 3 Co r-i M ii Co P1 vj 0 LO P-1 O a 3 a n a P-0 a Cfl ON rt tr CD Ln 1 Co o 7? Ui Cfl (ii) Morbidity * The prevalence of coronary heart disease in Slacks and whites * appears to be similar. Sampling techniques in national surveys * have not allowed definitive resolution of the question of dif- * ferences in prevalence. * Methodologic problems make comparisons of CHD prevalence in Blacks and whites less revealing than might be expected.(8) In the 1960-62 National Health Examination Survey,(9) the prevalence of definite or suspect CHD, diagnosed by electrocardiographic (ECG) evidence of healed myocardial infarction (MI) or myocardial ischemia, or a history of MI or angina pectoris, was 4-6% in all race-sex groups [Tables 5-6]. The prevalence of ECG evidence of MI in adults, ages 18 to 79 years, was less than 2%: within the "definite" category, 2% of white men had ECG evidence of MI, compared to 1.7% of Black men. In women, the corresponding rates were 0.7% and 0.4%. Blacks constituted 10.5% of this representative sample. In the 1971-75 National Health and Nutrition Examination Survey (NHANES I), (10) ECG evidence of healed MI was more common in white men than in Black men only above the age of 65 years, but was more common in Black women than in white women of similar age [Table 7], If significant, these differences might reflect the higher age-specific CHD mortality in non-white men than in white men in the decades of age 35-44, 45-54, and 55-64 years,(11) so that the lower frequency in older Black men might reflect the fact that these men have survived the period that is for their group the one of highest mortality risk. In the hypertensive stepped care subjects in the Hypertension Detection and Follow-up Program,(12) ECG-MI was detected at baseline in less than 2% of all race-sex groups, and a history of myocardial infarction diagnosed by a physician was given by about 5% of subjects in each group. The similar prevalence rates of MI in hypertensive subjects of both races were associated with similar all-cause mortality rates in the subsequent five years in each race-sex group. However, the data suggest that a Rose Questionnaire diagnosis of angina pectoris is less specific for CHD in Black women than in white women, since the five-year mortality rate in Black women with angina pectoris was much lower than that in similar white women. (iii) Incidence * Small studies in the South revealed lower incidence of coronary * * disease in Black than in white men. Among women, Blacks had * similar or slightly higher rates than whites. Studies of hos- * pital admissions for acute myocardial infarction indicate higher * * rates for whites than for Blacks. 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In addition to the 25.1 million adults ages 18-74 years, with definite hypertension, there were 17.1 million adults of that age with borderline hypertension, defined as systolic blood pressure greater than or equal to 140 mm Hg and less than 160 mm Hg and/or diastolic blood pressure greater than or equal to 90 mm Hg and less than 95 mm Hg in subjects not taking antihypertensive medication. The prevalence is 11.9% for white adults and 12.5% for Black adults. Isolated systolic hypertension, defined as the presence of a systolic blood pressure greater than or equal to 160 mm Hg but a diastolic pressure of less than 90 mm Hg, was more prevalent in Black adults, ages 55-74 years, (8.1%) than among white adults of similar age (4.8%). (ii) Trends in Blood Pressure Levels and Prevalence * In the period 1960-1980, mean systolic blood pressure has dec- * lined more in Blacks than in whites. The prevalence of definite * * hypertension increased significantly in whites, but did not * change significantly in Blacks. ..(..••.ImJ..'. It is possible to assess differences in mean blood pressures across surveys, and such an analysis has been performed for the first systolic blood pressure measurement in NHES I, NHANES I and NHANES 11.(31) This analysis reveals that mean systolic blood pressure has decreased significantly in the 20-year period between 1960 and 1980, in Black men from 138 to 136 to 130 mm Hg, and in Black women from 138 to 135 to 126 mm Hg. The age-adjusted mean systolic blood pressure declined more in Black adults than in white adults, 8 mm Hg compared to 4 mm Hg in men, and 12 mm Hg compared to 6 mm Hg in women. The improvement was greater for the older age-groups than for the younger. Over the 20-year period, the age-adjusted proportions of people with systolic blood pressure greater than or equal to 140 mm Hg decreased substantially more in Black adults than in white adults. From 1960 to 1980, the decline for Black men was from 41.2% to 28.3%, and for white men 32.4% to 27.0%. For Black women the decline was from 39.6% to 26.7%; for white women from 26.1% to 21.1%. The net result is that these proportions are similar in three of the four race-sex groups in the 1976-1980 NHANES II data, 27.0%, 28.3% and 26.7% for white men, and Black men and women, respectively, with white women constituting 21.1%. The available data also allow comparisons of prevalence rates of hypertension in 1960-62, 1971-75, and 1976-80.(31) [Table 1] Freeman et al(32) have demonstrated, using appropriate statistical methods, that there were no significant changes in prevalence in age-race-sex-specific groups between the National Health Examination 9 ro p- CL P- p- cr On VJ PL P- rt 0 ro p- On O 3 CD to h-' hi CO to h-' to i—1 £ CD £ 0 ro rt £ 0 po rt to rt 3 fOiH Co < p-3 er vj ro 3 z eu i'e 0- JS- ie it- * t CL CD p* er NO VJ p« 00 13 M CD < Co cn 3 •i < ro 00 Mi Mi 00 . Cl po 0 Co Co ii 3 Co 3 o ro i ro Co 13 tr > Jf :f O WW 3 Ml P> 3 Ml cr 3 On P- 0 CD o O CD CD rt CD 3 vj ^j po P- rt CD E_i. z £ Co CD CO r r—1 O IU p- ro ^5 ro CD ro P- 5-S O 7? 7? 7? 3 p- 3 OO -P- rt h-' M hi CD w * p- P- h-1 v; :T P- 1 3 on M rt ro 3 Mi p PL hi Mi po ro 3 P' cn er 3 CO CD rt- o cn Jj- ti- 3 CD 'S VJ ro CD 3 0 CD P- ro p- ro rt p- rt 3 CD CD £ 3 0 Co rt rt tO po VJ CD cr Co ro rt Jj- er h-1 < h-' $ ro to o 3 Co o 3 M. 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CD i'e 3 3 Co M VJ hi 0 CD ti- ro O m- tr ro CD ii < 'i- 1 p- I rt rt oo Co o po pJ er p- 7? VJ po » 0 CD i ii ii ro h-1 r-> 3 rt- VJ 0 3 rt P1 3 a * a ie 0 r-> ro P^ (iv) Trends in Awareness, Treatment, and Control * Though there was a significant excess of hypertension in Black * men and women in 1976-1980, the trends in awareness, treatment, * * and control during the 1960-1980 period indicate significant im- * * provements in the status of Black adults. The NCHS has published an examination of trends in awareness, treatment, and control status from 1960-1980. Unlike the NHANES II data on awareness, treatment, and control reported in earlier sections, these data are based on the population, ages 18-74 years, and report the frequency of awareness, treatment, and control in this population, rather than as a proportion of hypertensive subjects. This is appropriate since the prevalence of hypertension has increased significantly, at least in whites, from 1976 to 1980. The data reveal substantial improvements in all categories for both racial groups. The proportion of people with undiagnosed hypertension has declined from 1960-1980.(31) Over the 20-year period, the age-adjusted proportion of people, ages 18-74 years, with undiagnosed hypertension decreased from 10.7% to 9.8% in white men, from 7.7% to 5.6% in white women, from 21.1% to 9.9% in Black men, and from 13.2% to 4.5% in Black women. This decline was substantially larger in Black than in white adults. The age-adjusted proportion of people, ages 18-74 years, taking antihypertensive medication increased from 3.8% to 7.6% for white men, from 7.0% to 11.1% for white women, from 6.0% to 9.2% for Black men and from 15.9% to 19.3% for Black women. Again, the age-adjusted proportion of people taking medications was generally higher among Black adults than among white adults, and among women than men, but the amount of increase from 1960-1980 was similar for each of the four race-gender groups. The proportion of people, ages 18-74 years, with controlled hypertension increased significantly from 1960-1980 and was at least doubled for each race-gender group: from 1.5% to 3.4% for white men, from 2.9% to 6.3% for white women, from 0.6% to 3.3% for Black men, and from 6.0% to 11.6% for Black women. 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Among Black men, the greatest declines have been observed in the two decades of age: 35-44 and 55-64 years. (ii) Morbidity * A higher proportion of Blacks than of whites in the population * * has suffered stroke. * Data on stroke morbidity in minorities are less ample. The 1972 National Health Interview Survey(37) yielded an estimated prevalence of stroke among whites of 7.2/1000 and among non-whites 9.1/1000. Among the participants who were randomly assigned to the Hypertension Detection and Follow-up Program in 1973-1974(38), the prevalence of stroke was twice as high among Black men as among white men, while for women the Black-white ratio was 1.4. In 1967-69, there was a much more marked disparity in the prevalence of stroke between the Black and white racial groups in Evans County, Georgia (an area within the stroke belt).(39) The age-adjusted prevalence of stroke in Black women was 43.4/1000 compared to 15.0/1000 in white women, while there was less of a disparity among men, the rates being 58.6/1000 among Black men and 53.2/1000 among white men. The incidence of stroke is higher among Blacks than among whites. The age-adjusted incidence of stroke in southern Alabama in 1980 was 208/100,000 among Blacks and 109/100,000 among whites.(40) The highest age-adjusted rate was observed among Black women, 236/100,000, compared to 88/100,000 among white women (relative risk, 2.7), while in men the comparable rates were 172/100,000 for Blacks and 139/100,000 for whites (relative risk, 1.2). Similarly, the incidence of stroke was much higher among Black men and women in the Hypertension Detection and Follow-up Program than in white adults.(38) Clinical evaluation of the type of stroke in the southern Alabama study revealed that the majority of strokes in both races are due to cerebral infarction rather than to cerebral hemorrhage. 13 Hypertensive End-Stage Renal Disease * End-stage renal disease caused by hypertension occurs much more * * commonly in Blacks than in whites. Blacks with hypertension are * * at much greater risk of developing end-stage renal disease than * * whites. Blacks with hypertensive end-stage renal disease treated * * with dialysis have a more favorable cardiovascular mortality * outlook than whites. (i) Introduction End-stage renal disease (ESRD) is one of the sequelae of hypertension. Data collected by the National Center for Health Statistics(41) indicate that hypertensive heart and kidney disease, and hypertensive kidney disease together account for 23.6% of all deaths related to kidney and urinary tract disorders. (ii) Morbidity Primary hypertensive disease accounts for 13% of patients on maintenance dialysis. In 1976 the total population undergoing end-stage renal disease treatment was about 31,000, 70.5% white and 24.2% Black.(41) In 1982, the total population of Medicare ESRD dialysis patients was 56,046: 66% were white, and 30% were Black.(42) Hypertension was the cause of ESRD in 27.7% of the Black patients and 11.9% of the white, so that the total number of such Black patients actually exceeded that of whites [Table 16]. The proportion of Blacks is about double that expected from the 11-12% of the population which is Black, and attests to either or both a higher incidence and a greater duration of kidney failure in the Black population. (iii) Incidence Studies by Easterling(43), 1977, in southeastern Michigan confirmed that the incidence of end-stage renal disease is three times higher in the Black population than in the white, due to the higher prevalence of glomerulonephritis, and hypertensive and diabetic nephropathy in the Black population. In particular, Blacks were 16.9 times as likely to develop renal disease from hypertension. An almost identical result for the risk of hypertensive renal disease was obtained in a study in Jefferson County, Alabama in the 1974-78 period.(44) In this study, the risk of end-stage renal disease was four times higher in Blacks than in whites. The yearly incidence of hypertension-related end-stage renal disease was 6.4/100,000 in Blacks compared to 0.36/100,000 in whites (relative risk: 17.8). The most comprehensive, published data are those provided by Sugimoto and Rosansky(45) for the incidence of treated end-stage renal disease in 20 contiguous eastern states in the period 1973-79. 14 For white men and women, the incidence rates are 60 and 40/million person-years, respectively, since 1977, and the incidence rates in Blacks in 1979 were 125/million person-years in men and 100/million person-years in women. The incidence of treated end-stage renal disease was twice as high in Blacks as in whites, and hypertensive nephropathy was seven times as common in Blacks as in whites [Figure 6]. The hypertensive nephropathy rates for Blacks were 35/million person-years for men and 24/million person-years for women. These constitute 28% and 24%, respectively, of the total end-stage renal disease rates in 1979. Although it has been shown that hypertension control reduces end-organ damage, it is noteworthy that end-stage renal disease incidence rates were still increasing in both Black men and women during the late 1970s, a period in which hypertension control activities are thought to have been more effective.(26) The explanation for this is unclear. (iv) Mortality Survival of Blacks and whites undergoing dialysis or transplantation has been compared. In general, among patients receiving dialysis, Blacks had lower death rates than whites, but the rates were comparable among patients who underwent transplantation. It should be noted as well that Blacks undergoing dialysis are likely to be younger, 41% being under 50 years of age compared to 35.5% for whites.(46) For 1982, data on Medicare ESRD dialysis stations showed that mortality rates for hypertension-related ESRD in Blacks were 57% of those in whites.(42) The prognosis of patients undergoing dialysis for hypertensive renal disease is significantly worse than for those undergoing dialysis for end-stage renal disease associated with polycystic kidneys or glomerulonephritis, but better than those undergoing dialysis because of diabetic nephropathy. II: EXPLANATIONS FOR DIFFERENCES .t„>„t„>„i....i.. * * Major socioeconomic differentials exist between Blacks and * whites and affect their respective life experiences, biological * * risk factor distributions, and access to medical care. A simple * * biomedical model is thus probably inadequate for assessment of * * Black-white differences in cardiovascular disease morbidity * and mortality. A more comprehensive analytic strategy that * takes account of the social context of disease is required to * * clarify the causes of Black/white CVD differences. Introduction It must be stated clearly at the outset that the currently available data are inadequate to allow definitive explanations of the differences in the cardiovascular disease (CVD) experience and outcomes of the Black and white populations.(2) Hypertension and 15 hypertension-related diseases - in particular, stroke - have been studied more vigorously, and the treatment of hypertension has been the focus of major efforts in the last decade. In attempts to explain Black-white differences in cardiovascular disease morbidity and mortality, it is appropriate to examine and compare, in Black and white populations, the impact of: 1. Biologic, and/or physiologic variables affecting coronary heart disease, hypertension, and hypertension-related diseases. 2. Socioeconomic factors as they influence risk, incidence, prevalence, and severity of disease. 3. Behavioral and/or cultural variables such as health beliefs, health practices, and health-seeking and health-relevant behaviors. 4. Issues related to access to and utilization of the health care system. In view of the persistent social disadvantage of U.S. Blacks, a circumscribed biomedical view which focuses on biological and physiological factors independent of the context in which they occur would result in selective inattention to the social causation of disease.(47) Though satisfactory links between these different levels of analysis have not been established, a synthesis of the conclusions from these different levels of analysis is clearly required. Such a synthesis is essential for the formulation of interventions intended to eliminate these Black-white CVD differentials. In this analysis, as in the earlier sections, coronary heart disease, hypertension, stroke, and hypertension-related renal disease will be dealt with in that order. A: Biologic and/or Physiologic Variables * Because of the paucity of studies of coronary disease in Blacks, * * the data on the impact in Blacks of biological risk factors for * * CHD, identified in white populations, are inadequate. These de- * * ficiencies may cause coronary disease prevention programs de- * * signed for Blacks to be less effective than expected. * Coronary Heart Disease (i) Introduction The data on risk factors for coronary heart disease in Black populations were reviewed in 1982 by Gillum and Grant.(48) These authors noted that, though certain physiologic characteristics such as hypertension, hypercholesterolemia, low levels of high-density lipoprotein cholesterol, cigarette smoking, diabetes mellitus, and gender are considered independent predictors of coronary heart disease in white populations, there is a dearth of studies of CHD incidence in Black populations that examine the impact of the putative CHD risk factors. Since that review, more data have become available on the association of some of these risk factors with coronary heart disease incidence and mortality in Black populations 16 in the United States. However, the data remain inadequate, and this may adversely affect the design of appropriate prevention programs and educational interventions for the Black community. In this discussion of the CHD risks associated with these biological risk factors and their prevalence, data from population-based studies, especially recent ones, are given preference. (ii) Age, Sex, and Family History As in whites, CHD mortality, incidence, and prevalence increase with age.(48) The lower prevalence of ECG evidence of healed myocardial infarction in Blacks over the age of 65 years(10) may reflect increased mortality at younger ages from all causes, as well as a higher Black case-fatality from acute myocardial infarction. Black men are at higher risk of CHD than Black women, but in view of the small sex mortality difference, Black women appear to be at higher risk than would be predicted from their gender on the basis of data on whites. Aggregation of CHD within families has not been reported for Black populations, though some small studies have reported aggregation of risk factors in Black families.(49) (iii) Hypertension * The impact of hypertension on the development of coronary disease* * in Blacks may be somewhat less than in whites. However, hyper- * * tensive Blacks who develop coronary disease appear to be at par- * * ticularly high risk of death. Vigorous treatment of hypertension * * has a similar impact on reducing CHD incidence in Blacks and * * whites. Current data on population blood pressure levels and the prevalence of elevated blood pressures and hypertension in Blacks have been presented earlier. Population-based data on the impact of hypertension on CHD incidence and mortality in Blacks are available from the Evans County, Georgia study which began in 1960 (7 1/4-year follow-up for incidence(13), 20-year follow-up for mortality(14)) and from the 5-year follow-up, beginning in 1973, of men screened for participation in the Multiple Risk Factor Intervention Trial.(34) Because of the small number of cases in the Evans County incidence study, the statistical power was limited. In Evans County Black men(13) but not in Black women, age-adjusted incidence of CHD increased with blood pressure level. In addition, at each blood pressure level, CHD rates were lower in Black than in white men, but similar in Black and white women. In the Evans County 20-year mortality study(14) of Black men ages 40 to 64 years, there were 31 deaths attributed to CHD among 294 examinees. Blood pressure had a "monotonic, strong, highly statistically significant association with CHD mortality in middle-aged Black males' [Table 17].(14) In the MRFIT screenee follow-up(34), 23.7% of the 450 deaths in Black men 17 were attributed to CHD (ICD 410-414), compared to 37.1% of the 4,602 deaths in white men (a significant difference); 72% of the CHD deaths in each racial group were coded as ICD 410, or acute myocardial infarction [Table 18]. The age-adjusted logistic regression coefficients for the asssociation between diastolic blood pressure and CHD deaths did not differ significantly between Black and white men [Table 19], but it was noted that the difference in CHD rates in Black and white men occurred primarily in the upper quintile of diastolic blood pressure (>91 mm Hg) [Figure 7]. In this group, the age-adjusted rate was 8.4/1000 for white men and 5.2/1000 for Black men. Black hypertensive men appeared to be at lower risk of CHD mortality than white hypertensive men in this study. The data on the impact of hypertension on CHD are conflicting. Data from two clinical trials suggest higher CHD mortality rates for Black subjects who have both hypertension and CHD. In the Hypertension and Detection Follow-up Program (HDFP) (12), the 5-year mortality rates among Black men with angina pectoris and with ECG-MI at baseline were 1.8 and 2.0 times as high, respectively, as the rates among similar white men. In addition, in the Beta-Blocker Heart Attack Trial(50), the mortality rate in placebo-treated Black men was significantly higher than in placebo-treated white men. One feature of the Black group was a significantly higher prevalence of a history of hypertension (57%), compared to that for non-whites (39%). This characteristic, as well as a significantly higher prevalence of smoking might account for the observed mortality difference. Race-sex-specific incidence rates for stepped care participants in the HDFP(12) show only small differences in 5-year incidence of CHD (ECG MI, or history of MI, or MI by Rose Questionnaire) between Blacks and whites: rates of MI, diagnosed by ECG alone, were higher in Black men and women than in white men and women respectively. No specific attempt has been made to ascertain whether the impact of blood pressure on CHD incidence differed between the racial groups in this vigorously treated population. However, there is evidence that vigorous stepped care treatment of hypertension nearly equalized the risk of CHD between the races(51), since, in comparison with the referred care group, similar reductions in 5-year incidence of fatal CHD and nonfatal MI were observed in Blacks and whites. 18 (iv) Blood Lipids and Lipoproteins * Mean serum cholesterol levels in Black and white adults are sim- * * ilar and some data suggest similar effects of cholesterol on cor-- * onary disease mortality in Blacks and whites. High-density lipo- * * protein-cholesterol levels are consistently higher in Black men - * than in white men, but the same is not true for women. Higher * * levels of HDL-cholesterol may protect Black men from worse coro- * * nary outcomes. The lack of a HDL-cholesterol excess in Black * * women may account, in part, for their higher coronary mortality * * rates than white women. (a) Total Blood Cholesterol Total blood cholesterol distributions and the prevalence of values in excess of arbitrarily chosen limits have been studied in Black populations in the United States. The Health Examination Survey of 1960-62(52) reported that the age-adjusted mean serum cholesterol levels of Black men and women were 210.8 and 214.0 mg/dl, both lower than those reported for white men and women, 217.4 and 224.1 mg/dl, respectively. The Health and Nutrition Examination Survey of 1971-74 (NHANES I) (53) detected no consistent differences between Black and white adult men in cholesterol means or distributions. The same is true for women, except that Black women, ages 55-64 years, had slightly higher levels than white women. In NHANES 1(54), serum cholesterol level was related to body mass index, but the association of higher serum cholesterol levels with higher body mass index was less consistent in Black men than in the other groups. In addition, within each quintile of body mass index, the mean serum cholesterol level was lower in Black women than in white [Figure 8]. Data on the prevalence of elevated serum cholesterol levels, defined as levels of at least 260 mg/dl, have been published for Blacks examined in NHANES I and NHANES II. Between survey periods, there was a decrease in the age-adjusted prevalence of elevated serum cholesterol levels in Black adults, but the decrease was not statistically significant.(55) (b) High-Density Lipoprotein Cholesterol An inverse relation between plasma high-density lipoproteins and CHD risk has been detected in several white populations. In some population-based studies, Blacks have been observed to have higher high-density lipoprotein (HDL) levels and lower levels of low-density lipoprotein (LDL) cholesterol.(56) This has been found in pediatric and adolescent, as well as adult populations [Table 20 In the Lipid Research Clinics Study which included only a small number of Blacks (424 patients), the HDL levels were significantly higher and LDL levels significantly lower in Blacks than in whites.(57) The 19 differences are larger in men than in women, and in some studies of adult women, no Black excess was detected.(56) HDL levels are affected by a number of environmental factors. Significant direct relationships with physical activity and alcohol intake, and significant inverse relationships with measures of body mass index, cigarette smoking, and use of some antihypertensive agents have been detected. Some authors have speculated that the absence of significant differences between adult Black women and white women might be due to the high prevalence of obesity in Black women. In addition, because statistical adjustment for the environmental variables examined do not eliminate Black-white differences, there has been speculation that there is an inherent, possibly genetic, tendency for Blacks to have higher HDL-cholesterol levels.(58) It has been suggested that elevated HDL levels might account for the lower incidence of CHD in Blacks in some studies(59), but no analysis addressing this issue has yet been published. As in the case of blood pressure, few studies have assessed the relationship between serum cholesterol and CHD incidence in Blacks. In the Evans County incidence study(60), the interactive effect of cholesterol and age was significantly related to CHD incidence in white men, but the logistic function predicted an incidence of CHD in Blacks far in excess of that observed. The investigators concluded that Blacks do respond to the standard risk factors (including cholesterol) similarly to whites, but with a lower level of CHD than would be expected, given the levels of the risk factors. In the 20-year Evans County mortality study(14), cholesterol was significantly related to CHD mortality in middle-aged Black men [Table 17]. In the MRFIT screenee five-year mortality follow-up study(34), the age-adjusted CHD mortality rates for Black and white men were similar in each quintile of serum cholesterol concentration [Figure 9], and the logistic regression coefficients were similar for white and Black participants, 0.0071 for Black men and 0.0079 for white men. (v) Cigarette Smoking * The prevalence of cigarette smoking is greater in Black than in * * white men, but the prevalence of heavy smoking is greater in * * white than in Black adults. In recent years, there has been a re-* * duction in the proportion of Black adults who are light or mod- * * erate smokers. Smoking appears to increase the risk of coronary * * disease mortality similarly in Blacks and in whites. * National probability estimates of the prevalence of cigarette smoking in Black adult men and women in the period 1965 to 1983 are available from the National Health Interview Survey(61) and the National Health Examination Surveys, NHANES I and 11.(55) Age-adjusted national estimates of the percentage of current smokers indicate an 8-9% higher prevalence of smoking in Black compared to white men over the age of 20 years in 1965, 1976, and 1980.(62,63) 20 Age-specific tabulations indicate that the prevalence of smoking is high in 25-44 year-old men [Table 21]. In addition, the Black excess in prevalence is observed in every age-group in the NHIS and NHANES I and II data [Table 22]. On the other hand, the prevalence of heavy smoking (25 or more cigarettes per day) is substantially higher among white than Black men, and the rate of increase in heavy smoking rates between 1965 and 1980 was greater for white men. The age-specific data indicate that 35-64 year-old smokers are more likely to be heavy smokers than the other age-groups, but this is common to both Black and white men. Smoking patterns for women are very different from those of men. Rates are lower and consistent Black-white differentials are not observed. The age-specific data for women indicate a substantially lower prevalence of smoking in women 65 years and older compared to younger women. Heavy smoking is also more common among white women than Black women and, as among men, the rate of increase in the prevalence of heavy smoking between 1965 and 1980 was greater for white than for Black women. Between NHANES I and NHANES II, the proportion of Black people who currently smoke cigarettes decreased [Table 21]. The decline was greater for women than for men, 15 percentage points compared to five. The proportion of Black adults who smoked 25 or more cigarettes per day did not change significantly. Thus, the decrease in the proportion of smokers between NHANES I and NHANES II was due to a reduction in the proportion of Black adults who were light or moderate smokers. The impact of cigarette smoking on CHD risk in Black subjects has been examined in a small number of studies. A history of cigarette smoking was a significant predictor of 7 1/4-year CHD incidence in whites in the Evans County study and appeared to affect Blacks as well.(60) A history of current smoking was a significant independent predictor of death attributed to CHD in Black men in the 20-year Evans County follow-up.(14) In the MRFIT screenee follow-up,(34) the 5-year age-adjusted CHD mortality rates were very similar for Blacks and whites at different levels of cigarette consumption, except for those who smoked 26-35 cigarettes per day [Figure 10]. The logistic regression coefficients for Black and white men did not differ significantly from each other, and reflect a significant positive association between cigarette smoking and CHD mortality [Table 23]. In the American Cancer Society prospective study(64) of one million Americans followed for 12 years (1960-72), about 25,000 Blacks were enrolled. CHD mortality ratios in subjects grouped according to the number of cigarettes smoked were similar at given smoking levels in Black and white men, and slightly lower in Black than in white women. There was evidence of an enhanced effect of smoking on the risk of CHD death in individuals with a history of high blood pressure or other cardiovascular disease [Figure 11]. 21 (vi) Diabetes Mellitus * The prevalence of diabetes mellitus, both diagnosed and un- * * diagnosed, is greater in Blacks than in whites. The effect of * diabetes mellitus on coronary disease in Blacks has not been * assessed adequately. •■'•.''.'••■'••'*i'^'*..'»'"''.'.^'n'"'.*'iJiJ-'-'*.'*.'i.'"'.''"'r-'r-'--'--'--'--}—}~t~t^ Though all-cause mortality rates in non-white diabetics in the U.S. are twice those of whites, the impact of diabetes on CHD has been examined in few studies.(48) The prevalence of diabetes is higher in Blacks than in whites. In the Health Interview Survey, 1964-1965(65), the self-reported prevalence of diabetes in non-whites, 13.3/1000, was similar to that in whites, 12.1/1000. In the Health Interview Survey of 1973(66), the self-reported prevalence was 23.9/1000 for non-whites and 19.9/1000 for whites. More recently, NHANES II data on subjects, ages 20-74 years, reveal a higher prevalence in Blacks than in whites of a medical history of diabetes (self-report of a physician diagnosis and current or past use of diabetic therapy), 5.2% compared to 3.2%; and of undiagnosed diabetes, 4.4% compared to 3.0% [Table 24]. These differences are not statistically significant. Cooper et al(67) have reported that, in an employed Chicago population the prevalence of diabetes was approximately 3% in men of both races and 2% in women. Moreover, plasma glucose levels one hour after a 50 gram glucose load were lower in women than in men, and in Blacks than in whites. Black women had the lowest levels despite having the highest prevalence of obesity (relative weight>l.45), 21.1%. These data are consistent with those reported by a Kaiser-Permanente program(68) which studied 12,000 Blacks and 88,000 whites between 1964 and 1968. In this study, mean serum glucose levels one hour after a 50-gram glucose load remained significantly lower in Blacks than in whites after adjustment for height, weight, ponderal index, and triceps skinfold thickness. Such data suggest that Black women, even obese Black women, may be less prone to diabetes. However, the markedly high prevalence of obesity in Black women probably contributes to the excess prevalence of a medical history of diabetes as, for example, in 55- to 64-year-old Black women in NHANES II: 16.3% compared to 6.6% in white women of similar age. The Chicago investigators(67) observed that cardiovascular death rates in Black men with diabetes or hyperglycemia were slightly lower than those in white men. However, compared to normoglycemic people, Black men with diabetes or hyperglycemia had a relative risk of cardiovascular death of 1.43. It should be noted that these rate comparisons are based on small numbers of deaths. In the MRFIT screenees 35-57 years of age(69), 1.5% of those men without a history of heart attack were being treated with medications for diabetes; 0.2% were Black and 1.3% non-Black. Age-adjusted • 5-year CHD death rates among Black diabetics were more than twice those among Black nondiabetics, 8.5/1000 compared to 4.1/1000. 22 The comparable rates among non-Black diabetics were 14.2/1000 and 4.3/1000 which yields a relative risk of greater than 3. However, these analyses are based on only 7 CHD deaths among Black diabetics, a 1% mortality rate [Table 25]. (vii) Electrocardiographic Abnormality * Electrocardiographic abnormalities are predictive of CHD in * * some studies of white patients. Such abnormalities are more * common in Blacks than in whites. The impact of these abnormal- * * ities, especially electrocardiographic evidence of left ventric- * * ular hypertrophy (ECG-LVH), has not been assessed satisfactorily * * in Black populations. * In studies of white populations, electrocardiographic abnormalities - in particular ST depression, major T-wave abnormalities, and increased QRS voltage - have been associated with an increased incidence of CHD.(70) In the Framingham study(71), electrocardiographic evidence of left ventricular hypertrophy (ECG-LVH) was associated with a three-fold increased risk of CHD after adjustment for the effect of elevated blood pressure. A number of population-based studies, including the Evans County study(60), and the Birmingham Stroke Study(72) have shown such ECG abnormalities to be more common in Blacks than in whites. In Evans County(73), the age-specific prevalence of ECG-LVH (Minnesota Code 3.1) was 2-3 times higher in Blacks than in whites, and even when the rates were adjusted for differences in age, blood pressure, body habitus, habitual physical activities, and smoking habits, the Black/white differences persisted. Similarly, in the Birmingham Stroke Study(72), the contribution of race to increased R-wave amplitude was shown by multiple regression analysis to be independent of blood pressure, a history of treated hypertension, or a history of angina pectoris or prior myocardial infarction. In the Evans County study(74), white men had a markedly higher incidence than Black men of new coronary events in the presence of ECG abnormalities. Each of the abnormalities carried an increased risk of coronary disease for white men, but not for Black men. Black women had increased CHD incidence rates only with left axis deviation. No published studies to date have revealed a statistically significant excess risk of CHD incidence in Blacks associated with ECG-LVH. In the Evans County Study(73), ECG-LVH in the presence of hypertension was associated with an excess (not statistically significant) risk of death over 9-12-year follow-up in all four race-sex groups. However, in the HDFP referred care men(75), ages 40-69 years, with diastolic blood pressures of 90-104 mm Hg, and similar educational attainment (less than high school), the age-adjusted all-cause mortality rates were significantly higher in both Blacks and whites with ECG-LVH than in those without. The relative risk was lower in Blacks (2.1) than in whites (2.7) [Table 23 26]. The prognostic implications of LVH for CHD in Blacks are still in need of clarification. Analysis of data sets that include ECGs and echocardiograms should be of value in assessing the prognostic implications of anatomic LVH. (viii) Obesity * Obesity is especially common in Black women and may provide a * * partial explanation for their excess coronary disease risk. * Obesity is prevalent in Black women. The Health Examination Survey of 1960-62(76) found that despite similar heights in Blacks and whites, the proportion of the population weighing 170 pounds or greater was 38.9% for Black men, 30.3% for Black women, 45.4% for white men and 14.3% for white women. In NHANES 1(77), there was little difference in height or weight between Black and white men, but the mean weights and 90th percentiles were significantly higher for Black women than for white women. The entire weight distribution for Black women was shifted towards higher weights [Figure 12]. Comparison of the NHES and NHANES I data indicates that Black women less than 44 years of age weighed more at the latter examination. NHANES II data(58) revealed that the Quetelet index (weight, divided by [height squared]) was higher in Black than in white women, but similar or somewhat lower in Black than in white men. In the three age-groups 21-45 years, 45-65 years and over 65 years, Quetelet indices were considerably higher in Black than in white women, but not significantly different for Black and white men. In addition, maximum self-reported weight, minimum weight, and weight at age 25 years were higher in Black than white women, but comparable in Black and white men [Table 27]. It has been speculated that pandemic obesity might explain the apparently higher CHD mortality in Black than in white women, perhaps by means of an association with lower HDL-cholesterol levels.(58) The evidence presented earlier suggests that the higher prevalence of diabetes mellitus in middle-aged Black women may be related to obesity, and an association between elevated blood pressure and obesity has also been reported. The Evans County investigators reported a 2.2-fold higher incidence of CHD in Black men in the upper tertile of Quetelet index compared to those in the lower tertile.(78) The age-adjusted rate in white men in the upper tertile was still four times greater than that of Black men in that tertile. No report was provided of the impact of obesity on CHD risk in women. No significant independent relationship of Quetelet index to 20-year CHD mortality was observed in Evans County Black men.(14) 24 (ix) Conclusion: Do Multiple Risk Factors Explain Racial Differences? * Some data suggest that the impact of cigarette smoking and elev- * * ated serum cholesterol on coronary disease mortality is similar * * in Blacks and whites, though the effect of hypertension appears * * to be less in Blacks than in whites. Smoking prevention and * cessation, and cholesterol reduction should reduce the incidence * * of coronary disease in Blacks. Because of the higher prevalence * * of hypertension in Blacks, coronary disease risk attributable * to hypertension in the Black population is substantial. Hyper- * tension control should decrease coronary disease incidence and * mortality in Blacks. * In view of the excess of hypertension in Blacks (granted the similarity in serum cholesterol levels, and the overall similarity in cigarette consumption in Blacks and whites), it can well be asked why are not CHD rates for Blacks higher than they are? In fact, CHD mortality rates for Black women exceed those for white women. It is unknown whether obesity and effects mediated via lower HDL-cholesterol levels and elevated blood pressure levels might account for this, although this is a plausible explanation. It has been speculated that there might be measured or unmeasured risk factors other than hypercholesterolemia, hypertension, and cigarette smoking which might protect Black men against further elevation of CHD rates.(60) HDL-cholesterol may be the major protective factor(59), but this hypothesis has not been examined in large prospective studies that included adequate numbers of Black and white men. Physical activity(60) associated with occupation has been suggested as a factor which might protect Black men against CHD. This effect might be mediated by means of lower blood pressure, lower body weight, and higher HDL-cholesterol levels. However, the data to test this hypothesis do not exist. Some studies have suggested that differences in a number of hemostatic variables between Blacks and whites, such as higher fibrinolytic activity, and longer platelet survival in Blacks might protect them against the development of coronary atherosclerotic lesions and coronary thrombosis.(8) Some of these factors are thought to be affected by diet and physical activity levels. Long-term studies in this area have recently been sponsored by the NHLBI. It has already been noted that the multiple logistic risk function derived by the Evans County investigators suggested that elevated serum cholesterol, hypertension, and cigarette smoking all increased CHD risk in Blacks, but to a lesser degree than in whites.(60) In view of the low incidence of CHD in the Evans County population, the generality of these findings to the U.S. population cannot be assumed. However, the consistency between racial groups of the logistic regression coefficients for the association of bloqd pressure, cigarette smoking, and serum cholesterol with CHD deaths in 25 the MRFIT screenee five-year follow-up study is striking. These data derived from studies of 23,490 Black men and 325,384 white men in 18 U.S. cities from 1973 are perhaps the most reliable data available on the impact of these risk factors on CHD mortality in Blacks. However, it must be re-emphasized that these analyses and the 20-year Evans County analyses employ possibly unreliable death certificate diagnoses of CHD. These data raise the provocative suggestion that the impact of blood pressure on CHD mortality is less in Black hypertensives than in whites. The MRFIT investigators noted that the Black/white relative risk of CHD death (after adjustment for age, serum cholesterol concentration, and cigarettes smoked per day by logistic regression) was 1.15 for men with diastolic blood pressures less than 91 mm Hg, and 0.69 for those men with higher diastolic blood pressures. This difference was statistically significant. However, as noted earlier, a history of hypertension in Black men with CHD is hardly a benign finding. Rowland and Fulwood(55) have presented an analysis of the changes in risk factors that took place in Blacks and whites from NHANES I to NHANES II, (the period from 1971-75 to 1976-80), and have attempted to correlate these changes with the observed CHD mortality rates for adults, Black and white, 35-74 years of age, during this period. In the absence of a risk equation derived from observation of a large Black cohort, they used a multiple logistic function, based on observations in the predominantly white Framingham Study, and estimated that the greater decline in elevated blood pressure and cigarette smoking in Blacks during this period could account for the greater estimated decline in expected CHD mortality for Blacks compared to whites: 13?o and 16% for Black men and women; 7% and 8% for white men and women [Table 28]. The observed mortality declines corresponded more closely to those expected for Blacks than they did for whites. In the absence of more reliable data, public policy and clinical practice for primary prevention of CHD in Blacks should be based on these observations and analyses. Hypertension (i) Introduction In 1979, Gillum(79) reviewed the literature on racial blood pressure differences in the United States. He concluded that the cause of these differences remains speculative, and noted that racial differences in renal physiology and environmental influences such as socioeconomic status are likely candidates for important contributions to blood pressure differences. In the CHD risk factor review published in 1982, Gillum and Grant(48) asserted that selected studies published since this initial review have added nothing to contradict its conclusions. 26 (ii) Inadequacy of Genetic Explanations * "Black" in the United States is a sociological category. Some * investigators have confused ethnic identity with genetic con- * stitution, simplistically equating them. The heterogeneity of * blood pressure levels and hypertension prevalence in Black pop- * * ulations in Africa, the Caribbean, and the Americas casts doubt * * on the proposition that genetic factors are primarily respon- sible for the blood pressure excess in U.S. Blacks. Many hypotheses have been advanced to explain the higher prevalence of hypertension in U.S. Blacks. Among them are theories that have in common the postulate that the tendency of Blacks to develop excessively elevated blood pressure has a genetic basis. If so, the genetic predisposition to elevated blood pressure should be a characteristic common to Black-skinned people everywhere. Thus, Black people in Africa and elsewhere should share approximately the same rate and severity of hypertension. However, when the available epidemiologic data on blood pressure levels in Black populations in Africa, the Caribbean, and the Americas are examined, it becomes clear that any explanation of blood pressure differences between Black populations must take explicit account of environmental determinants and influences. Though Blacks in the Caribbean and the Americas are mostly of West African descent, an extensive process of miscegenation occurred during and subsequent to the period of slavery(80), so that Black populations in these regions are racially heterogeneous. In the United States, the term "Black" encompasses an identifiable, visible, ethnic group, with a distinctive historical, social, and economic experience. This creates significant problems for the interpretation of racial data on blood pressure differences since these differences have important socioeconomic and psychosocial correlates. Moreover, since "Black" is a sociological category, it does not describe a group with unequivocally identifiable or uniform genetic characteristics. In scientific investigations of blood pressure distributions in the U.S. Black population, the racial heterogeneity that is characteristic of this ethnic group is, typically, not even assessed.(8) Moreover, assessment of the degree of admixture between genes of presumed(81,82) Black and white racial origin relies on a number of unverifiable assumptions.(83) (iii) Blood Pressure Distributions in African and Other Black Populations Examination of published data on blood pressure in African populations since the 1920s reveals marked diversity. In particular, hypertension has been shown to be rare in many rural communities- in Kenya(84), Uganda(85), Tanzania(86), and the Gambia.(87) Large-scale epidemiologic surveys in Ghana, West Africa(88) have reported little 27 00 ro mi cr a ro 0 p- O £ P 3 I * ie * * * * 0- * J < H h-' p- CD O 3 Mi er O P- 0 0 Ml 3 £ O p- O ro 5r CL 3 O Mi ro O M P rt O H Cfl o rt p- < rt tr cn ;{. CD CL ro p- M ro 3 ro 3 ro ! 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X O £ P- CD Mi ro 3 P p- CD P P- cr to ro Xi Mi tr O h-■ a p-1 O p h-1 O p ■^J M o h-■ p- cn P 0 pi P» 3 3 3 rt- P- rt- rt 3 rt rt Ln a M ro O ro ■ a O P P- ro ro p- h-1 O rt - ro Mi area could be attributed to a greater dietary intake of sodium. These investigators noted that, although Blacks and whites ingested similar quantities of sodium, dietary potassium intake for Blacks was consistently less than that for whites. Similar conclusions have been reached from dietary recall studies in other U.S. populations(97) and in NHANES 1.(98) Though dietary recall methods are less accurate than analysis of duplicate dietary collection, it has been speculated that the excess of high blood pressure in Blacks might be related to relative potassium deficiency and the impact of this on renal sodium handling.(99). One fairly consistent observation in the area of renal physiology has been that suppressed plasma renin activity is found more commonly in U.S. Blacks.(79,100) However, this is not a universal observation, since studies in a group of "Black Jamaican hypertensives revealed a prevalence of low-, normal-, and high-renin groups that was 31%, 45%, and 24% respectively.(101) More recently, evidence to support a genetic hypothesis has been sought by examination of the activity of cell membrane transport systems for electrolytes and intracellular electrolyte concentrations in Black and white subjects. Blaustein(102) has recently reviewed the available data and concluded that they give little cause for hope that the key to Black-white differences will be found therein. Trevisan et al(103) have concluded that the pattern of sodium countertransport across erythrocyte membranes in race-sex groups is "not consistent with a direct relationship between countertransport or sodium concentration and blood pressure which applies across both racial groups". Ringell et al(104) have concluded that furosemide-sensitive sodium and potassium cotransports and intracellular sodium content are not clinically useful in the identification of essential hypertension in Black men because of substantial overlap in observed values between hypertensive and nonhypertensive men. Tuck et al(105) also could not find sodium-potassium cotransport assay useful in identifying hypertension-prone Black normotensive subjects. (v) Correlates of Hypertension Incidence: Implications for Primary Prevention Observations of Black populations in both rural and urban areas show correlations between the incidence of hypertension and some physiological factors, which suggest possible approaches to primary prevention. In Black women, ages 15-29 years, in Evans County(106), the seven-year incidence of elevated blood pressure was associated with weight gain. A similar observation was made in Black women, ages 30-69 years, in an inner-city (Baltimore) population.(107) Reported change in weight was a significant predictor of elevated pressure. These findings indicate the importance of weight control for hypertension prevention in Black women. In addition, Voors et al(108) have shown that potassium administration produced marked natriuresis and decreased blood pressure levels in Blacks. Such data suggest that, at levels of potassium intake similar to those observed in Whites, blood pressure levels in Blacks would be lower. 29 Stroke (i) Hypertension The major risk factor for stroke is hypertension. Since the prevalence of hypertension is significantly higher in Blacks than in whites, this accounts in part for the Black excess of stroke incidence and mortality. In the MRFIT screenee follow-up study(34), the logistic regression coefficient for the relationship between diastolic blood pressure and death from cerebrovascular disease in Black men was significantly higher than for white men [Table 19, Figure 13]. In the Framingham study(109), the dominant predictors of stroke risk were blood pressure level and ECG-LVH. In the Hypertension Detection and Follow-up Program(38), mortality rates, including those for stroke, were increased among men with ECG-LVH by Minnesota Code criteria. In the Evans County study, the presence of any ECG abnormality was associated with a slightly higher risk of stroke in both Black men and women.(110) Thus, Blacks with hypertension and evidence of ECG abnormalities are at higher risk of stroke. (ii) Cholesterol and Cigarette Smoking In the Evans County Study(llO), there was no consistent relationship between the serum cholesterol level and risk of stroke among Blacks or whites. No consistent relationship was noted between age-adjusted cerebrovascular disease mortality rates by cholesterol quintiles in the MRFIT screenee follow-up study [Figure 14].(34) Similarly, the logistic regression coefficient relating number of cigarettes smoked per day to death from cerebrovascular disease for Black men indicated no significant association. (iii) Conclusion The major factor which accounts for the Black-white disparity in stroke incidence, morbidity, and mortality is probably hypertension. Since stroke mortality rates have been declining since the 1930s, but have declined even more rapidly in the late 1970s, it is likely that part of the increased rate of decline in stroke mortality in Blacks is the result of improved hypertension control.(Ill) Hypertensive End-Stage Renal Disease The higher prevalence of hypertension in Blacks can be invoked to explain much of the disparity in incidence rates of end-stage renal disease (ESRD). Blacks have a disproportionately high rate of renal failure from hypertensive disease, and though the diagnoses in the studies reported(43,440 patients) were based on clinical rather than histological evidence, diagnostic error could not totally explain the 17-18 fold disparity. No explanation, other than a greater 30 prevalence and severity of hypertension especially in Black women in the fourth decade of life has been proposed. It appears likely that earlier recognition and more vigorous treatment of hypertension might reduce the incidence of ESRD in Blacks: the continued increase in Black ESRD incidence in the eastern U.S.A. until 1979 may represent a cohort effect. White subjects with ESRD have a higher risk of cardiovascular mortality and, possibly, of CHD than Blacks, probably due to enhancement of the rate of progression of atherosclerosis.(112) Racial differences in HDL-cholesterol levels between Blacks and whites with ESRD may account for lower CHD incidence and mortality rates in Black subjects with ESRD.(113) Conclusion (i) The Role of Hypertension in Black CVD Mortality and Morbidity The analyses presented suggest a central role for hypertension, both as a major cardiovascular disorder and as an explanation of enhanced individual risk, if not of CHD, at least of stroke and ESRD in Blacks. Even if the risk of CHD in hypertensive Black males is somewhat less than in hypertensive white males, as the MRFIT screenee data suggest, the impact of hypertension on CHD risk in the Black population as a whole, remains sizeable because of the high prevalence of hypertension. (ii) Racial Trends in Hypertension-Related Mortality: Role of Hypertension Treatment * Stroke mortality has declined more rapidly in recent years than * * before. The initial decline preceded antihypertensive therapy. * * Similarly, the decline in coronary disease mortality preceded * * vigorous blood pressure treatment programs. Hypertension control * * has improved in the last decade.However, this does not complete- * * ly explain observed decreases in Black CVD mortality rates. * If hypertension exerts a major force on mortality in the Black population, do recent trends in hypertension awareness, treatment, and control account for reductions in hypertension-related mortality? The analysis by Hardy and Hawkins(114) of the impact of antihypertensive therapy on mortality among mild hypertensives in the Hypertension Detection and Follow-up Program reveals that 36% of the overall mortality reduction is attributable to indices of treatment, measured annually. It is clear from examination of the referred care group in this study that hypertension control was not as vigorous in the community as in the stepped care intervention group, and that Black subjects were less likely to be treated than whites.(115) The drug regimen to which the stepped care group was subjected was only 31 part of a medical care program in which the care provided for hypertension was comprehensive, of high quality, free, convenient, and easily accessible. In the fifth year of the trial, 75-82% of the subjects in the four race-sex, stepped care groups were receiving drug therapy, and only 5.2% of all the stepped care participants were lost to follow-up. Though some investigators are wont to emphasize that pharmacologic therapy is the major cause of the observed differences, to focus exclusively on the drugs is to neglect the other essential components of the health care system devised for the trial, including the "strong support system"(116) which made excellent compliance and improved noncardiovascular health outcomes(117) more likely. As Wing has clarified(118,119), consideration of hypertension-related mortality declines and improvements in hypertension treatment on an age-race-sex-specific basis indicates trends that are not consistent with the hypothesis that the mortality decline is entirely attributable to improved awareness, treatment, and blood pressure control. It is probably inappropriate to regard improved hypertension control in Blacks as a complete explanation for trends in hypertension-related mortality. B: Socioeconomic Factors * There are persistent differences between Blacks and whites in * * education, occupation, and income. On average, Blacks have less * * education than whites. Those with equivalent education have * * access to fewer job opportunities than whites. Those with equiv- * alent employment are likely to be paid less than whites. * Social Epidemiology There is abundant evidence of disparities between Blacks and whites in the U.S. in income, occupation, and education, three of the major variables employed for assessment of socioeconomic status (120-124). Table 29 shows the ratio of non-white to white median income in the U.S. from 1945 to 1977 for men and women and lists such data specifically for Blacks from 1964. The distribution of family income in Black and white households, categorized according to the gender of the head of the household is shown in Table 30. The distribution for Black families, especially for those headed by women, is skewed toward the lower incomes. Despite a rapid increase in the percentage of white-collar workers and rapid declines in the percentage of farm workers among non-whites, especially non-white women, in the period 1963 to 1973, the vast majority of non-whites, especially men, remain blue-collar or service workers. These changes in occupational profile occurred simultaneously with gains in the percentage of non-whites, 25-34 years old, who completed high school or four years of college.(122) By 1981, the median number of years of schooling for Black men and 32 rt M ro 3 ii CO ii ro P rt n 3 0 3 rr P- r~> ti- n C_i h( P- & er ro ro CD ro h-1 ro 0 00 er 0 0 Mi CD ro 3 O er p CD 3 p 13 r-> 3 13 P h-1 o ro p 3 ii 3 rt O £ ro 9 3 h-' rt rt 0 CD 0 o P p- i 3 3 rt £ £ P- CD P £ O M 0 rt ii 7T rt p rt rt P tr /—> CD PL ro p- p ro rt tr 3 rt rt rt 0 rt p- p' P- rt VJ h—• p- p-1 CD CD O 3 3 ^> p- p- O £ CD CD 3 O 3 er >• p- rt- 0 3 3 O p- PL p* O rt < 0 Ml PL cr P- ro 3 ro CD p rt ro £ o P- rt LO 3 CD ro ii ro 3 ro rt 1 rt CT v; i tr ro O P- ro O Cfl Tr o 0 CO rt tr P P ro 3 cn p- ro P O ^ er id vj er 3 pJ On tr p- p- rt PL 0 0 ii CD moo a o h-1 o P1 p- O /—\ p P p» ro 3 13 3 l_i. 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For both Blacks and whites, a distinct social class/blood pressure gradient exists with those of lower income and lower educational attainment having higher blood pressures. In the HDFP screening(136), there was an inverse relationship between blood pressure (and the prevalence of hypertension) and the number of years of education [Figure 15]. This relationship was more striking for Blacks than for whites and persisted even after account was taken of body weight. For example, in Blacks with less than 10 years of education, the prevalence of hypertension was 43.9%, but in Blacks who had completed college education, the prevalence was- 27.7%. The corresponding rates for whites were 23.1% and 13.5%. The persistent Black excess of hypertension across all educational levels has been reported in national health surveys and mean systolic and diastolic blood pressures were inversely related to the amount of formal schooling received by examinees in all race and sex groups in NHANES II. This association was more marked for women than for men. A similar association of per capita income to blood pressure level has been observed in a 1981 survey of individuals examined in a representative random sample of Georgia households.(138) Per capita income was significantly lower among individuals with moderate or severe hypertension than in those whose hypertension was mild or controlled [Table 31]. This applied to all race-sex groups except white women. In studies that employed social class categories (assessed by education and occupation), a higher prevalence(139) and incidence(140) of hypertension has been detected in Blacks of low social class. In the latter investigation, a community-based study in Charleston County,(140) the association of hypertension with skin color was minimal and substantially less than the association with social class. These investigators concluded that social class may be among the primary determinants of hypertension in Blacks. Similar observations have been made in a study of the incidence of hypertension in an inner-city (Baltimore) Black population(107): in both sexes there was an inverse association between the incidence of hypertension and income. Sons of professionals had an incidence of hypertension, over a three- to four-year period, that was approximately one quarter that of sons of laborers. 35 ON ro p- M, 3 Mi PL ro p- o < rt p- p. 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This may be related to inadequate treatment of hypertension, particularly in those with the lowest incomes. The Georgia 1981 survey(138) revealed that those with the most severe hypertension, in addition to being the poorest, would have to spend the largest proportion of their income on medications to attain adequate blood pressure control [Table 33]. C: Behavioral and/or Cultural Factors Introduction Some of the factors that may increase risk of cardiovascular disease, such as cigarette smoking and physical inactivity, are behaviors. Other physiological characteristics that may enhance risk are themselves the consequence of dietary and other behaviors. Some of these behaviors are part of particular cultural patterns, many of them grounded in socioeconomic circumstances associated with increased risk. In addition, certain cultural patterns may impede efforts to reduce risk. In particular, cultural factors may influence the effectiveness of efforts to prevent hypertension, to reduce CHD risk by reducing risk factors, and to treat hypertension more effectively. This section reviews evidence from national surveys and other studies on health beliefs, health practices, and health-relevant behavior that have implications for cardiovascular disease in Blacks. Coronary Heart Disease (i) Health Beliefs/Knowledge * Data on Blacks' beliefs and knowledge of coronary heart disease * * are inadequate. Available data suggest significant deficits in * * Blacks' knowledge concerning the association of CVD with diet. * Some recent data on health beliefs, knowledge, and information in Blacks concerning coronary heart disease and on health practices which predispose to it are available. 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For example, in one school-based, cardiovascular health education study in Chicago, Sunseri et al(153) detected racial differences in the increases in knowledge concerning nutrition, exercise, and smoking and their relationship to cardiovascular disease after an intervention. Black children had a smaller increase in knowledge than others and, at follow-up nine months later, had persistently lower knowledge scores even after adjustment for reading achievement. Black reading achievement was significantly lower than that of whites. The analyses also revealed that reading achievement was significantly related to nutrition knowledge and attitudes, but not to behavior. (ii) Health Practices (a) Dietary Practices Some of the available data suggest differences in health practices between Blacks and whites that may be important for CHD outcomes. For example, some anthropologic data indicate that frying of foods is a very common method of food preparation among Blacks.(154) In one New York ghetto Black population, one-third of Black mothers cited frying as the method of food preparation of first choice.(155) There are few data on the likelihood of dietary change in Blacks in response to physician advice, though in the FDA-NHLBI national survey on diet and cardiovascular disease, Blacks appeared to be more likely to be on a medically-prescribed diet that included fat and cholesterol reduction [Table 34]. In the Multiple Risk Factor Intervention Trial(156), Black men at baseline reported lower daily caloric consumption, similar consumption of saturated and of polyunsaturated fatty acids and significantly higher consumption of cholesterol than did whites. In the Special Intervention group, Black-white differences in changes in intake of specific nutrients and in weight were small, which suggests that under medical supervision, similar changes are possible in Black and white men. However, this group may not be representative of the general population. (b) Physical Activity No national survey has compared physical activity patterns in Black and white populations. Thus, it is unknown whether the preponderance of Blacks in lower-status, often more physical, occupations results in higher levels of overall physical activity than in whites. 40 Cfl n 73 13 ro PL H rt rt 13 CD rt o 13 3 0 3 ro p1 tr tr £ p- p Ln P* PL Ln 0 ro CD O 13 rt ii P' ro £ hi 3 ro CO P h-1 ro n 3 p CD CD CD P- tr er er CD X er ro er P- ro ro rt O ro ro P- 3 3 NO CD CD H> 3- rt X CD ii er CD NO rt CD ro 3 3 h-1 3 P- p p- 0 3 Cfl ii M h| p- ro ro CD id ro ro VJ O Cfl pl M £ p ti- PL ro O . 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M vj 3 3 O O VJ 3 O CD O ro O P- rt- er P p 3 3 rt M P. to P- ro p w 3 O 3 P- CD CD O 3 3 ro a CD 00 rt <"—N 3 rt Ox CD ro 3 P» O VJ vj O CD ro O CO rt- o ro ro 0 ro ro ti- P 1— CD »o p 3 P- 3 er M p N.^ O M 3 3 p- CD ro ro o p- Mi Cfl oo Mi O 3 3 rt M pl Tr Cfl er p er ' CO hi tr ro 3 P Cfl ro vj 1— 3 i— O 3 CD 3 13 13 >H p P O Ml < PL O p ro tr o rt O p- rt 3 i— m ro 7? P- PL rt M O £ ro M ti- O er O tr O CD ro P 3 13 ro 3 p- ii P 3 3 M 3 rt- P- PL ro PL Mi 0 CD Cfl CD 3 ro 3 00 VJ p-O £ M ro rt £ tr 3 tr 3 P O ro p- rt h i— 3 ro p- rt- er CD CD 3 3 ro ro 3 (b) Determinants of Adherence * A number of studies, some of predominantly Black groups of * * patients and others of somewhat evenly mixed Black and white * * groups, have examined determinants of adherence to antihyperten- * * sive therapy. The results of these studies have important implie-* * ations for hypertension control in Black populations. a^W-JLa^a^aAMj-UJU^J^JU^^ Caldwell(166), in a pilot study of social and emotional factors influencing a patient's ability to follow antihypertensive therapy, compared a group of dropouts from antihypertensive therapy who later developed a hypertensive emergency, with a radically different group of patients who had remained in treatment for more than five years. The dropouts were more likely to be non-white, less-educated, of lower occupational status, to have lower incomes, to be younger, and to have a briefer duration of disease. In contrast, Nelson et al(167), in a study of 142 hypertensive patients attending a medical clinic at < large urban hospital, detected no independent relationship between race or socioeconomic status and compliance with antihypertensive therapy. Characteristics of those patients less likely to be compliant were male gender, social isolation, and the presence of side effects of antihypertensive medications. In this study, the impact of side effects on compliance appeared to be greater in Blacks than in whites. However, in the 1979 National Survey(151), 18% of Blacks and 17% of whites compliant with medications reported side effects and, among noncompliers, whites were much more likely to say that the medicine had side effects. Two analyses of patient participation and adherence to therapy have been published from the Hypertension Detection and Follow-up Program.(168,169) At the end of the first year, Black men and women were less likely to be in active treatment (76.6%, 78.6%, respectively) than white men and women (87.1%, 81.9%). Employment status in Black men under 50 years was a predictor of active status: these men were more likely to be active at the end of the first year if employed full-time than if they were not so employed. Similarly, Black men under 60 years of age were more likely to be in active treatment if they had more than high-school education than if they were not high-school graduates. Thus, markers of socioeconomic disadvantage were associated with lower rates of adherence to therapy. A subsequent analysis that considered four-month periods within the first two years of follow-up found that being Black was a predictor both of passage from active to inactive status (though not significant at the 5% level) and of passage from inactive to active status. Other investigations of predominantly Black patient groups have revealed a variety of predictors of compliance and noncompliance. In 1979 Hershey et al(170) examined a 92.5% Black sample, 56% unemployed, greater than 50% with a family income of less than $5 000 They found that perception of high control over health matters a minimum of unfavorable attitudes to antihypertensive 45 £ 13 Cfl tr '"N Pi H P 13 13 ro 13 tr p rt er p- Cfl er^ ^ CD tr rt p P CD P VJ 3 O ro rt vj 0 03 03 p- rt rt rt < rt p tr o 3 03 J3 Co ro P P- P- CD P- p 5 rt- i— tr P- Cfl P. rt P- CD CD 3 CD O CD rt- p 0 PL Cfl Pi ro 3 3 3 i 3 n c P er Ui P. N! P. rt p- rt- rt 3 rt O rt O h| 0 tr co a 3 3 ro Cfl O ro 3 ►1 er ro CD 0 ro <-t CL Pa 00 3 3 CD PL 13 pa p. P. 13 VJ p- 3 rt 3 3 03 rt 3 0 p 3 a Hi 03 O 3 3 tr CD 3 n tr O h| pa- O 0X3 H, H. ro O a CD p- a- ro P rt rt- P. rt 3 3 rt CD p- rt rt 5 3 rt pa ro 13 r> v. 00 rt tr M 3 VJ O cr 3 PL CD C 00 M ro rt- rt P P M vj rt- 0 Pi O ro O n ro er trxi tr CD rt 13 rt yj ro Pi 0 M ro ro 13 0 P n h( er p. 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CD »c P Mi o p sr^ CD rt 3 PL 3 M >!-id p 3 sa p 3 trxi CD P- CD 5.-13 rt 1— g- o P ro h-a ro 3 * o er tr *f o P- ii P- X H- P i'e ii ro P ro ro 3 ro P id 3 P h-i i'e rt P- 3 w 3 ro h-1 i'e ' ii Pa P- ■*», Cfl P- P O h( i—1 ro si >• 3 Sfm 3 3 CD P- NO rt P ;[- ro 13 \*m rt CL CD "-J 3 ro si 0 P- h) 0 rt 3 00 a ro % o 3 0 tr £ O VJ 0 ie P- ro < 5[- O ro er r\3 CD 0 o * P ti- ro '5- P M O ro Ml 0 P- '•- PI ro p. M p 0 0 Mi P ie p n" CD 13 erid Ml 1— rt sa 3 Pa cr st' s. vj p 1— CD ro CD ie CD M vj It pl CD ro ro o CL *e CD p P- Cfl ON a •»». 3 p £ Pi £ 3" Cfl | PL er ro rt P' 'f 0 tr rt * t p er * i'e * * * 3 unfavorable psychosocial and socioeconomic circumstances on blood pressure control in a Detroit population of both Black and white patients. The impact on Black hypertensive patients of social support from family members or a peer group has been demonstrated by investigators at Johns Hopkins University.(175-179) They presented data on a controlled educational trial, in a Black inner-city clinic patient population, that assessed the impact of three interventions, singly and in combination: an exit interview to review the drugs and to increase the patient's understanding of the medical regimen; a home-visit to enhance family support for drug and dietary therapeutic measures; and a small group intervention designed to enhance the capacity of subjects to deal with their blood pressure problem. Significant differences were observed between the control group and the intervention groups in blood pressure control and hypertension-related mortality at five years. In particular, in this group of predominantly Black, inner-city, hypertensive patients, the family support and small group interventions were the most effective. Whitehead et al(180) have described an intervention employed in a poor, rural, Black community in Mississippi(181), that was based on home-visitation by a specially trained, hypertension health counselor. These counselors were also responsible for training and monitoring volunteer counselors who became leaders of self-help groups either within extended families or in church settings. The investigators were able to compare improvements in the proportions of subjects with controlled hypertension among single clients of the hypertension health counselor and in the two types of self-help groups, the extended family and church groups. They observed that, after six months, a significantly greater proportion of hypertensives was controlled in the extended family setting than in the church groups or among the clients of hypertension health counselors. D: Access to and Utilization of the Health Care System Introduction Because the chronic cardiovascular diseases require ongoing contact with the health care delivery system for their prevention and/or treatment, they pose special problems with regard to access to and utilization of the health care delivery system, and with regard to coordination and continuity of this process.(182) This is especially so for disadvantaged population groups, among whom Blacks are over-represented. In the last two decades, several federal programs have been established to improve access to health care for the disadvantaged(183-185). The evidence suggests that, though such programs have decreased disparities in access to care and have increased utilization rates, substantial problems with the adequacy of care remain.(184-188) Measures of access to and utilization of health services, though largely accounting for differences between majority and minority health status 10-15 years ago, may no longer be 47 £ H 3 PL O croo P CD M a pl rt tr Cfl 0 p 13 13 0 Mi p1 tr a er n tr Cfl 13 P- Pa rt 0 13 3 ro o 3 rt- cn p ro tr tr 3 CD er ro 0 hi X P- P- O 0 ro ro p 3 P hj cr O O 0 P- vj p vj VJ 0 P- P- 0 0 O P rt p ro er ro 13 3 to h-> p- ro 3 < M 0 0 rt Xi ro Ml p ro Cfl PL rt O rt M 3 £ P 13 ii 13 ro 13 ro ro 3 13 VJ M M 0 p ii 13 Mi • o Cfl tr CD 0 0 pi ro ro Tr M, 3 P- i— Tr ro P- hj M 13 hi P P- rt y—s w p- O 13 n £ > 1— > p p 13 0 3 3 0 p- P ro PL 00 Ml 3 rt CD P 3 CD ii cn ro CD ro rt PL p- p- er P- rt 1— 3 P- p 3 CD ii P- p- O 0 o ii 3 0 CD 3 P 00 < 0 3 Pl ro o ro i ii tr rt li va CD 3 ro 3 P- CD rt rt p 3 P- P- M 00 ii O va P- ro rt 0 o o CD rt Mi PL 0 PL CD h-1 ii CD rt rt P- X p n P- 13 Cfl h-1 P- 3 PL cn TT Cfl 0 X VJ vj ro 00 O rt CD NO P- h( P 3 er 0 P ro tr p P- 0 P- P O CD 3 hj ec rt M CD 3 rt p- P- p- h-1 3 3 P" 3 P va p-1 CD rt rt rt 3 rt ro P- 0 P- cr hj ro CD rt 13 PL ii Tr P CD 3 a P- 0 P 3 rt er cr 0 3 0 3 P P- p- N er rt P pa vj P tr CD i—' 13 3 P- ro 3 hj 3 VJ PL 0 cn vj tr P- P- ro rt- P- < < 3 P- O M ro VJ 3 00 3 oo rt- 3 3 ro ro P ro 3 sO ro 0 3 VJ ii 0 0 p- 13 Cfl 13 P- 3 ro VJ P 3 3 3 ro ro ro P- p- Pa 3 3 ro rt M ro p rt PL O M P- 3 CD 0 PL 3 cr 0 0 ■n 0 ro P 0 00 O PL PL CD p- ro rt Pa cn p id 0 P- P P er 0 rt P p i— p S_^ CD 3 oo ro ro < P P- h| tr ii ro < cn M P p 3 PL Pa O ro 3 vj VJ CD 0 P rt p 0 cn 3 3 P- 3 rt CD O o ti- er oo O Cfl 00 tr Cfl ro P- rt 0 h-1 rt P rt 3 p p- VJ M 3 O P- O CD hj TT rt 3 hj Mi rt 3 rt 3 PL PL ro 13 M hj n 0 er P- p M H 3 3 PL P- Mi P" -P < P 0 Cfl 0 a CD PL Cfl Mi hh 3 P- ro 13 rt O ii CD P- 3 00 Cfl CD 3 ro ro oo p- oo er i— P CL 0 CO CD 0 rt 3 ro 3 tr o 3 rt P" P1 P- 3 M rt O P- PL 0 CD 3 ro 3 CD PL n M P ro w ro 0 er 3 p ro rt o ro Mi p- M 3 rt v rt rt p 3 ro Mi O P- O P- VJ 3 oo id O 3 M 3 P rt 3 3 3 P- tc ro 13 rt w ro p ro ro 3 >i o ro rt Cfl Va er p. 3 i—1 0 O o P 3 va P hj 3 rt- rt- 3 < rt rt P- CD P C3 ro p1 3 0 ii ro rt P- ro P- ro 0 o p- v. ro 0 P- ro P w P 0 rt M rt rt- 13 ro ro er ro oo CD 3 P- rt ii 00 Va 13 P CD Mi rt CD rt N 3 ro M p < 0 hj 3 Cfl ro 7? hj Mi O p P- CD 3 13 p rt ro hi ro 3 ro ro 3 VJ p 3 CD O 3 0 O p p- Cfl P- M ro hi o o 13 VJ ro 3 3 O ii VJ M 3 p y—\ p p- 3 3 1— O a o CD rt ti- > Ml M O rt ro P tr CD h-1 h-1 rt hi CD Pu P p- P PL 3 P O O PL rt 3 13 o tr ro rt rt Cfl ro p" ro P" rt ro er o i— O P- 0 P- rt P- p rt P- 0 tr P- 0 P P- o 00 M O o 13 P- Cfl p rt ro 3 0 rt 0 VJ p- Ml va 0 ro p rt- hi ro hi O ro O 0 3 M ro er CD O p- tr rt- 3 Cfl 0 3 VJ ti- tr rt p M 3 O 3 rt P- rt hj hi ro Ml ro Mi h) er Tr PL 3 0 O 00 CD ro 3 P ro ro ro PL CD ro P- er ro P- hi P- P- 3 P P- 0 p CD tr tr CD p CD rt X p CD 0 3 P- 3 0 P O id rt rt pl P Cfl Mi M ro o O Pa P Cfl i— ro 3 Mi p- X ro ro ro ro 3 hj tr CD 3 PL va 3 P y—n 3 O CD M 3 P CD M M ro P- 0 0 H W Cfl P- CD hi O 3 P- rt- p- O p-1 3 Ml 0 3 3 VJ P ro 0 3 CD oo L-i. 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(ii) Hospitalization A 1982 U.S. survey(188) confirms that, in traditionally disadvantaged groups, including minorities, the unemployed and the poor are highly unlikely to obtain medical help when they need it. In this survey, 2% of American families had experienced a serious illness that caused major financial problems during the previous year. Six percent of families reported that they needed medical help during the year but failed to get it, and 2% of families were refused care for financial reasons. Blacks and other minorities are over-represented in these subsets. (185) There are some indications that members of minority groups admitted to public hospital emergency rooms for evaluation are sometimes transferred to other facilities, despite the risk of life-threatening arrhythmias, because of their inability to pay for medical care.(194a) Many examples of "dumping" of poor patients for economic reasons have been provided by other observers.(194b,194c) (iii) Prognosis After Myocardial Infarction In a Baltimore study(195) of Black and white patient groups assembled in 1966-67 and 1971, in-hospital case-fatality rates (both crude and adjusted for a number of prognostic variables) were not significantly different between Blacks and whites (21.0 vs 24.2%). Follow-up of 94% of these patients (90% white, 85% Black) revealed no significant differences between 3-year case fatality rates in Blacks and whites. In contrast, Shapiro et al(196) reported a 48% risk of dying within one month of first myocardial infarction in non-whites and 35% among whites. Over the next 3 1/2 years, the death rate among non-whites (23%) was almost twice that noted for whites (12%). Because of the small numbers, these data do not provide a definitive answer to the question of the prognosis of Blacks compared to whites after acute myocardial infarction. In a study of 197 consecutive patients (10.7% Black) discharged after acute myocardial infarction from a metropolitan hospital in North Carolina, Kottke et al(197) observed that the lower social class patients (19 Black of 116 total) had poorer prognoses, perhaps because of other medical conditions, than those of upper social class. In particular, uncontrolled hypertension in lower social class patients was a significant predictor of new cardiac events. (iv) Hospitalization for Chronic Coronary Heart Disease Data on hospital admission for chronic ischemic heart disease do not provide definitive evidence for a Black disadvantage. Yelin et al(198), in an examination of the 1976 National Health Interview Survey, found that a reported lack of insurance coverage resulted in fewer hospitalizations in a year for chronic ischemic heart disease 50 03 13 rt P. 13 0 M O crop -p- ON O O P O cn 0 rt h s: # ?!■ ?:- ie 3 3 PL CD ii P-3 ro 3 M CD PL CD < P-PL CD 3 ro X 3 P-P 0 hh 3 h-a 0 H- o H £ cr cr cr a oo p. a cd a-H 01 C3 CD C a ro t> M H P-03 0 0 3 cn CD ro o < M P- 0 CD 3 3 ro 3 p. < p. < ro ro ro rt m fc-S Ln NO CO -P-Pa CD 3 rt-ro 0 M O ii rt rt O CD O 3 M 3 p-3 P-1— 3 P-VJ tr er s, pro $: rt si P- 5| 13 P £ 03 cr l- *e ie ti-er ro rt >T CD CD PL t-v. p. tr rt 0 er o ro p-w o 3 Ml p pa tr 1— o ro 3 Xi 3 P-3 rt tr p ro p- m p- ro 0 ro 3 3 p. 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Pa p- 00 er ro Cfl 1 a- ?*r 3f 3 % rates of hypertension awareness, treatment, and control [Table 9]. The NHANES II data(26) indicate that, despite recent improvements, 35.7% of Black male and 14.5% of Black female hypertensive subjects, ages 25-74 years, were unaware of their elevated blood pressure (not significantly different from 40.6% and 25.2% for white men and women, respectively). Of aware Black hypertensive subjects, 59.1% of men and 39.4% of women were not currently taking antihypertensive medications (not significantly different from 61.7% and 41.4% for white men and women, respectively). Of aware Black hypertensive subjects, 83.9% of men and 61.7% of women did not have their blood pressure adequately controlled (similar to 79.1% and 59.7% for white men and women). Though a higher percentage of hypertensive Black subjects reported taking medications, the percentage of hypertensive Blacks with adequate blood pressure control is not significantly lower than in whites, but control was significantly less likely in Black men than in Black women. Data from selected statewide high blood pressure control programs indicate that there is substantial regional variation in the degrees of awareness, treatment, and control when Blacks and whites from the same state are compared [Table 36]. (iii) Perceptions of Access and Impact on Medical Care Use * Some data indicate that Blacks perceive the medical care system * * to be less accessible to them. These perceptions have been chan- * * ged and medical care use increased in a number of settings by * * targeted interventions. Such interventions must be persistent, * * apparently, if good results are to be preserved. * A 1980 community survey in Edgecombe County, North Carolina(207), showed that, compared to whites, Blacks used the medical care system on the basis of need less frequently, had more difficulties in entering the system, and expressed greater dissatisfaction with medical care services. It is of interest that these results were not specific to hypertensive patients. Since they applied to the normotensive Black population as well, they suggest that cultural factors have an adverse impact on the appropriate use of medical care in that rural setting. An analysis of men (races combined) revealed that men aware of their hypertensive status but currently untreated had significantly more problems getting to the doctor than did those who were treated. Women who were aware but untreated were less likely than those treated to consider the health services accessible and the cost of medical care affordable. It is in the light of such observations that the high Black drop-out rates from antihypertensive therapy in a number of urban and rural areas should be considered. The characteristics of the health care delivery system that account for this vary with the clinical setting. 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O p ii P3 P- £ p CD 3 cn P 3 n rt- 3:- o h( 3 CD ti- ro P- > p- CD PL X ro p- rt- p P- O N ro 3 O p- H M PL 13 > w P ro er s:- 3 P O P1 er o 1— i *e cn 3 ii P- rt cr tr 3 p 3 3 3 CD 3 p1 CD Cfl P 3 va. i— 3 3 s;- h-i 3 3 P ro 3 P PJ 3 0 o P 3 13 ro 3 PL PL w M P p- P- P 3 CD ro ro p- 3- P rt- 3 rt p- cr CO p- rri 3 p rt- rt p- PL ro CD P rt rt 1— < rt M p- h( id 3 O 3|- hj ro o P- ii P P- 'f 00 £ 3 3 ro P- P P ro < va 3 O h~> 13 ro VJ CD O P- 3 P ro 35- P* va ro < P ii h-' 35- hH M P- rt i3 ro PL O O 3 rt- CD y-\ PL VJ h( M ro o CD 3 y—\ 3 S|.VJ .e a CD rt- P- Z P pa 3 3 3 CD CL er ro M LO VJ 73 0 VJ O PL p hi PL Ui P- P ro PL rt 3 1— »i CD P ro 3 VJ O P- P- hi < Ml P- £ 3 rt O 3 i'e P- 3 hj hi P- vj ec rt CD M 3 rt- O P i3 ii rt ■P- 3 O CD p- P- Cfl tr ro O 3 LO O ?:- 3 P. 3 P Ml Cfl va *f PH Cfl er rt Pa er Ml M 3 13 3 er ^-y 00 P 13 pi P" rt rt 0 va CD v_^ M ^'a. ii ti- 0 ro t cn p ro O p CD CD ro P P- 3 M ro 3 tr M 73 X p- sl- £ rt- P ro hi p Cfl pj P- < rt 3 rt ec M M 3 3 P- tu ro CD p- p- P- tr 3 P- p- H rt i'e O er i— ro 0 '1 > 3 ro 3 73 CD P- rt rt ro CD 00 3 p- ro er rt cn tr p O O 0 ervj s:- 3 ro i P- 3 ro 0 si- Z rt PL P- X Cfl Cfl VJ O O va < ro CD ro ro ro 3 < ro P p p- sj- ro si- 3 rt Cfl 0 3 hH 0 rt P- O p- rt 13 13 3 Mi CD 13 < 3 p PL 13 rt- ro rt 3 3 ro P- id O 3 P« *f a 0 CD P 0 3 p P- 73 Xi ii ro P ro rt i— O CD ro 3 s!- • hi i 3 i Cfl rt 35- rt- Cfl 3 p PL 3 O P- Cfl p O rt 3 h( p ti- 13 pi 3 O va > p- a.r *e CD 3 3 K O »•- > er 0 ro 3 P- p- P o hi 3 p- p- rt er 3 p- Mi 3 ro rt 'f < ii CD P' p '1 3 ro 0 P- CD 0 P- p 13 CD 00 O O P- £• 1— p 00 3 CD er ie P cr X Cfl cr PI 3 3 P Cfl ro P- 3 ii 3 P P Cfl cr < ro P O hi £ O M P ro a» h-' p 13 13 3 ro ie 73 cn 3 VJ ro CD rt rt rt CD rt ro rt M p er ro P- i CD 3 CD P P hH P- tr Pa 0 p- va Mi P ro O p- p p P- O rt 0 rt O < G 3 O 3 <—.. ii 1 n P< 0 3 rt- CD P1 p- ii ro P- rt O ro CD 3 P CD a ! o rt- P- O ro P> CD ro P Ii 3 ro 3 3 3 ro PL O 3 h| cn ro ro o ii 3 z hi p- h) 13 er CD ro va hh Cfl VJ a Pa i CO ro CD i— O a va j* Pa CD £ st- >* ?'f ie * 3J- Mortality reports from vital statistics records are also hampered by the fact that a separate Hispanic identifier is not included or required on the death certificates in some states (e.g. California). Therefore, for example, the Los Angeles County Heart Association report on cardiovascular disease mortality determined the rate of Hispanic mortality from CHD by inference from the number of deaths that occurred in predominantly (75% or higher) Hispanic census tracts.(304,305) To further complicate the task, it should be noted that the designation Hispanic is not a racial but an ethnocultural code. As such, individuals from diverse racial backgrounds (i.e. whites, Blacks, Indians, and mixed races), but who share a common Hispanic cultural heritage are included in this population. Therefore, genetic explanations for any observed differences between Hispanics and other groups are probably unfounded unless specific assessments of percentage of genetic admixture are considered. Coronary Heart Disease (i) Mortality * National epidemiologic data on coronary disease mortality in His-* * panics are limited to date, though the Hispanic HANES study * "'" should remedy this. Regional mortality rates for Mexican Amer- * * icans in Los Angeles County and Texas are lower than in whites * * for both sexes. Limited preliminary findings suggest that the * * rate of decline in CHD mortality in Hispanics may be comparable * * to that in whites during the last decade. * A review of the NCHS data on excess mortality from heart disease, stroke, and atherosclerosis for 1969-1971, and from heart disease, hypertensive disease, ischemic heart disease, and cerebrovascular disease for 1979-1981 did not report any results specific to Hispanics. CHD mortality data for this population were included with those of non-Hispanic whites. Therefore, it was not possible at this time to even speculate about recent national mortality trends from cardiovascular disease in this population. Proposed plans at NCHS to obtain CHD mortality data from those states that provide an Hispanic code on death certificates will help to fill this information void. The recent report on cardiovascular disease mortality in Los Angeles County(305) showed that major cardiovascular disease is a major cause of death for all ethnic groups including Hispanics, and accounts for nearly half of all deaths in all the ethnic groups reviewed [Table 40].(305) Results on age-adjusted mortality rates per 100,000 population for Hispanic men in LA County between 1979 and 1981, as inferred from deaths in census tracts where 75% or more of the population was Hispanic, showed that mortality from major cardiovascular disease was lower for Hispanic men than for whites and Blacks (441.9/100,000 vs 536.6 and 558.2 respectively). The same was 60 true for mortality from diseases of the heart (357.8/100,000 vs 432.6 and 438.9), from ischemic heart disease (220.4/100,000 vs 274.2 and 223.9), from myocardial infarction and acute IHD (98.2/100,000 vs 235.7 and 106.9), from chronic IHD (102.2/100,000 vs 138.3 and 117.0), from hypertensive disease (20.4/100.000 vs 22.0 and 57.0) [Table 41].(305) The comparable age-adjusted mortality rates for Hispanic women in LA County were similar to those of the men. Hispanic women had mortality rates that were lower than those for white and Black women from major cardiovascular disease (316.7/100,000 vs 335.7 and 384.4 respectively), from heart diseases (242.4/100,000 vs 245.8 and 278.0), from ischemic heart disease (148.6/100,000 vs 158.1 and 158.5), from myocardial infarction and acute IHD (66.8/100,000 vs 70.1 and 70.9), from chronic IHD (81.8/100,000 vs 88.0 and 87.6). In the case of hypertensive disease, however, Hispanic women had a higher mortality rate than whites (18.6/100,000 vs 15.8), but their rate was still significantly lower than that for Black women (40.2/100,000) [Table 42].(305) These results are similar to those reported by Schoen and Nelson(306) for California, and by Bradshaw and Fonner(307) for Texas. Both studies concurred that CVD was the leading cause of death among Hispanics, and that the mortality rate for Hispanic men was lower than the rate for white men in both states (82% of the white rate in California and 85% of that rate in Texas). However, CVD mortality rates in California for Hispanic women were virtually identical to those for white women, but slightly higher in Texas (7%). It appears from the limited mortality data available that cardiovascular disease is far from uncommon among Hispanics although their relative mortality risk from CHD and related causes appears to be lower than that of non-Hispanic whites. This lower CHD mortality rate is more apparent among Hispanic men than Hispanic women. The latter appear to be slightly more vulnerable than non-Hispanic women to hypertensive disease and strokes. In all cases, however, mortality from all major cardiovascular diseases is higher in Hispanic men than in Hispanic women. There are very few studies of secular trends in cardiovascular disease mortality that have explored whether Hispanics also show evidence of the marked decline in CHD deaths observed in U.S. white and Black populations in the last decade. Two studies of such secular trends between 1970-1976 in Texas found that the CHD mortality decline in Hispanics to be comparable to that in whites in Bexar County,(347) but that the decline was slightly less steep for Hispanic men in the entire state.(309) (ii) Morbidity Data on CHD morbidity in Puerto Rican, Cuban, Mexican American, and other Hispanics are also sparse, and due to presumed group differences in a number of parameters, such as use of the traditional medical care system, severity of illness required before an individual enters the system, and variability in the disease 61 classification given to a specific symptom complex, the available data are considered to be of marginal value especially for comparisons among groups. Stroke (i) Mortality .<—•«•—•—■--'--■„'-..>_^..a..--.--.-~a...-„-„a-.a..a^^^ "'" National data on stroke mortality rates in Hispanics are lack- * * ing. Compared to whites, some preliminary regional data suggests * * lower rates in Mexican Americans, but the possibility of slightly* * higher rates among younger Puerto Ricans in New York. In the absence of national data, no firm conclusions can be made about stroke mortality and morbidity among Hispanic Americans. Certain regional data, some of it inferred from census tract examination, give some indications of mortality rates for certain regional Hispanic subgroups. Age-adjusted stroke mortality rates per 100,000 Hispanic men in Los Angeles County, between 1979-81, were inferred from data from census tracts where 75% or more of the population was Hispanic. The rate per 100,000 Hispanics was 63.1; for whites it was 75.4; and for Blacks it was 94.6 [Table 41].(305) Comparable rates per 100,000 women were 57.6 for Hispanics; 71.0 for whites; and 84.6 for Blacks. Regional data for Puerto Ricans in New York indicate a slight excess stroke mortality rate compared to whites; this is particularly the case in the younger age-groups.(310) Data based on 1980 census figures seem to indicate that the rate of stroke mortality decline for Mexican American men from 1970-1980 was half as steep as for white men in the same period(304), though the comparable rate of decline for Mexican American women was 1/3 to 2/3 steeper than for non-white women.(311) Hypertension ''* National data on hypertension morbidity in Hispanics are sparse. * * Some regional data for Mexican Americans indicate that hyperten- * * sion prevalence is greater than in whites, but lesser than in * * Blacks, for men younger than 60 years of age. In older Mexican * * .American men, prevalence is increased, matching that in Black * * men. In Mexican .Americans, the rate of hypertension control for * * women is similar to the national rate, but for men it lags far * * behind. * There is ample and indisputable evidence of excess hypertension morbidity in Black Americans, but comparatively less information has 62 been available about this disease among Hispanics. Hazuda,(304) Castro et al,(312) and Kumanyika and Savage(313) reviewed several studies that compared blood pressure levels and percentages of actual hypertensives in the population of Mexican American and non-Hispanic white men and women. These studies found diastolic blood pressures in men and systolic blood pressures in both men and women to be roughly comparable in both groups.(314,315,316) The Laredo Project also assessed prevalence of elevated blood pressure (DBP>95mm Hg) among low SES Mexican Americans. Among men, the prevalence of elevated blood pressure in these Mexican Americans was intermediate between those of whites and Blacks in the Hypertension Detection and Follow-up Program (HDFP). Hypertension prevalence in Mexican American women, on the other hand, was lower than in either Blacks or whites in the HDFP.(314) A comparison in these groups of prevalence of actual hypertension (i.e. those with DBP>95mm Hg and those with DBP<95mm Hg but with either an history of hypertension or on antihypertens ion medication), the results showed that Mexican American men in Laredo, Texas had rates intermediate between the rates in whites and Blacks in the HDFP up to age 59 years. Older Mexican American men had rates of actual hypertension that equalled the rate of Black men in the HDFP. Mexican American women, however, had rates of actual hypertension that were slightly higher than in whites in the HDFP and, in the 60-69 year-old group, actually matched the rates in Blacks in the HDFP. These data also suggest that, like Blacks, Mexican American women in Laredo were more likely to have their hypertension controlled than were Mexican American men.(314) Two other reports, one from a study in California,(317) and the other from the San Antonio Heart Study(318) presented data concerning gender and SES differences in hypertension prevalence in Mexican Americans. In the California study, which used elevated blood pressure as its criterion, there was a strong inverse relationship between SES and prevalence of elevated diastolic blood pressure in Mexican American men. This is consistent with trends observed in both Blacks and non-Hispanic whites. The overall prevalence of hypertension in Mexican American men was intermediate between that found in non-Hispanic whites and Blacks. In the San Antonio Heart Study, which used actual hypertension as a criterion, there was no SES gradient in prevalence of actual hypertension in either Mexican American or non-Hispanic white men. For women, however, there was a strong inverse relationship between socioeconomic status and prevalence of actual hypertension in both ethnic groups. These data suggest that rates of hypertension appear to be comparable in Mexican American and non-Hispanic white men but lower in Mexican American women than in non-Hispanic white women. When adjustments for obesity are made, Mexican Americans tended to have lower rates of hypertension than non-Hispanic whites at comparable SES levels. Hazuda et al(319) also reported data on the proportion of hypertensives previously diagnosed and under treatment, as well as the proportion under adequate control in the San Antonio Heart Study. The results showed that the proportion of previously diagnosed and 63 s:- sj. ie ••c. Sf- i'e «■„ S a.'. -.a. af S |P. > 0 Mi O i'e s'm "1 '- s- cn ti- hi P '1 **. ii er 0 ii 35- ■>] sj- P. 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Caution * must be used in interpreting these data: not enough is yet known * about risk profiles in non-white populations. * Risk Factors * Limited regional data indicate there is a higher prevalence (gen-* * erally) of obesity, noninsulin-dependent diabetes, hypertension, * * and high LDL-cholesterol levels in certain Hispanic subgroups * * than in whites. However, available data seem to indicate the risk* * of CHD in Hispanics to be lower than in whites, though such data * * is scant. * Two recent papers on coronary heart disease in Hispanics(304,312) provide an excellent review of the available evidence on cardiovascular risk factors in Mexican American and Puerto Rican populations. The majority of the studies reviewed reported data on Mexican Americans in California and Texas, and a few were based on Puerto Ricans in Puerto Rico and New York. The authors of both review papers note that mortality and morbidity from CHD would be expected to be higher in Hispanics than in whites given the strong association between low-income status and risk for CHD, and the over-representation of Hispanics in low-income, urban groups. Yet the available evidence suggests, at least for Mexican Americans and Puerto Ricans, that the rates of CHD mortality are lower than in whites. Both papers hypothesized that the observed trends may be due to sociocultural and risk factor differences between Hispanics and whites, some of which may confer some degree of CHD protection on Hispanics. Also, since the pattern of CHD mortality and morbidity is not uniform across gender/nationality/age-groups of Hispanics there may well be differences in risk factors between these groups. The data bases that established the relationship between certain individual factors and subsequent CHD are primarily from white populations(322,323), thus limiting our understanding of (1) the relationship between known cardiovascular disease risk factors and the prevalence of CHD among Hispanics(324,304); (2) the relative predictive significance of each risk factor to CHD mortality and morbidity in Hispanics as compared to whites and other minorities; (3) the possible existence of group-specific factors which may confer some protection against CHD(324) or increase the risk for same.(323) 65 Nevertheless, the available evidence on four major biologic risk factors for CHD is reviewed here, namely: triglycerides, lipoproteins and cholesterol in abnormal amounts; hypertension; obesity; and diabetes. Limited data have been obtained only on Mexican Americans and Puerto Ricans. Any conclusions that may be drawn for those two these groups should not be assumed to apply to the other Hispanic groups. (i) Lipids and Lipoproteins Hazuda(304) and Castro et al(312) reviewed five studies on Mexican Americans and one study on Puerto Ricans that compared these Hispanics to non-Hispanic whites on levels of cholesterol and triglycerides. These studies typically show that Mexican Americans, especially low-income men, tend to have higher age-adjusted serum cholesterol levels(314,318,316) and higher overall percentages of hypercholesterolemia (cholesterol>260mg/dl) in the population than non-Hispanic white men.(317) On the other hand, Mexican American women typically have cholesterol levels comparable to those of non-Hispanic white women.(316,318) Studies that compared cholesterol levels between Hispanics and non-Hispanic whites as a function of social class found no evidence of the inverse relationship between SES and cholesterol level in Hispanics found in whites.(317) However, Friis et al(316) found that cholesterol levels in Mexican American men were comparable at the lower SES levels and increased dramatically in the high SES group. In both Hispanic and non-Hispanic white women, cholesterol level was found not to be related to SES. In contrast, data on Puerto Rican men, ages 45-64 years, compared to white male cohorts in the Framingham study, found that the PR men had diets that were lower in total calories, total cholesterol, saturated fats, and alcohol, and higher in complex carbohydrates.(325) These differences are similar to those obtained from rural vs urban men in Puerto Rico.(326) Studies that assessed triglyceride levels found consistent and significantly higher triglyceride levels in Mexican Americans than in non-Hispanic whites.(315,314,318,316) A positive relationship between SES and level of triglycerides was observed in Mexican American men but not in Mexican American women. Friis et al(316) also examined the relationship between low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C) and social class in Mexican Americans in the San Antonio Heart Study. Their results paralleled the relationship between SES and total cholesterol. In Mexican American and white men, LDL-C was low at the lower SES levels and increased significantly at the upper SES levels. For women in both groups, LDL-C levels were comparable across SES levels. For HDL-C, the levels were the same at all SES levels in both Mexican American and white men, but increased significantly with SES and were similar in both Mexican American and white women. Therefore, the apparent lower CHD mortality rate in Hispanics does not appear to be due to differences in HDL-C.(327) 66 Two reports from the San Antonio Heart Study noted that, in Mexican Americans of both sexes, avoidance of fats and cholesterol in their diets increased significantly with SES.(328) However, Mexican Americans were less informed and less likely to attempt dietary modifications to reduce risk of heart disease than non-Hispanic whites. Health promotion information and behaviors did increase with SES in Mexican Americans.(319) (ii) Hypertension * Although overall prevalence of high blood pressure appears to be * * lower in Hispanics than in Blacks and in whites, certain Hispanic* * subgroups seem to have more hypertension: Puerto Rican and Cuban * men and women. * The data previously reviewed showed that although the prevalence of high blood pressure appears to be lower in Hispanics than in Blacks and whites, several specific age/gender/nationality subgroups of Hispanics had excesses of hypertension, for example Puerto Rican and Cuban men and women. Also, reports from the Laredo and San Antonio Heart Studies(304) indicated that hypertension prevalence, whether assessed as proportion of the population with elevated blood pressure or as proportion with actual hypertension, was highest in low-income Mexican American men, especially after age 60. At this age, Mexican American men in Laredo, Texas had hypertension rates comparable to those found in the HDFP Black sample. This group was also least likely to have high blood pressure diagnosed and under control. There was evidence of an SES gradient in hypertension risk in Hispanics similar to that found for Blacks and whites. This risk gradient appears to be mediated by obesity especially in Hispanic women, and limited knowledge about hypertension appears to increase the overall risk for hypertension and perhaps other CHD-related diseases among Hispanics. (iii) Diabetes Mellitus * Noninsulin-dependent diabetes mellitus is a major health problem * * in Hispanics, especially in Mexican Americans and Puerto Ricans. * * However, the relationship between this risk factor and CHD has * * not been adequately studied in all of the major Hispanic groups. * .•-.■--'"•--■-.■-•.■"•"■"•-■.--.•-■-•^^^^ Noninsulin-dependent diabetes mellitus (NIDDM) is recognized as a major health problem for Mexican Americans, especially those from low socioeconomic backgrounds.(318,329) The prevalence of NIDDM in low SES Mexican Americans ranged from 8.3% in both sexes in Starr County, 67 OS 00 hi 3 P Xi > Mi 00 Cfl 3 > SJ- SJ" •.»„ SJ" P CD 3 M 3 M CD 0 CD < rt- X PL ro CD 0 3 0 X P CD P- < hi 3 CD P- P' P- i'e "i ro ro CO Cfl O •f> p P- M 0 0 1— Sj" P- 0 3 O P ■*> P- 0 Z P ro P P i'e m o o 3 0 3 CD p ec 1— o 3 tr s|- TT Pa ro CD Ml 00 3 3 > 0 i— P > ^ O ro z c 3 > ro % 3 P< 0 P- LO 3 CD PI ■ 0 3 s[- 0 Mi P o CD P- P- 00 CO 3 CD ro ?«• ii 3 rt s^ M 3 0 3 P- h| < sj- ro O 0 P P- Mi hH 0 P- P- cr cr 0 o £ rt 13 0 PL Sj" P. 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LO LO O P w M 3 w O CD LO M h-> v_/ P' ii Cfl 3 ro tc PL 3 ii P1 NO ■■^^ 3 ro p- 3 er ro P- oo P ■P- N-^ rri 1— CO 3 3 p p P er h-1 va Cfl 3 3 p PI P' < M cr LaO rt 3 M CD rt CO tr 3 H ro rt ro rt- c ha"1 O 00 rt X P- 0 oo tr rt tr 00 oo er p- 0 P- rt- ro 0 CaO ro ro CaO N___/ p1 ro ro 0 3 3 er rt- ro 0 rt ro M Ln Cfl hj p Cfl 0 er ro 1— 3 ro H rt 3 3 er h| ro ro 1— a P- 13 er »-J 0 P- CD ro ro CD vj 3 p O ro •5^5 rt- M >pj P X er rt O M id ro tr ro 3 ro ro p- 3 rt- P O ro 3 ro P- P va CD tr CD ro oo PL CD 3 O h-a 3 rt M ro ro er P- PL PL M < P M i P- rt p ro CD O ro rt P 3 P- CD O £ ys, 3 ro ro CD tr 3 M P- rt CD 3 13 P CD LO PL rt X p P vj O ro 3 O O 3 CD Pa p- rt- M M 3 ro hj M 3 00 P- M PL ro CD VJ Mi P CD rt- £ v^-/ 3 P- CD 3 P- CD p 3 P ro 0 CaO ro 3 ro O tr £ M PL Cfl 3 PI > tr TT rt P' ro ro CD Mi ro CaO PL 0 P- < ro p ro i— PL M 3 Pa rt 0 Mi ro rt M rt ro ON O va P P- er Ml V 3 rt 3 P- a P 3 3 rt Pl a PL 00 h-» O tr PL P- 3 Z Pa p P" CL P- 3 cH? o rt- 3 O CD hH 0 rt CD P- CD P- 3 er rt Z 3 X cd £ P ro ro Cfl Mi p- 1— ro hH P P- o va ro P' 3 rt 3 a i— o 3 CO O P rt o 3 z O a p PI 3 P ro er p £ M p rt 3 P 3 CaO 3 CD p 3 O P rt 3 p rt PL rt rt 3 rt P- P- 3 P > 3 3 tr P- I— CD P- O 3 P i— 3 a CD p- rt- 3 er VJ 3 O 3 VJ vj CD X ro er p 3 P 3 Cfl M. rt P" ro TI < er P- h-a CD tr ro P- tr 0 13 3 ro p- 3 M X ro Cfl O p p M cd CD OO CD td P- P rt 3 O P- M P- er tr ro P- O 3 ro 3 cr P rt 3 ro p 3 P P CD 3 ro Z > P1 tr O < M M 1— cr 3 PL 00 hH 3 CD ro ro CD rt ro P- 00 P o CD 3 rt- 73 ro rt- PL CD rt- > P CD 3 cd M ro P- rt er O a ro 3 rt- cn PL 3 P- P- Cfl o p- p ro CD ro rt o 3 p oo 3 p- M a 3 id p > 3 p 3 Cd P- rt- O M 3 3 h-a Cfl rt- rt p O rt- er 3 CD CD CD va ro tr rt P er p i < £ X M a 0 P 3 M rt ec P O P- rt rt- Ui 0 P- 1— 3 o tr rt- ro 3 rt ro CD CD p OO ro er 00 eri3 3 3 3 rt ro O er ro P 3 P-o O CD P 3 Pa 3 PL VJ CO P 3 Ml Data from the San Antonio Heart Study also identified a significant gender-SES trend whereby body mass index (i.e. weight/height) decreased slightly with increased SES in Mexican American men but decreased dramatically with increased SES in Mexican American women. Comparisons within SES-matched strata still found excess adiposity among Mexican Americans of both sexes.(318) Studies on dietary beliefs and attitudes noted that more Mexican Americans at each SES level were likely to express the belief that Americans are too concerned with losing weight, and Mexican Americans in both low and upper SES levels were less likely than non-Hispanic whites at comparable levels to avoid sugar or to diet.(332) These differences were especially significant for women in the low SES groups. A recent report by Hazuda et al(330) found a significant decrease in body mass index in Mexican Americans of both sexes as level of acculturation increased. Finally, there has been increased interest recently in the hypothesis that the distribution or patterning of body fat may be an important determinant of metabolic disorders such as diabetes mellitus, which may be related to heart disease. Limited evidence suggests that Mexican Americans have relatively more central distribution of body fat than non-Hispanic whites(338,340), and that body fat in Mexican American men increases with increasing SES though it decreases with increased SES in Mexican American women.(338) Other evidence suggests there is more upper body fat than lower body fat in Mexican American diabetics as compared with non-diabetics.(336,337) (v) Cigarette Smoking * What data there are indicate that, though more Hispanics smoke * * cigarettes, fewer are heavy smokers. There are some indications, * * however, that there is heavier smoking among Hispanic youth com- * * pared to white and Black youth. Little is known about the impact * * of smoking by Hispanics on CHD risk. * Hazuda(304) reviewed six studies that compared smoking behavior in Mexican Americans and non-Hispanic whites, and Castro et al(312) reviewed two additional studies on smoking in Mexican Americans and one study on Puerto Ricans. These studies suggest that (i) the overall rate of current smoking appears to be approximately the same or slightly higher in Mexican Americans than in whites, with the proportion of Mexican American men smoking the same or more than white men and the proportion of current smokers lower among Mexican American women than among white women(316,335,341); (ii) these trends hold, regardless of socioeconomic status; and (iii) Mexican American smokers smoke significantly fewer cigarettes per day than non-Hispanic whites.(314,335,341) Recent reports on smoking among Black, white, and Mexican American youth, however, show a marked increase in smoking among Mexican 69 0 vj P-1 p-3 Cfl > Cfl O hh p- ro O 3 P 3 3 cn > n .—-V H 3 0 0 tr ro 3 O Mi p- 3 P < CD 1— ro CD o 3 p CO er rt 3 £ ro o CD 3 M O P- CD P rt- X X er CD Cfl Pl ro 3 3 CD O M rt 0 ro hj PL ii 3 er p- p- 0 M rt CaO P 00 ro 0 3 P- tr 3 rt CD P P- 0 0 O O P- M ••—•a 3 CO M CD rt < PL o £ rt i P Z 0 h-a 3 3 p P i— O O va p 0 M M ro 1 p ro 3 Va ro CD Mi P" 00 OO 3 3 P t—i. o P- v» P M 00 3 ro P p- < va Mi er p 3 ro Cfl O P- P 3 p ro ro rt M cn 3 CD P3 3 > > 3 cn rt O hi 0 00 3 0 1— 3 va ro hi CD 00 M 3 ii i— 3 3 3 PL 0 CD ro 0 3 1— ro M P- 0 p- rt- CD CD O CD CD P p p- ii O h| 00 M h-> 3 P 0 vj er M h-1 3 rt M M Mi ro h-a p CD 0 M CD P- P M 00 3 ro rt P id CD P- P- hi «—'•< 1— 13 3 p 3 3 rt ^ ro ro a 3 1— O rt £ £ O O 0 ro LO O O rt ro CD O P- rt i O CD P- P O P P 3 3- 1— 3 h| 3 ro PL X P- O £ P p va h| ro 73 < M M 3 3 O N> 0 rt- p< ro 3 P- a 3 CD rt- 3 ro ro P- CD PL rt O £ ■•—' tr ro o 1 o O ro va hi CD O P va O er £ 3 0 3 p- pi p P 3 CD cn 3 3 p P rt ro VJ O CD 1— M i— ^ rt- 3 O P 00 PL o ec 3 O er Va 3 3 1— cr CD p- ro p H ro CD 3 Mi p- o P- ro p- CD ro vj 13 rt O O er PL > a P- 3 3 rt- 3 Cfl /—s 3 Ml P 3 P oo O VJ o rt ro 3 O M CD er i— 13 LO O rt- hi M ro p- M va p- O ro 3 CD Mi Ln Cfl h-> X p- rt p ■P- 3 ro CD CD CD va 3 rt O ii ro CD h OO rt NO P- M 3 3 Ln i 3 O P ro ro X P- O ^5 i -■J O pl M P- >•—/ ec p- 3 rt- CD cr M P- 3 0 rt p- o 3 00 o P i P o va p- 3 O CD 3 VJ CD 3 PL 0 M o p rt £ CD va 3 00 rt- Cfl Cfl rt h( Xi P id 3 ro p 3 3 CD 3 ro ro 013 ro CD i— p- ro ii i— O 3 3 Cfl P M CD £ > 3 pl p 3 p O Cfl PL O 3 CD O CD 3 a a hi CD M er 3 CD hi cr 3 o p- vj o ro < < P- ro > ii P p- CD ii p CD p p- p- 00 rt- CD ii CD CD o 3 P- rt rt o M P ro 3 o p 3 er PL CD p- 3 1— P ro tc P tr P- er P- rt P ro p" P- ro P 3 CD Mi M M o 00 P- O O P- M 1— va £ Mi P- ro 3 O P CD p- £ CD M 3 0 P O CD 3 er ro P- P1 3 ro rt rt- Mi o o CD PL 0 3 3 Ml O P p- rt 0 P ro er ro rt 1— p < P- i > 3 P-a ro 3 rt- P p tr 3 ro P O P- 3 CD ro 00 3 rt £ 3 ro rt PL ro rt 3 O O p- p- 0 M TT M ro CD P O CD n ro 3 rt- hi 3 3 3 3 o ro CD £ va p< 3 M P- 3 X rt- O O • Cfl P 3 3 h-1 0 O ro P- 3 CD P- ro CD rt- ro hh 00 O 3 rt i— P VJ 3 rt- £ M O 3 O Pi M er 0 3 0 h| o cr er rt M CD tr P P P ■ P rt ro h-] Ml O M P- 0 ro ro 3 ro rt 3 ro P rt 3 tr 3 p- P M cr 3 O O 3 ii ii 0 3 P- Cfl O 3 p- ro 300 CD 3 13 ro ro P w tr rt O O va 3 hH > 3 ec CD er i— P O rt 0 cr p ii 3 3 rt 3 3 ti- h-a p- ro X rt rt 00 0 P- n ro < ro OO LO CD er vj ro P P- rt 3 P- hi p- O p- ro 3 > O NO rt M ro id 3 0 O h-3 M O P P 3 0 ro Pa ec 3 v^S o er P- cr P CD p er P 3 PL P" ro p- ti- ro p- CD ^5 ro 0 13 ro 3 3 13 ro P-a P 3 0 3 er ro M £ p ro o P- O M ro i— P ro 0 P- ro ro 13 P- CD 0 Mi 3 M 0 O O > 0 ro L-i- rt rt ec 3 1— tr P O M Mi p- ro o 3 ro 3 3 PL 0 ro P- P p 0 P er 0 3 P CD < ro P- a 1— CD 3 p- tr rt 3 rt N 3 M p- £ p- 3 P ro P 3 3 f----\ CL hi o 3 cn P 00 3 3 P- 00 O Cfl 1— 3 rt 00 LO P- ro 13 Va rt cn PL 0 Ml er rt- Cfl . h-- a P 013 0 M 3 Ml P 0 ro tr y\ 00 LO M p p O P ro M 0 ys. ro ii Cfl p p Ui 3 rt- CD \~y O 3 3 < 3 O hh Ui rt rt rt 3 $> CD er cr ro VJ CD PL P 3 O P ti- Pa Ln X ro 0 p 3 Cfl 3 ■F> rt er va P- hh cr CD 3 er CD V—-• 3 ro LO ON O P 3 hi p rt-ro h-< VJ cr ro 3 rt Ui O hi ro 3 O ii CD p-00 er X p-0 p 3 P 3 PL Cfl »e af S'f i'e SJ- * 3J- «;. 03 ecoo < Cfl > cr rt Cfl > M PL Cfl £ > a.f- 5C. p- ro CD 3 3 ro er P- 3 CD P- 3 tr 3 3. *e sS- w 3 M O CD rt ro 00 CD PL ro cr p- CD •!. 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This group differential also held true for men and women. In an earlier report on cardiovascular disease mortality in L.A. County(407), data were reported for Filipinos. These data show that the annual mortality rate/100,000 in 1980 was lower for Asians than all other races for major cardiovascular diseases. Within the Asian group, the Koreans and Filipinos had the lowest rates, the Chinese had higher rates, and the Japanese had the highest rates. For hypertension, the mortality rates for the Chinese were slightly higher than the other Asian subgroups. Filipinos had the lowest age-and sex-adjusted mortality rates of all the subgroups. Yu et al(400) suggested that the relatively higher socioeconomic status of this population due to the disproportionate migration of educated^ Filipino professionals might account for the relative "resilience of the population as compared to other groups with a broader socioeconomic status distribution. Mortality rates for Japanese for all types of cardiovascular disease, though lower than for whites, Blacks, and Hispanics, were the highest of all Asian groups [Table 62].(407) Interesting age and gender differences in mortality rates are also observed between Filipinos and Koreans, with Filipino men and women between ages 45-54 having higher rates than their Korean cohorts. The total Filipino male mortality rate for major CHD is higher than that for Koreans, though the reverse is true for women. In the case of heart disease, once again the mortality rates for the Japanese exceed rates for all of the other groups for both men and women, and at most age levels. There were no significant differences in heart disease mortality between Chinese and Filipino men, and Korean men had the lowest mortality rate. For women, the mortality rate in the Chinese was lower than in the Japanese but significantly higher than the rate for Korean and Filipino women [Table 63].(407) Similar trends across age, gender, and nationality groups were also observed for ischemic heart disease [Table 64].(407) Data from several sources on CHD mortality for Chinese men, ages 35-74 years, in Hawaii(409,410) showed CHD rates lower than for whites but higher than for Japanese. On the other hand, Chinese women were at higher risk than women of all other ethnicities except Hawaiians.(410,411) Trends in CHD mortality in Japanese men in Hawaii showed significant increases between 1940 and 1970, but declined somewhat between 1970 and 1978. Since 1970, there have been declines in CHD mortality rates in women of all ethnic groups except Hawaiian and Filipino women who showed declines since 1960. Gerber and Madhavan(411) compared proportional mortality due to CHD among Chinese in Hawaii, native and foreign-born Chinese in New York City, and whites in New York City between 1968 and 1972. CHD deaths were proportionately higher in Chinese in Hawaii vs those in New York City in every age-group with the size of the difference narrowing with increasing age and disappearing in the 75+ age-group. Among the Chinese in New York City, CHD deaths were proportionately greater in U.S.-born vs foreign-born Chinese at all ages 25 and over. 77 A lower proportion of deaths was due to CHD mortality among Chinese in both Hawaii and New York City vs whites in New York City, except in the 25-44 year age-group where proportionate mortality was higher in Hawaiian Chinese. Death from CHD occurred later in Chinese populations than in New York City whites and later in foreign-born New York City Chinese than in the other two Chinese subgroups. These findings are consistent with an increasing and earlier CHD risk with increasing U.S. exposure (i.e. acculturation). It has been suggested that the overall higher socioeconomic status of Asians as a group may partially account for their more favorable cardiovascular status.(400) However, within-group differences in SES and nativity need to be explored to determine whether there are particular subgroups of Asians who are at risk for excess cardiovascular mortality (e.g. recent Chinese immigrants with low SES). The Japanese, who generally are more acculturated to U.S. lifestyles, diets, etc., appear to be at higher CHD risk.(406,412,413) (ii) Morbidity * Data on nonfatal events are too sparse for any conclusions to be * * made about incidence, prevalence, or trends. * .•.-W----.W..'.---.'--'..>..'..'^ Stroke (i) Mortality * National data suggest stroke mortality rates in Asian Americans * * are similar to whites; that stroke is the third leading cause of * * death. Recent age-adjusted data for Asian subgroups indicate * " that Japanese men are unique among most ethnic/gender groups, * * including whites, in having the highest stroke mortality rates. * National data, which identify Asian Americans as a single group, are quite limited, but suggest that the mortality rate for cerebrovascular disease is similar to that in whites.(425) More recent (unpublished) national data, compiled by Yu et al(400) and which identify Chinese, Japanese, and Filipino Americans separately, indicate that stroke is the third leading cause of death in these groups; and that stroke accounts for a slightly higher proportion of all-cause mortality for Japanese (11.2) and Filipinos (10.1) than for Chinese (8.6). The proportion for whites is the same as for Chinese (8.6). Age-adjusted mortality ratios (i.e. minority rates compared to white rates) showed that Japanese and Chinese Americans are equally at risk for cerebrovascular death.(400) The Heart Association Report on Cardiovascular Disease Mortality in Los Angeles County(408) indicates that cerebrovascular disease was 78 p p id cr rt m 0 rt O < M Mi ro p- p- i cr 1— ro 3 Cl P- hi 00 o er TT rt- CD CD hh >Xi O ro O m p-id P 3 rt 3 p er p p- oo ro ro h{ Cfl p oo ro p. •< 3 3 tr ro ro ro O ii rt ro 3 P rt p- < X Cfl M w id o pat tr p p. id ro p- mi w o H p er m ro Pa p- p- 3 P- rt- ro pl P 3 M rt rt > Cfl o p- o ro o o 3 O 3 p- P- O P 3 ro rt O PL P- p. 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CD VJ ro VJ 13 rt er M 3 C-H 3 h-> Ml ro p P • 0 P NO < 13 rt M cr p 3 P CD P- VJ Mi 3 rt- o Mi • O CD CD P £ ro 0 3 tr P rt t £ Mi tr CD 0 £ ro ^ P1 ii tr CD ro Ui h-1 p- tr P tr O VJ P M O p- a er 3 ro rt h-> P- ro ro p- 0 CD ro 3 p ii 13 hi 3 3 M vj > 3 CD CD 00 3 3 0 P- ro rt 3 ro ro rt- CD tr CD 13 3 P 3 er ii Ml Pi P ii ro P- M er 3 £ P-a ro ro o ec 3 ro P- rt ro 0 rt 3 ro P- P rt- O 0 er 0 13 M 3 00 PL p- 3 va M erid P. £ O ro p- ro £ p- 0 CD tl 00 N-aa 0 Pa- ro 11 tr 3 £ 3 P- ro P rt- Pa 0 CD va CD 3 rt- P rt) hH p- CD Mi P- ro CD P ro v—/ ro ro rt 3 n Cfl er P1 < Cfl ii ro CD rt- 3 11 00 P- ■ P 13 p- cn P P- rt CO ro rt- ro Cfl ro 3 CD ro O oo 3 3 ii < p- Pa Cfl P- 3 er P- CD £ 3 p P- ro 3 ro 3 CD CD ro 0 Pa- 3 M 3 0 ro P- er M p- 3 p 3 a O 3 ro i— 3 rti P P < CD 3 p- CD ro P oo Ln P er ro vj 0 rt- CD 3 00 P 3 rt- cn i— ro C-H O £ p" /-\ 3 V—/ £ hi 3 CD VJ tr 3 ro ro 3* CD ro p P 00 p- ho ii ■ P 3 3 Cfl va P" O 3 3 vj 13 0 M i 0 NO CD ro P- i— y—s. 3 £ 3 oo 3 13 O p- P ii CD ■*> £ p rt 0 -P- CD OO 0 ro PL CD 0 00 3 3 NO CD P" P r*l ro 3 P- Ml h-- C-H P- Ml 3 CD hi 3 i CD 3 CD M 6^ 3 0 p- ro NO P oo rt- a h rt 3 ■p- Cfl O cn VJ O M p- Lh rt rt- N-^ 13 er tr ro ro CD rt- NO ro ii ro ro rt- < 3 OO P P er P rt ro p- M O 3 ro CD p er ro 00 3 erid oo ro £ 3 i ro 3 O ro M VJ £ P M p CD rt P CD tr a tr CD P- O 3 P- 13 ro O VJ 3 ro 3 Ui C-H 3 i— 3 13 p- h-a 1— 0 rt < p p 3 CD O va 00 p vj CD 13 hi o O o P tr ii CD h| h( CD P 3 Ml • 13 O Cfl M CD er 0 o M 0 O W rt Cfl 3 M 00 P 0 Ln P < er CD O 0 3 £ 13 i— er CD P ro 3 p- 3 0 CD ro ro CD M £ 13 CD P LO p- 00 hi V t— O hi ro P- h( O CD P hj 3 a rt- ec 3 ro P- CD rt- cn £ 3 •w" < h( CD CD NO ro VJ CD rt- p rt ro 3 CD rt CD CD ro s^ 13 3 Ln er oo vj 0 PL hi ii ec ii H ii PL er CD £ CD o p CD Ml CD ro p CD tr va P- < O ii tr 3 Cfl Cfl cr £ P ro rt 0c w 3 rt vj VJ P 0 P rt £ O tr CD CD CD P' p- 3 rt- P- 3 CD ro Ui 3 3 ti- P 3 00 13 tr P- CD M M ON cn er hi i i— . 3 CD a P p- p- Cfl ■(> CD rt rt O 3 ro NO H tr ro Smoking The prevalence of cigarette smoking in the Honolulu cohort of Japanese men, ages 45-54 years(417), was 46.4%. The percentage of men smoking more than a pack of cigarettes per day was 19.2%. In the comparison of 45-64 year-old Framingham and Honolulu men reported by Gordon et al(418), 44.1% of Honolulu men vs 57% of Framingham men were smokers. Robertson et al(422) compared baseline smoking status for Japanese men, ages 45-68 years, in Japan vs Hawaii and found a higher percentage in Japan of smokers (75.6% vs 44.2%); however, they found more Japanese men who smoked 21 or more cigarettes a day in Hawaii than in Japan (16.6% vs 11.6%). Taken together, these data indicate that Japanese men in Honolulu smoke more than Japanese men in Japan but less than white men in Framingham. More recent estimates of cigarette use among Japanese Americans in California are available from the 1979 survey results. Overall, 50.6% of the Japanese American men were classified as "ever smoked".(419) Fewer Japanese men and women described themselves as current regular smokers and as current or former smokers. Japanese smokers typically also smoke fewer cigarettes than their white male and female cohorts, but fewer Japanese than white smokers wanted to quit. B: Overall Impact of Risk Factors on CHD in Japanese Americans * Though the standard risk factors for CHD are significantly less * * prevalent among Japanese on the mainland, in Japan, and in Hawaii* * than in white .American men, generally similar associations are * * found between the major risk factors and fatal and nonfatal CHD, * * nonfatal MI, & acute coronary insufficiency. High blood pressure,* * cigarette smoking, and high cholesterol levels are important * * risk factors. * Reed et al(405,426) presented total and fatal myocardial infarction (MI) incidence data for 50-59, 60-63, and 64-67 year-old men in men of Japanese ancestry in Hawaii. cohort. Incidence rates for total MI increased overall between 1967-70 and 1975-78 for men, ages 60-67 years, and appear to have remained constant in the 56-59 year-old men. Fatal MI rates showed a slight increase in the 60-67 year-old men with evidence of tapering off after 1971-74. Fatal MI rates were constant in the 56-59 year-old men [Table 70].(405) Analyses by birth cohort indicate upward slopes for total and fatal MI incidence during this time period in all cohorts of men born between 1900 and 1919. Gordon et al(418) reported that, although the standard risk factor associations were observed among men in the Honolulu cohort, two-year CHD incidence (defined by ECG) was twice as large in the Framingham study, and CHD mortality was four times larger than in the 82 pi n CO af ie fr * i'e * ie ie ie p er p- »!, rt p- 00 af 1 af P 3 ro 3 P- af £ 3 CD £ er rt 0 t ii Mi ro Mi si af tr 3 P- CD 0 ii CD P- af 0 ti- er hj 3 i'e 0 0 0 ro p P- $ 3 > p i'e ro < ro < O ti- 3 3 i'e 3 CD a CD P er ie rt- CD rt 0 ii 3 ro er ii P- I af TT a M ro *c ro P" VJ CD Cn 0 0 va h-> ie O O £ £ P- ec P 1— Ml CD CD P 3 p 3 CD ie CD VJ < ii P« *e £ ro Cfl st^. £ ro CD o rt- ie P Cfl '? ro p hi pj p ro 5!" p- rt- ii hi St CD 3 P. s\. p- er p- ro < rt ie p 3 cr o rt CD P- p. i'e ec 3 Mi p- P- 0 tr l—> 0 P 11 CD 0 0 00 Mi CD ro 3 rt P Ml M 0 p ro P st. 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Other than the mortality data for Filipinos previously reviewed, the only other specific data - identified from the California Hypertension Survey on blood pressure and smoking - are noted below. Hypertension aVaV--VaV-aVaW» aVaWwVaVaVawwVaVaVaV'«-aV^ * Hypertension is a significant public health problem in Filipino * * Ajmericans. The sajme number or more Filipinos are receiving treat-* * ment for their hypertension compared to their white cohorts, yet * * fewer have achieved blood pressure control. In striking contrast * * to other gender/ethnic groups, Asian and non-Asian, Filipino * * women, in particular, were more likely to have high blood pres- * * sure that was not under control. * Mean blood pressure levels among Filipino men in California in 1979 were estimated from the California Hypertension Survey data. Stavig et al(419) note that the Filipino population of California tripled between 1970 and 1980. Estimates of elevated blood pressure prevalence (BP >140/90 mm Hg) among California Filipino men and women were higher at all ages and substantially higher than for whites in the age-sex groups with relatively higher prevalences. Among Filipino men, ages 18-49 years, 29% were found to have elevated blood pressures as compared to 15.0% of whites. Among those Filipino men, ages 50+ years, 50.8% had elevated blood pressures as compared to 38.5% of white male cohorts. Filipino women were similarly more likely to have high blood pressure than their white female cohorts. Filipino women were more likely to have elevated blood pressure at an older age, although Filipino men were more likely to have elevated blood pressure when they are younger. Smoking * Filipinos, like their fellow Asians (at least those in Califor- * * nia) do not show evidence of an excess prevalence of smoking com-* Data on the prevalence of smoking and pattern of smoking among younger and older Filipino men and women compared to whites were also available from Igra et al.(420) Like the Japanese and Chinese, fewer Filipino men and women in all age-groups were current regular smokers compared to whites (26.0% vs 63%, respectively, among men and 14.3% 85 vs 29.4% among women). Filipino men smoked 17.7 cigarettes on the average vs 27.4 cigarettes smoked by white men. Filipino women smoked 8.0 cigarettes vs 23.2 cigarettes smoked by white women. Of those who were smokers, slightly more Filipino men than white men expressed a desire to quit smoking, though comparable or fewer Filipino women wanted to quit smoking than white women [Table 72].(421) 86 CARDIOVASCULAR AND CEREBROVASCULAR DISEASES IN NATIVE AMERICANS / INTRODUCTION The available epidemiological data on Native Americans are limited by many of the same deficits found with other minorities; namely, data on these groups are either aggregated in a "non-white" or "other" category, or Native Americans are treated as a single group with no distinctions made for tribal origins. Although many may debate the validity of these subgroup distinctions, given the relative homogeneity of social status across all tribes, there is ample evidence, nevertheless, of important health differences between Indian tribes. These differences have been attributed to differences in cultures, in level of acculturation, in degree of urbanization, and in degree of conflict between the native culture and the social standards of the contiguous American communities.(500,501,502,503) Thus, some of the evidence reviewed here reflects estimates of the overall status of Native Americans and Alaska Eskimos, but almost certainly does not directly reflect the specific cardiovascular status of all tribes. In certain cases, the data are specific to one or more tribes, and caution should be taken in these cases not to overgeneralize these findings to other Native American tribes. The census designation "Native American" includes American Indians, Eskimos, and Aleuts. Native Americans comprised 0.6% of the U.S. population in the 1980 census - 1,418,000 of the 226,505,000 Americans counted.(504) This is an increase from the previous 0.4% of the U.S. population in the 1970 census. The Navajo, the largest of several hundred Native American tribes, numbered approximately 150,000 in the mid-1970s.(505) States with the largest Native American populations are Arizona, Oklahoma, California, New Mexico, and North Carolina, but the federally recognized Indian tribes are spread throughout more than 25 states.(505,524) Prior to 1940, 90% of Indians lived on reservations, but by 1977 more than 50% lived in urban centers. Sievers and Fisher(506) point out that southwestern Indians have remained more isolated and less racially mixed than Indians in other regions. At the time of the Sievers and Fisher review(506) 6% of southwestern Indians over age 15 versus 20% of this same population under age 15 are reported to have some non-Indian admixture. The Native American population is disproportionately poor, has a lower life expectancy than all other U.S. races, and is younger than the U.S. population as a whole (i.e. median age 18.4 vs 28.1 years for the U.S. population in the 1970 census).(506,507) 87 ex (X > er p 3 rt £ erid 3 3 0 £ 00 p Mi 13 P-a PL P- > 3 P 3 P-00 3 p- 3 PL P. 13 13 PH 1 ie * * * * * ie 3- 3 ro 3 0 P- 0 ro 0 0 0 rt- er M cn 0 0 NO P- 3 3 0 O 0 ro ro 0 3 P- p- CD hi 0 3 CD p a M 3 3 p id hi ii tr p- 0 hi 13 Ln Cfl Ml CD hi O h| p 3 M 3 Mi P 0 13 •T M hi rt CD (D M 3 rt rt ro rt- 3 P 3 Ln CD P h| rt P- CD rt- CD rt tr 0 Mi rt 13 3 P ti- P o ti- P- S T P- rt P- P 3 rt 1— P P ii ro X3 h-> i— va P 3 P- P P- er ii P 0 ii CD tr 0 p1 er O 0 er 3 ro T Cl o va NO i— P- « va P i— z p- ro ••w' ro NO 3 P W rt O 0 h-> CD rt- p h-1 rt- P- h( 11 P M CD n 3 p p ){■ o p ■^J p- 3 3 PL rt P- p P- 3 • • P- --J O rt cr CD rt- p P- 3 tr M p- P- er rt Cfl p rt rt CD ro P- rt 3 Z ti if M 3 o NO rt 3 cr p- P- rt rt rt p- 3 IO M P- 3 va 3 er 3 rt rt- p p rt P- 3 P- P- o P" ro P< ii P rt /—\ O ro ro 1 VJ a P 3 ro 0 VJ P- vj 3 00 1 rt O rt O ro ro VJ ro 3 rt 13 VJ rt CD Mi a 0 0 ro ie 3 CD P- P- rt I p- 3 hi h-» ec 3 rt CD 3 < 0 p] td i— p-1 P 3 P hi h| ro O tr Cfl hi 3 3 3 o p 3 cr 3 P- P- N/ P rt- ro NO P" td vj P ro P- (D CD ii er p CD NO I— ii 0 rt F-—■| Ml p- rt- Cfl 13 Mi ro • 0 3 P Cfl rt ie ii ii rt- 3 < P- I M tr tr oo 3 P- 3 Cfl a 3 X P- ro rt 00 P- CD 0 P 0 H ii 3 tr 3 M 3 O rt- va if CD CD ro rt rt ro Cfl VJ p ii o 3 TT P ro > P- rt ii P 00 P> rt CD 3 P- p- 0 P 0 m p p- O hH rt- CD h| % p P- tr ro ;{■ 3 rt 0 rt- 0 P v; 3 3 W VJ ro M vj < P P- P- 3 cr 3 rt- ro ii P 3 3 > rt- CD W CD ro cr P 0 ro r p H" o ec < p er hi p- > CD CD rt- Ml O 0 P- CD P- CD rt 13 p- er ro CD rt Pa 1— tr CL 3 3 13 ii af CD ro 3 3 ro -1 ii ro £ p H ro rt P cr ro rt 3 h| 00 0 3 3 3 h( 3 3 3 VJ ro ro O ro P- er P- rt- ro 0 3 0 rt P. 00 CD ro rt p P ro CD P 3 ro P- tr M M 13 O P rt va rt er rt 3 0 ro P er rt h) P hi t P- rt- 0 ro hi p M cn o p h-1 PL ro P P 0 CD 0 CD ec w i— rt- P PL Ui p- 00 M 00 P- CD 3 p 3 0 G tr rt 3 rt 3 CD o hh 3 P- P- P1 rt 3 h-a < P- ro p- ►— 3 p rt 3 va p- va 3 ro ro P- Va 3 3 O 0 ro 3 P 11 3 • p P vj % ii er CD O ro P- 0 i— P" p rt CO 1—00 P1 Pa 3 £ 13 ro PL ro cn O 00 i—i 3 3 CD M I——i rt P 00 cn rt P- P- 0 13 hi 3 ii P ie rt a 0 P 3 P- VJ p p- 3 ro CD ro 0 id £ CD M 13 P M P- CD cn 1— H 3 er P- TT 3 *-!. '* hi n 0 0 P 3 P i 'i v; p- 3 ii P- P- < 00 P- P P- CD 0 P er Mi CD ii 3 rt 0 ys, O ii VJ P p- P- rt- rt P ie CD 0 3 3 h-1 ro ro 13 va rt P tr p er Mi 00 3 ro 3 P 3 3 p- O ii O O a P p Ln p P cr P- rt X er vj O aj < 3 P- o va ro CD P CD tr vj 00 rt P- CD tr 3 id P- rt- 0 O CD id i— 3 O I— 1— w P h-1 Cfl oo tr 0 ro P P P rt n p 13 P- P ii P Pi Pa- ro i— o Cfl £ 0 rt a p o ro 3 3 3 0 P P- ro 00 P- cn CD ro ro ro id Ml 3 ii h-1 hi ii O croo Cfl P 3 CD p ys. vj p 0 £ tr M ro 13 rt h| p- rt CD *s-y < 13 er p 3 3 3 M a PL ie CD 0 1— P-13 3 3 ro cr PL P- 00 Ln 3 P 3 ro £ P- 3 va P O i— rt o VJ Cfl CD 0 P- er 00 ro CD 3 P-a 0 0 P- '1 3 P- P- P- 3 rt P' 4 m CD P- PL CD Ml ii p- .a-'J < 1— P P- ii cr o rt tr Mi p 3 rt hi PL h-1 ro CD h| p er 3 0 rt- > 0 CD 1— P- CD hi ro ie CD P- rt 3 P 0 P- *c ro ro PL o 3 ro 0 ro Z > 3 cr ro PL p- z P ro 13 Mi tr 3 3 P 1— P" PL CD CD t TT 0 ro 13 3 cr \ ro p- pl CO p h( 3 PL ec £ P p ro PL h-' ii ro 0 p i— P- 0 ii ro CD ro rt- CD < P t CD CD 13 P 3 hi ro o ro td rt Mi rt- 3 P- tr rt 00 p- Z P- CD o ro rt ro 3 ii 0 hi va er P rt P- cn * r-> p ro P ti- rt < M p p > 0 P er o Cfl p P" oo P P ro rt- h| p- P- 0 P- rt 3 ro P- cn Cfl 0 0 CD CD *■!• CD VJ p" ii ro 0 ro 3 Cfl < rt Cfl hi 3 ro ro 13 rt- < M 3 rt rt) 00 er ro ro —i 3 Cfl < hi 3 ro ro 3 ro ii M Z rt- Pa 3 i'e 0 tr n o rt rt p. rt £ ro 0 3 P- £ 0 er P- ro > P ys, CD CD • ro 00 > p- P p Cfl CD 0 P tr '1 p p P er h-> 1— O 3 P 3 ro ro P 0 3 ro O ii 3 rt- rt cn y-\ p- a p 3 p.pj rt- ii rt 13 3 rt ro rt- Z t 3 rt- 3 VJ ro Pa- P rt er o 3 id p Cfl CD ro M > Ln 3 ro CD CD P CD rt 0 P- I Mi P- M tr P Cfl Cfl p Cfl P rt- pa p er 0 r—, TT CD p M • P- ii Pa CD 3 ii O cn rt ii 3 rt TT Cfl 0 M rt- < ro rt *'- er CD ro rt ro h-' er rt 3 tr ro £ H 3 h| rt P- P- P CD CD 00 rt p- M P- rt rt- 3 PL ro id 0 er CD 3 P- j|- I—1 ro 0 P-1 ro VJ P 3 p P > p Mi O £ rt- hf 13 N_/ 3*00 O O ro 0 P- 3 tr 0 3 ro p ro < »e Pa p 3 p 0 1 h( h-1 M o cr 3 cr PL Mi P P- CD P- O CD 3 P- P p- M M ro va p M > i—i. < CD af < ii 0 3 ci- hh O 00 P- TT P rt er p- CD 3 P- p- CD 3 rt- PL 0 ii p- 3 3 3 3 rt CD i— rt er 0 3 0 p- CD rt ii rt er P ro 3 CD rt p ro hi 0 CD Cfl hi ro er p rt- 00 Mi rt- ro P p P Mi p- ro rt- CD ii a > % rt 0 ro P 3 i'e 3 Pa p- a 3 P- rt CD CD P 3 ro CD p- ro Z 0 Pa- Cfl 0 0 p er ii ro 3 h-' P. P 3 ro i'e ro 3 0 p- oo 00 0 rt £ P 3 P Pa Cfl Cfl a 3 0 ro Cfl P Mi Pa ro 0 rt- 3 M ro P- O 3 CD i af 0 p. p- o 00 O ro t h( P PL 3 ro ro ro p P tr ro O 3 p CD p rt 3 rt rt p- tr P rt hi 0 P 0 M 3 ro P- cr ii 0 p rt CD ro CD ro 3 i— p- CD CD Pa rt P ys\ cr hi 3 p- o P- CD VJ P a p rt- p 3 CD P- 00 CD rt P- CD 3 3 i'e p-1 P- 0 P . p- rt- Cfl p rt VJ P rt 3 er < X 3 ro rt CD P- hi 3 Cfl o ro P VJ Pa- P rt 0 a- P hi Cl 3 p- CD 173 P- ro ti- ro 1— Ml % p- ro rt P« si NO 3 0 ec CD Pi 3 er CD h-' 3 0 rt }{- p. "-J PL 3 td O ro 4 h-' ii VJ & 3 Ln CD ie * * * * * * * * population between 1970-1975. There was a substantially smaller decrease, however, in mortality from hypertension [Table 83]. However, the sharp increase in mortality due to suicide and cirrhosis of the liver raises the possibility that the reduced CHD mortality may have been due, at least in part, to competing causes of death rather than to a basic reduction in CHD risk. Under age 35 years, the heart disease death rate for Native Americans is approximately twice as high as for all other ethnic groups. Above the age of 44 years, heart disease mortality increases less steeply with age in Native Americans than in the general population, and Native American rates are lower than those in all other groups for age-groups over 45 years.(508,510) A later crossover in atherosclerosis and cerebrovascular disease death rates is also observed. (ii) Morbidity aWwV-aWwVaV-aV-awVaVaVaVVwVV-aVaVaW'aW * Some preliminary data point to a pattern of increasing CHD in- * * cidence in certain urban Native Americans. However, other data * * for southwestern tribes indicate low prevalence of CHD despite * * high rates of obesity, of diabetes, and increasing hypertension * * rates. * Preliminary prevalence and incidence data suggest that coronary heart disease and stroke risk may be increasing substantially in this population, especially among those residing outside the southwestern states.(506,511) Sievers and Fisher(506) report that CHD is a relatively uncommon problem in southwestern Indian tribes despite high rates of obesity, diabetes, and increasing rates of hypertension. They attribute these findings to low prevalence of major biologic and behavioral risk factors. However, the recent report by Gillum et al(511) on CHD risk factors in Native Americans in Minnesota and Montana (mainly Chippewa/Ojibwe people were studied) points to increases in both standard CHD risk factors and in the incidence and prevalence of cardiovascular diseases in urban American Indians. This pattern of increasing CHD is also beginning to be evident in the form of increasing rates of myocardial infarction in southwestern American Indians, especially among the Hopis.(508,506) II: EXPLANATIONS FOR DIFFERENCES * In general, the data on CHD risk factor status for Native Amer- * * icans are even more limited than that available for other minor- * * ity groups. Such data that do exist represent a particular tribe * * or subgroup rather than the entire Native American population. * * Cautious interpretation is therefore required. * .I.J..I.-I.-I..'--}--}-- -<--'--'-.<--l--'-~'--<.-<--'--l..'..'.*1~<.-l.-l--'--'-*>*J~'..'-.<--l.-1~1.-l~<—X~l^t^J,. 89 Kumanyika and Savage(508) noted that a large portion of the literature pertinent to cardiovascular risk factors reports on Indians in the Southwest and, in particular, on Pimas, who are reported to have the highest prevalence of type II diabetes in the United States.(506) This group appears to be the exception to the rule that a high prevalence of obesity is related to high cholesterol and a high prevalence of heart disease.(512) However, other tribes have been studied including the Papago, Navajo, Apache, Hopi, Ojibwe, Sioux and Winnebago in Minnesota, the Crow and northern Cheyenne in southwest Montana, the Arapaho and Shoshone in Wyoming, the Seminoles in Oklahoma and Florida, the Alaska Eskimos and Aleuts, and the Seneca in upstate New York. Nonetheless, these papers provide an incomplete picture of CHD risk for the subgroups listed and ignore a substantial portion of the Indian population. It is also important to note that the history of the Native American population is unique and varies greatly between the Indian tribes. These factors have affected the amount and quality of the health and disease data available for this population. To further complicate the problem, many of these data are based on potentially biased data sources and on anecdotal material. Explanations of the patterns of cardiovascular diseases observed need to consider not only genetic/biological factors, but cultural and economic factors as well. Native Americans, as do most Americans, differ in their degree of racial admixture, and there are significant inconsistencies in the classification of racially mixed Indians (i.e., they are classified as either Indians or as whites). A: Biologic and/or Physiologic Variables Hypertension *-_W„-„W„l„-„W...l-..l-^ * Hypertension appears to be an important health problem for Native* * Americans, though apparently less so than for the white popula- * * tion. * .L.U.J..a..a..a..a-y..'..a..L.W.J..'..a.^ The limited evidence available on the prevalence of hypertension in Native Americans does not permit us to draw confident conclusions about the significance of this risk factor for all Native Americans. Sievers(513) noted that, over the past 35 years, reports typically find lower prevalence of hypertension in Native Americans than in whites.(506) This difference was evident both in the southwest and in other regions. However, he also noted higher rates of high blood pressure among Indians who had migrated to urban centers, and higher blood pressures in Indian diabetics than in nondiabetics. However, these trends are not consistent for all Indian groups. For example, studies on White Mountain Apache men found a high prevalence of high blood pressure. On the other hand, no blood pressure differences were found between Seminoles and whites in Florida, despite significantly higher percentages of obese and diabetic Seminoles. 90 The results of a survey on a diverse but nonrandom sample of Navajos in Arizona and New Mexico found that Navajo men had higher resting blood pressures and a greater prevalence of hypertension than Navajo women, but they did not show the expected positive increase of blood pressure with age. Level of acculturation was not found to be associated with blood pressure.(514) Gillum et al(511,515) reported a survey of blood pressure and related CHD risk factors in all first-, second-, and third-grade children in Minneapolis public schools, and a survey of two adult Indian populations in Minneapolis (one from an Indian housing project and the other from community screenings during American Indian week). Both studies were mainly on Chippewa/Ojibwe Indians. The results from the children's survey found higher systolic pressures but lower diastolic pressures in the Native American children than in their white peers. Similar results were obtained in the survey of the adults. Blood pressure readings were comparable in both Native Americans and whites. These American Indians also reported a higher prevalence of diabetes, obesity, and smoking. Thus, though hypertension prevalence appears to be approximately equivalent in whites and in urban 0jibwe Indians in Minnesota, 0jibwe Indians have a higher associated risk profile due to a higher prevalence of obesity, diabetes, and smoking. Blood Lipids and Lipoproteins -•--•-.■--•.-•--•--■-.^ * Serum cholesterol levels in some American Indians are lower than * * in the general population but the relationship of these lower * * levels to CHD incidence is not clear. * Kumanyika and Savage(508) note that comparisons of cholesterol levels between whites and Native Americans indicate equal or lower levels in Native Americans. Sievers(516) reported that, in a comparison of 746 southwestern Indians, 70 non-southwestern Indians, and 163 whites, both Indian groups had lower cholesterol levels than whites, showed no cholesterol level increases with age, and no differences in levels between men and women. Lower cholesterol levels were found in Pima and Papago Indians than in Apache and Navajo Indians, despite greater prevalence of obesity among the Pimas. In a report of cholesterol levels in children, Savage et al found that Pima and white children had similar cholesterol levels at birth, but cholesterol levels in Pimas did not increase with age in adulthood. Comparisons of diabetic and nondiabetic Pimas indicated slightly higher cholesterol levels in the diabetics, but all other relationships were consistent with previous data on cholesterol in Pimas.(517) Metabolic studies have suggested that there may be significant differences in apoprotein and lipoprotein metabolism in Pimas which might account for their different lipid profile.(518,519,520) 91 Diabetes and Obesity ■aV-aV->V->V--»WV-iWHWwC->V">WrawV-a^ * It appears that both obesity and diabetes are major public con- * * cerns in Native Americans. * Diabetes and obesity are major public health problems in most Native American populations. The Pima Indians have an unusually high prevalence of diabetes, but an excess of glucose intolerance prevalence appears to be typical of many adult Indian populations.(521) Cigarette Smoking and Alcohol Use .W-..a..a„.„.„a„.„|„a„.„a_.„.„.„a„a„a„^^ * Although insufficient data are available to draw firm conclusions* * about trends in cigarette and alcohol use, or their contribution * * to CHD, the available data do suggest that prevalence of cigar- * * ette smoking is less consistent between Native Americans from * * different geographic subgroups, but that prevalence of alcohol * abuse is more consistent. Native American men have higher rates * * of cigarette smoking and alcohol use than do the women. Sievers(516) documented cigarette and alcohol use patterns in American Indians in a report based on interviews of patients at the Phoenix PHS Hospital. He found that heavy cigarette smoking (i.e.>l pack/day) was rare among southwestern Indians, that smoking habits of non-southwestern Indians were similar to those of the general population, and that Indian women outside the southwestern area were more likely to be heavy smokers. Heavy alcohol (i.e. >1.6 ounces of absolute alcohol, more than once a week) was most common in southwestern Indians and significantly greater in other groups of Indians than in whites. Further, that both heavy cigarette and alcohol use were more frequent among men than among women in all groups studied. This is consistent with the results of the review of alcoholism in American Indians by Brod and Thomas.(522) A similar study by Porter et al(523) of students, under age 20 years, in Anchorage, Alaska found that Native American students were more likely than white students to be users of substances, and more likely than any other ethnic group students to have tried drugs in addition to alcohol and tobacco. B: Socioeconomic and Sociocultural Factors Native Americans have a peculiar social, political, and cultural history in the United States. What is especially unusual about their history is the fact that though they share (with other minorities) a history of racism, Native Americans were not originally foreign to the United States. 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(There are no tables 73-79) NATIVE AMERICANS „, ._.. Qn Qo ......186-190 Tables 80-83 ............... 95 Black Americans TABLE 1 Disability Days Attributed to the Atherosclerotic Diseases and Other Major Chronic Diseases, United States* Disease All Atherosclerotic Diseases Coronary Heart Disease Cerebrovascular Diseases Other Atherosclerotic Diseases Other Leading Chronic Diseases Arthritis Hypertension Back Problems Cancer Hospital Days 33 20 8 5 5 2 • • 22 Restricted Bed Worfc-Loss Activity Days Days Days 86 21 241 61 18 184 21 3 47 4 • * 10 95 19 404 58 12 235 34 • * * 11 * * * 127 * • * Source: Prepared by the National Heart, Lung, and Blood Institute; data from the National Center for Health Statistics. •All data in this table are for 1978, except hospital days, which are for 1977. Categories of disability days are not mutually exclusive. "A numerical value is not cited because it was too small to meet standards of reliability or precision. • • 'data unavailable. From: Report of the Working Group on Arteriosclerosis of the National Heart, Lung, and Blood Institute, 1981 [Table 7, p.40]. Arteriosclerosis: 1981, Volume 1, NIH/PHS/DHHS. NIH Publication No.81-2034. 96 Black Americans TABLE 2 Black/White Ratios of Death Rates for Coronary Heart Disease By Age and Sex, United States, 1980 Total J1' (1) 0.90 25-64 1.11 35-74 (D 0.98 25-34 2.28 35-44 1.45 45-54 1.19 55-64 1.00 65-74 0.84 75-84 0.75 85+ 0.64 Total i1' (1) 1.19 25-64 1.98 35-74 (D 1.54 25-34 3.30 35-44 2.90 45-54 2.28 55-64 1.78 65-74 1.22 75-84 0.90 85+ 0.65 Male Female Coronary Acute Other AGE Heart Disease Myocardial Infarction ™d„M 410-414 410 411-414 0.79 1.06 0.94 1.49 0.83 1.26 2.00 2.81 1.28 1.82 0.98 1.66 0.84 1.34 0.71 1.04 0.66 0.84 0.64 0.63 1.15 1.26 1.75 2.42 1.36 1.83 3.28 3.33 2.70 3.27 2.02 2.83 1.54 2.22 1.07 1.46 0.84 0.95 0.72 0.62 (1) Based on rates age-adjusted by the direct method to the U.S. population, 1940 From: Vital Statistics of the U.S., National Center for Health Statistics 97 Black Americans TABLE 3 Proportionate Mortality for Coronary Heart Disease By Age, Color, and Sex; U.S., 1980 MALES FEMALES AGE Deaths Deaths Percent Deaths Deaths Percent All Causes CHD CHD All Causes CHD CHD Black Total 130,138 22,760 17.5 102,997 20,605 20.0 25-64 56,224 8,695 15.5 .34,415 5,124 14.9 35-74 77,306 15,046 19.5 54,743 10,712 19.6 25-34 8,013 210 2.6 3,400 74 2.2 35-44 8,521 844 9.9 4,819 370 7.7 45-54 15,156 2,617 17.3 9,660 1,333 13.8 55-64 24,534 5,024 20.5 16,536 3,347 20.2 65-74 29,095 6,561 22.6 23,728 5,662 23.9 75-84 21,046 5,172 24.6 22,371 6,031 27.0 85+ 8,534 2,273 26.6 13,115 3,767 28.7 White Total 933,878 285,771 30.6 804,729 233,288 29.0 25-64 282,125 80,575 28.6 154,716 24,269 15.7 .35-74 500,826 164,231 32.8 308,643 71,595 23.2 25-34 27,303 744 2.7 10,395 159 1.5 35-44 28,344 5,189 18.3 15,520 966 6.2 45-54 68,306 21,066 30.8 38,328 4,769 12.4 55-64 158,172 53,576 33.9 90,473 18,365 20.3 65-74 246,004 84,400 34.3 164,322 47,495 28.9 75-84 229,619 78,931 34.4 240,748 83,194 34.6 85+ 118,549 41,727 35.2 215,691 78,265 36.3 From: Vital Statistics of the U.S., National Center for Health Statistics 98 Black Americans TABLE 4 Myths and Facts About CHD in U.S. Blacks Myth Fact CHD is uncommon in blacks. Blacks rarely have myocardial infarction. Blacks rarely have angina. Whites have much more CHD than blacks in the United States. Blacks are immune to CHD. CHD is the leading cause of death in U.S. blacks. Myocardial infarction hospitali- zation rates are high in blacks, with higher case fatality rates than for whites. Angina occurs with high prevalence in U.S. blacks. CHD mortality and prevalence rates are similar in black and white males. Black females have higher CHD mortality and prevalence rates than white females. Ade- quate data on incidence are lacking Blacks are relatively susceptible to CHD, but it is surprising that they do not have rates even higher than those observed. From: "Coronary heart disease mortality in United States blacks, 1940- 1978: Trends and unanswered questions," Gillum, R.F. and Liu, K.C. [Table 1]. American Heart Journal 108(3;2): 729, 1984 99 Black Americans TABLE 5 Prevalence of Definite and Suspect Coronary Heart Disease in United States Adults Ages 18 to 79 Years By Sex and Race: 1960-1962 Num ber of adults in thousands Rates per 10C 1 adults Both sexes Met i Women Both sexes Men Women Manifestation White Black White Black White Black White Black White Black White Black All forms 4948 586 2753 328 2195 258 5.1 5.1 5.9 6.3 4.3 4.2 Definite Total 2832 293 1776 169 1055 124 2.9 2.6 3.8 3.2 2.1 2.0 Myocardial infarction* 1305 116 926 89 379 27 1.3 1.0 2.0 1.7 0.7 0.4 Angina pectoris 1388 160 773 62 615 98 1.4 1.4 1.7 1.2 1.2 1.6 Othert 139 17 77 18 61 — 0.1 0.2 0.2 0.3 0.1 — Suspect Total 2117 293 976 159 1140 134 2.2 2.6 2.1 3.1 2.2 2.2 Angina pectoris 2059 293 976 159 1083 134 2.1 2.6 2.1 3.1 2.1 2.2 Othert 58 — — — 57 — 0.1 — — — 0.1 - Source: Gordon T, Garst CC: Coronary heart disease in adults. United States 1960-1962. National Center for Health Statistics, Series 11. No. It Washington. DC, 1965, U.S. Government Printing Office. *On electrocardiogram with or without angina pectoris or history of myocardial infarction. + Myocardial infarction history with myocardial infarction outside criteria or left ventricular ischemia on electrocardiogram. tMyocardial infarction history with electrocardiographic evidence of myocardial infarction or left ventricular ischemia. Note: All categories exclusive, in descending priority. From: "Coronary Heart Disease in Black Populations: Mortality and Morbidity", Gillum, R.F. [Table III]. American Heart Journal 104(4;1):844, 1982 100 Black Americans TABLE 6 Prevalence Rates of Definite and Suspect Coronary Heart Disease in United States Adults By Age, Sex, and Race: 1960-62 Rates per 100 adults Total Definite Suspect Men Women Men Women Men Women Age (yr) White Black White Black White Black White Black White Black White Black 18 to 79 5.9 6.3 4.3 4.2 3.8 3.2 2.1 2.0 2.1 3.1 2.2 2.2 18 to 24 — — — — — — — -— — — — — 25 to 34 0.1 3.1 0.4 — 0.1 3.1 0.2 — — — 0.2 — 35 to 44 2.2 3.5 0.9 1.9 1.2 — 0.4 1.0 1.0 3.5 0.5 0.9 45 to 54 6.6 10.2 3.7 8.0 3.0 7.4 1.3 3.9 3.5 2.8 2.4 4.1 55 to 64 14.4 13.4 10.0 9.8 10.3 5.7 4.7 5.5 4.2 7.7 5.3 4.3 65 to 74 17.3 10.9 14.4 14.2 12.2 3.4 8.2 5.1 5.1 7.5 6.2 9.0 75 to 79 14.0 — 13.5 — 9.8 — 5.1 — 4.1 — 8.5 — Source: Gordon T. Garst CC: Coronary heart disease in adults, United States 1960-1962. National Center for Health Statistics. Series 11. No. 10. Washington, D.C., 1965, U.S. Government Printing Office. From: "Coronary Heart Disease in Black Populations: Mortality and Morbidity", Gillum, R.F. [Table IV]. American Heart Journal 104(4;1):845, 1982 101 Black Americans TABLE 7 Incidence or Hospitalization Rates for Acute Myocardial Infarction In U.S. Black and White Populations Per One Thousand Subjects Age/Sex Evans County,GA 1960-1967 Nashville 1967-1968 Baltimore 1970-1972 Newark 1973 Colusbie.SC 1968 35-44 Black sen White sen Black wosen White wosen 1.79 8.28 3.72 0.69 1.02 1.84 0.19 0.20 0.783 0.193 0.113 0.84 1.25 0.36 0.O6 45-54 Black sen 5.79 White sen 10.48 Black wosen 5.10 White wosen 4.14 1.55 5.50 1.41 1.05 0.6 1.9 0.2 0.4 1.16 1.09 0.65 0.26 3.97 5.76 0.66 1.33 55-64 Black sen 1.52 White sen 17.79 Black wosen 6.97 White wosen 5.52 3.47 9.82 1.64 2.77 0.6 2.9 1.0 1.1 2.41 3.38 1.64 0.68 7.61 10.75 2.91 2.56 65-74 Black sen 8.69 White sen 32.14 Black wosen 6.21 White wosen 19.72 3.67 12.75 1.77 6.49 4.61 5.37 2.18 1.31 6.27 18.62 5.75 6.47 Source: RF Gillum, Rei 2 From: "Prevalence and Incidence of Ischemic Heart Disease m U.S. Black and White Populations", Henderson, M. and Savage, DD [Table 7]. Paper commissioned by the DHHS Task Force on Black and Minority Health, 1984-85 Black Americans TABLE 8 EStimrVned Rate(1) of H°sp*tal Discharges(2) for Acute MI and Chronic CHD for White and Black Men and Women in Selected Age Groups; United States, 1981 AGE HEN WOMEN D1AGN0SJS(3) WHITE BLACK WHITE BLACK TOTAL CHD 25-44 45-64 65-74 754 2.8 26.6 43.6 51.6 2.1 13.2 18.6 24.2 0.7 9.7 25.0 43.9 1.3 9.5 18.1 26.7 ACUTE Ml 25-44 45-64 65-74 754 0.7 6.5 13.2 14.5 0.6 3.1 5.6 4.8 0.1 2.4 6.0 10.2 0.2 1.4 5.3 5.2 CHRONIC CHD 25-44 45-64 65-74 754 2.1 20.1 30.4 37.1 1.5 10.1 13. C 19.4 0.6 7.3 19.0 33.7 1.1 8.1 12.8 21.5 (1) Per 1,000 (2) Discharged (3) First-list pop al ed mlation (civilian). ive or dead. diagnosis (1CD/9 code) Coronary heart disease (410-414) Acute myocardial infarction (410) Other CHD (411-414). From: Unpublished data from the Hospital Discharge Survey, the National Center for Health Statistics 103 TABLE 9 Black Americans Prevalence Rates of Hypertension for Persons 25-74 Years of Age By Treatment History, Race, and Sex, With Standard Errors of the Percent: United States, 1960-62, 1974-75, and 1976-80 Hypertensive^ Never diagnosed*^ On medication Race and sex ___________________________ ___________________________ ____________________________ __________________________1960-62 1974-76 1976-80 1960-62 1974-76 1976-80 1960-62 1974-76 1976-80 Percent of population* Percent of total with hypertension All people 25-74 years5 . . 20.3 22.1 22.0 51.1 36.4 26.6 31.3 34.2 56.2 White men......... 16.3 21.4 21.2 57.6 42.3 40.6 22.4 25.9 38.3 White women........ 20.4 19.6 20.0 43.9 29.7 25.2 38.2 48.5 58.6 Black men......... 31.8 37.1 28.3 70.5 41.0 35.7 18.5 *24.0 40.9 Black women........ 39.8 35.5 39.8 35.1 28.9 14.5 48.1 36.4 60.6 Standard error of percent All people 25-74 years5 . . 0.83 1.26 0.68 1.66 1.70 1.53 1.62 2.21 1.99 White men......... 0.95 2.19 1.04 3.75 2.63 1.80 3.07 3.22 2.47 White women........ 1.07 1.14 0.66 2.77 2.08 1.97 2.24 3.61 2.40 Black men......... 3.37 5.94 1.86 7.07 10.38 4.27 5.53 10.79 4.52 Black women........ 3.73______3_^60______1^96_______3.72 7.42 2.73_______3.87 8.30______3.22 ''Elevated blood pressure (that is, a systolic measurement of at least 160 mm Hg or a diastolic measurement of at least 95 mm Hg) or taking antihypertensive medication. ^Reported never told by physician that he or she had high blood pressure or hypertension. ■^Subset of "On medication" group; those taking antihypertensive medication whose blood pressure was not elevated at the time of the examination. ^Age adjusted by direct method to the population at midpoint of the 1976-80 National Health and Nutrition Examination Survey. 5Includes all other races not shown separately. On medication and controlled--1 1960-62 1974-76 1976-80 1,4 16.0 1.65 19.6 1.49 34.1 11.8 15.1 20.9 21.9 28.1 40.3 5.0 M2.7 16. 1 20.2 *22.3 38.3 2.02 2.59 2.56 2.01 2.24 2.93 2.99 2.18 6.69 3.72 3.21 7.93 4.35 From: Blood Pressure Levels and Hypertension in Persons Ages 6-74 Years, U.S. 1976-81. Advance Data No. 84, DHHS Publication No. (PHS) 82-1250 Black Americans TABLE 10 Age-Adjusted Death Rates Due to Cerebrovascular Disease (430-438) 1981 - United States By Race and Sex Ratio to Number of Deaths Rate/100,000 White Women Total 163,504 38.1 1.1 Men 66,429 41.7 1.3 Women 97,075 35.4 1.1 White Men 57,000 38.9 1.2 White Women 85,765 33.1 1.0 All Other Men 9,429 65.6 2.0 All Other Women 11,310 53.2 1.6 Black Men 8,760 72.7 2.2 Black Women 10,656 58.1 1.8 From: "Stroke Report," Kuller, L. [Table 1]. Paper commissioned by the DHHS Task Force on Black and Minority Health, 1984-85 105 Black Americans TABLE 11 Ratio of Stroke Mortality By Age, 1980: Black and White 25-34 35-44 45-54 55-64 65-74 75-84 85 + Total Black Men/ Black Women/ White Men White Women 3.5 3.5 4.5 3.2 3.8 3.3 3.0 2.8 2.0 2.1 1.1 1.3 0.8 0.8 1.8 1.8 From: "Stroke Report," Kuller, L. [Table 2]. Paper commissioned by the DHHS Task Force on Black and Minority Health, 1984-85 106 Black Americans TABLE 12 Age-Adjusted Stroke Death Rates By Geographic Area 1978 Per 100,000 Ages 35 to 74 Years White White Black Black Men Women Men Women Colorado 43 38 Kansas 50 43 Utah 38 47 New York 48 39 91 75 Maryland 47 38 115 73 South Carolina 79 54 231 173 Georgia 82 59 283 158 Mississippi 77 45 169 103 North Carolina 70 47 197 145 From: "Stroke Report," Kuller, L. [Table 7]. Paper commissioned by the DHHS Task Force on Black and Minority Health, 1984-85 107 Black Americans TABLE 13 Trends of Mortality Rates from Cerebrovascular Diseases (ICD 430-438), Age-Adjusted, Persons Aged 35 to 74 Years By Sex and Color, United States, 1968-78 White White Nonwhlte Nonwhlte Year Men Women Men Women All 1968 155.4 110.8 340.2 292.1 148.1 1969 150.3 106.8 317.1 274.3 142.2 1970 146.8 105.8 304.0 261.9 139.3 1971 143.8 100.7 292.9 248.6 134.2 1972 144.8 99.7 280.4 249.8 133.6 1973 137.4 96.8 282.0 239.8 128.7 1974 129.4 91.3 260.8 216.6 120.7 1975 117.8 83.7 233.7 190.1 109.7 1976 108.9 78.5 216.6 176.9 102.2 1977 100.9 72.4 202.2 162.4 94.6 1978 93.9 68.7 194.7 148.6 88.7 Change 1968-78 -62.1 -42.1 -145.5 -143.5 -59.4 Percent Change -40.0 -38.0 -42.8 -49.1 -40.1 Slope 1968-73 -0.0174 -0.0190 -0.0348 -0.0359 -0.0288 Standard Error 0.0035 0.0036 0.0049 0.0048 0.0032 Slope 1973-78 -0.0789 -O.0707 -0.0769 -0.0951 -0.0761 Standard Error 0.0017 0.0021 0.0054 0.0041 0.0020 Report of the Working Group on Arteriosclerosis of the National Heart, Lung and Blood Institute. Arteriosclerosis 1981. Volume 2. From: "Stroke Report', Kuller, L. [Table 25]. Paper commissioned by the DHHS Task Force on Black and Minority Health, 1984-85 108 Black Americans TABLE 14 Trends in Stroke Mortality 1974-1978 By State: In Percent, Annual Change, Age-Adjusted (35-74 Years) White White Black Black Women Men Women Men Colorado 6.6 6.7 Connecticut 9.2 6.0 Massachusetts 10.0 11.0 18.2 -1.0 Maryland 6.9 8.2 11.2 6.1 North Carolina 4.8 9.1 10.9 7.3 Pennsylvania 6.8 8.4 9.0 8.3 Georgia 6.7 6.1 10.4 6.1 South Carolina 5.8 10.9 6.4 6.6 Mississippi 5.0 10.0 9.9 5.3 From: "Stroke Report," Kuller, L. [Table 28]. Paper commissioned by the DHHS Task Force on Black and Minority Health, 1984-85 109 Black Americans TABLE 15 Percentage Decline in Stroke Mortality By Age, Race, and Sex, 1970-80 WM WW BM BW 35-44 1 44.9 i--------------------------------------- 41.7 44.6 56.0 45-54 39.0 38.7 39.8 48.2 55-64 47.6 37.6 44.8 48.9 65-74 42.9 43.0 39.3 46.2 75-84 37.2 37.9 26.0 31.3 Health United States, 1983. From: "Stroke Report", Kuller, L. [Table 29]. Paper commissioned by the DHHS Task Force on Black and Minority Health, 1984-85 110 Black Americans TABLE 16 End-Stage Renal Disease Prevalence By Primary Diagnosis and Race in Dialysis and Transplant Patients, 1982 Prevalence, 1982 ______________White___________Black__________Other_______ Dialysis Patients Primary Diagnosis (3 Leading) 1. Nephritis/Nephrosis 7,499 (20.6%) 2,130 (12.6%) 409 (20.8%) 2. Hypertension 4,347 (11.9%) 4,687 (27.7%) 205 (10.4%) 3. Diabetes 4,318 (11.8%) 1,884 (11.1%) 290 (14.8%) Total 36,475 (66%) 16,938 (30%) 1,963 (4%) Transplant Patients Primary Diagnosis (3 Leading) 1. Nephritis/Nephrosis 820 (24.8%) 158 (19.2%) 43 (28.7%) 2. Hypertension 178 (5.4%) 198 (24.1%) 15 (10.0%) 3. Diabetes 466 (14.1%) 33 (4.0%) 9 (6.0%) Total 3,302 (77%) 822 (19%) 150 (4%) From: ESRD Systems Branch, Health Care Financing Administration, 1984 111 Black Americans TABLE 17 Multivariate Association of Risk Indicators With Time to Death and 20-Year Cumulative Risk of Death Attributed to IHD in Black Males Aged 40 to 64 Years in Evans County* Proportional Logistic risk hazard functions coefficients (P) coefficients (_£_) Intercept -12.128 (0.14) Age 0.101 (0.002) 0.086 (0.01) SBP * 0.023 (0.0000) 0.018 (0.01) Cholesterol -0.066 (0.06) -0.081 (0.05) Cholesterol2/100 0.013 (0.10) 0.016 (0.09) Smoking current 1.406 (0.007) 1.209 (0.03) Smoking past -0.092 (0.93) -0.125 (0.91) Quetelet index 2.726 (0.42) 5.305 (0.19) Quetelet index2 -0.295 (0.49) -0.614 (0.19) X2 (8 df) 38 26 £ 0.000 0.00] . *Number with IHD: 31; number of examinees: 294. From: "Ischemic heart disease risk factors and twenty-year mortality in middle-age Evans County black males," Tyroler, H.A. et al. [Table VI]. American Heart Journal 108(3;2):745, 1984 112 Black Americans TABLE 18 Number of Deaths By Cause for Black and White Males Screened For the Multiple Risk Factor Intervention Trial Cause of death (ICD-9) Black males White males No. Rate/1000 Percent* No. Rate/1000 Percent* 450 19.2 100.0 4602 14.1 100.0 203 8.6 45.1 2226 6.8 48.4 30 1.3 6.7 152 0.5 3.3 78 3.3 17.3 1225 3.8 26.6 29 1.2 6.4 483 1.5 10.5 17 0.7 3.8 26 0.1 0.6 1 0.0 0.2 7 0.0 0.1 48 2.0 10.7 333 1.0 7.2 247 10.5 54.9 2376 7.3 51.6 0 0.0 0.0 14 0.0 0.3 5 0.2 1.1 37 0.1 0.8 128 5.4 28.4 1440 4.4 31.3 15 0.6 3.3 155 0.5 3.4 12 0.5 2.7 124 0.4 2.7 4 0.2 0.9 16 0.0 0.3 63 2.7 14.0 455 1.4 9.9 20 0.9 4.4 135 0.4 2.9 Total with death certificates All cardiovascular diseases Cerebrovascular diseases (430-438) Myocardial infarction (410) Other ischemic heart disease (411-414) Hypertensive heart disease (402) Other hypertensive disease (401, 403-405) Other cardiovascular disease (390-459 exclusive of above) All noncardiovascular diseases Genitourinary diseases (580-629) Diabetes mellitus (250) Neoplastic diseases (140-239) Gastrointestinal diseases (520-579) Respiratory diseases (460-519) Infectious diseases (001-139) Accidents, suicides, and homicides (800-999) Other disease ♦Percent of total number of deaths in racial group. From: "Total and cardiovascular mortality in relation to cigarette smoking, serum cholesterol concentration, and diastolic blood pressure among black and white males followed up for five years," Neaton, J.D. et al. [Table II]. American Heart Journal 108(3;2):762, 1984 Black Americans TABLE 19 Comparison of Logistic Regression Coefficients^) for Diastolic Blood Pressure for All-Cause and Cause-Specific Mortality For Black and White Males in the Multiple Risk Factor Intervention Trial Screenee Cohort PC Black Whit e Difference in Coeff Coeff SE Coeff SE SE All-cause mo rtali ty It 2? 0.0195 0.0202 0.0033 0.0035 0.0170 0.0171 0.0013 0.0013 0.0025 0.0031 0.0035 0.0037 CVD death 1 2 0.0261 0.0299 0.0051 0.0055 0.0301 0.0322 0.0019 0.0020 -0.0040 -0.0023 0.0054 0.0058 CHD death 1 2 0.0188 0.0244 0.0072 0.0078 0.0263 0.0289 0.0021 0.0024 -0.0075 -0.0045 0.0075 0.0082 Death from cerebrovascular disease 1 2 0.0623 0.0624 0.0105 0.0109 0.0372 0.0324 0.0068 0.0072 0.025H 0.0030§ 0.0125 0.0131 PC = Participant category; Coeff = coefficient; SE = standard error. ♦Estimated for fixed age, serum cholesterol, and cigarettes per day. tCategory 1 includes all participants in racial group. •^Category 2 excludes those participants who reported previous hospitalization for a heart attack or who were taking medication for diabetes. §£ < 0.05. From: 'Total and cardiovascular mortality in relation to cigarette smoking, serum cholesterol concentration, and diastolic blood pressure among black and white males followed up for five years," Neaton, J.D. et al. [Table III]. American Heart Journal 108(3;2):763, 1984 TABLE 20 HDL Cholesterol By Age, Black-White Differences^) Males Females Age group____________________ Black_____White___________Black_____White Neonates (cord blood) (No consistent black-white differences within sex) Preschool children ++ ++ Prepubertal children +++ +++ Schoolchildren during sexual maturation +++ +++ Sexually mature adults ++++ (No consistent, significant differences) Plus signs denote significantly higher levels. From: "High-density lipoprotein cholesterol in blacks and whites: Potential ramifications for coronary heart disease," Glueck, C.J. et al.[Table I]. American Heart Journal 108(3;2):817, 1984 Bl.ick Amp ricans TABLE 21 Cigarette Smoking Status and Cigarettes Smoked Per Day for Black Persons, 25 to 74 Years Old, By Sex and Age: United States, 1971-1975 and 1976-1980(*) Current smokert Smoking 25 or more cigarettes/day 1971-1975 1976-1980 1971-1975 1976-1980 Sex, age (year)____________Rate________SE___________Rate_________SE________Rate________SE___________Rate_________SE Per 100 Populationf Males: age-adjusted rate§ (25-74 years) 55.4 3.7 50.7 1.9 7.5 1.9 8.5 1.8 25-34 72.1 7.4 61.0 3.4 12.3 4.7 5.8 2.4 35-44 52.7 9.7 50.0 7.2 6.3 3.7 14.1 5.4 45-54 52.8 6.7 52.1 6.1 8.5 4.2 7.8 2.3 55-64 45.9 6.8 50.1 4.6 4.4 2.9 11.0 3.2 65-74 39.4 8.3 26.9 4.5 1.6 1.0 2.8 2.2 Females: age-adjusted rate§ (25-74 years) 46.2 3.0 31.6 1.8 3.0 l.l 3.9 1.2 25-34 62.7 5.3 35.6 3.1 7.6 3.1 4.7 2.3 35-44 57.4 6.9 40.7 6.8 3.8 2.5 8.0 3.1 45-54 49.8 6.8 34.8 4.0 3.2 2.3 55-64 21.7 5.4 24.1 5.2 0.3 0.3 65-74 19.1 5.4 12.8 2.4 1.2 1.2 SE = Standard error; = data not available (quantity zero). *Data from the National Health and Nutrition Examination Survey, Division of Health Examination Statistics, National Center for Health Statistics, Hyattsville, Maryland. tA current smoker is a person who has smoked at least 100 cigarettes and who now smokes; Includes occasional smokers. fBase of percent excludes persons with unknown smoking status. §Age adjusted by direct method to the total U.S. population as estimated at the midpoint of the 1976-1980 From: "Coronary heart disease risk factor trends in blacks between the first and second National Health and Nutrition Examination Surveys, United States, 1971-1980," Rowland, M.L. and Fulwood, R. [Table III], American Heart Journal 108(3;2):774, 1984 Black Americans TABLE 22 Percent Distribution of Adults Ages 35 to 64 Years By Cigarettes Smoked Per Day: United States 1965 and 1976(*) 1965 1976 Cigarettes smoked per day Cigarettes smoked per day Age (yr) Nonef <15$ 15 to 24$ 25 or more} Nonef <15t 15 to 24} 25 or moret White men 35 to 44 43.3 12.1 25.4 19.2 53.5 8.0 18.8 19.7 45 to .54 45.3 11.8 25.3 17.6 57.3 6.5 17.7 18.5 55 to 64 54.9 13.3 19.8 11.9 62.2 6.7 17.3 13.9 Whits women 35 to 44 56.1 15.9 19.9 8.1 61.9 11.3 17.3 9.6 45 to 54 61.8 15.9 16.5 5.7 61.8 11.0 17.6 9.6 55 to 64 74.3 11.3 11.0 3.5 69.3 11.2 13.4 6.1 Black men 35 to 44 32.7 28.6 30.6 8.1 41.1 22.6 26.4 9.8 45 to 54 37.6 25.3 30.6 6.6 43.3 19.5 27.4 9.8 55 to 64 48.2 30.0 17.9 3.9 59.5 15.6 22.3 2.5 Black u omen 35 to 44 57.1 27.2 13.0 2.6 58.7 24.9 15.7 0.6 45 to 54 67.8 21.5 9.6 1.2 63.4 16.5 16.5 3.7 55 to 64 83.5 12.8 3.2 0.5 59.9 25.3 10.7 4.2 "Data from Kleinman JC, Feldman JJ, Monk MA: The effects of changes in smoking habits on coronary heart disease mortality. Am J Public Health 69:745, 1^79. By permission. ♦Excludes respondents with current smoking status unknown. [Excludes respondents with number of cigarettes smoked unknown. Source: Heaith Interview Survevs 1965 and 1976. From: "Coronary heart disease in black populations II. Risk factors", Gillum, R.F. and Grant, CT. [Table III]. American Heart Journal 104(4;1):855, 1982 117 TABLE 23 Comparison of Logistic Regression Coefficients^) For Number of Cigarettes Smoked Per Day For All-Cause and Cause-Specific Mortality For Black and White Men in the Multiple Risk Factor Intervention Screenee Cohort Black White PC Coeff SE Coeff SE Difference in coeff SE Al l-cause mortal! ty It 0.0244 0.0032 0.0226 0.0008 0.0018 2t 0.0261 0.0034 0.0239 0.0008 0.0022 CVD death 1 0.0256 0.0051 0.0223 0.0012 0.0033 2 0.0293 0.0054 0.0248 0.0012 0.0045 CHD death 1 0.0309 0.0067 0.0222 0.0013 0.0087 2 0.0324 0.0074 0.0250 0.0014 0.0074 Death from 1 0.0103 0.0147 0.0260 0.0042 -0.0157 cerebrovascular 2 0.0146 0.0147 0.0287 0.0044 -0.0141 disease 0.0033 0.0035 0.0052 0.0055 0.0068 0.0075 0.0153 0.0153 PC = Participant category; Coeff = coefficient; SE - standard error. ♦Estimated for fixed age, diastolic blood pressure, and serum cholesterol. {Category 1 includes all participants in racial group. ♦Category 2 excludes those participants who reported previous hospitalization for a heart attack or who were taking medication for diabetes. From: "Total and cardiovascular mortality in relation to cigarette smoking, serum cholesterol concentration, and diastolic blood pressure among black and white males followed up for five years," Neaton, J.D. et al. [Table V). American Heart Journal 108(3;2):766, 1984 TABLE 24 Black Americans Prevalence of Previously Diagnosed and of Undiagnosed Diabetes in the United States' Population Ages 20-74 Years, NHANES II, 1976-1980 Age: 20-74 2C )-44 4f i-54 55- -64 65-; 74 Race and Sex Percent of Population (Standard Error) Medical history of di abetes* : All races Both sexes Male Female 3.4 2.9 3.8 (.14) (.25) (.24) 1.1 .6 1.5 (.11) (.12) (.22) 4.3 4.3 4.3 (.53) (.32) (.67) 6.6 5.6 7.4 (.66) (.64) (1.10) 9.3 9.7 8.9 (.45) (.71) (.56) White Both sexes Male Female 3.2 2.8 3.6 (.16) (.27) (.23) 1.0 .5 1.4 (.12) (.15) (.22) 4.2 4.5 3.9 (.55) (.92) (.60) 6.0 5.3 6.6 (.58) (.66) (.91) 8.9 9.1 8.8 (.49) (.78) (.64) Black Both sexes Male Female 5.2 4.5 5.9 (.49) (.60) (.99) 2.2 1.8 2.6 (.58) (.63) (1.00) 5.7 3.6 7.5 (1.46) (1.48) (2.33) 13.1 9.2 16.3 (2.65) (2.55) (4.03) 13.6 17.2 10.8 (1.35) (2.87) (1.51) Undiagnosed diabetes - NDDG Criteria** All races Both sexes Male Female 3.2 2.8 3.6 (.35) (.41) (.42) 0.9 0.8 1.0 (.31) (.39) (.38) 4.2 3.6 4.7 (.81) (1.28) (1.14) 6.2 4.0 8.1 (1.03) (1.03) (1.68) 8.4 9.5 7.6 (.85) (1.62) (.89) White Both sexes Male Female 3.0 2.5 3.4 (.38) (.36) (.52) 0.7 0.5 0.8 (.31) (.27) (.40) 4.0 3.2 4.6 (.90) (1.25) (1.25) 5.9 3.8 7.9 (1.24) (1.00) (2.08) 8.0 9.0 7.3 (.85) (1.38) (.95) Black Both sexes Male Female 4.4 4.0 4.6 (.91) (1.72) (1.35) 0.9 1.0 0.9 (.68) (.98) (.91) 7.2 7.5 7.0 (3.05) (6.40) (3.70) 7.7 5.2 9.1 (3.75) (3.94) (5.92) 12.3 12.2 12.3 (3.94) (7.23) (4.50) Undiagnosed diabetes - WHO ( :riteria** All races Both sexes Male Female 3.4 3.0 3.9 (.35) (.41) (.43) 0.9 0.8 1.0 (.35) (.48) (.41) 4.2 3.6 4.8 (.81) (1.26) (1.15) 6.8 4.3 9.0 (1.11) (1.06) (1.76) 9.4 10.4 8.5 (.89) (1.60) (.93) White Both sexes Male Female 3.2 2.7 3.7 (.38) (.36) (.53) 0.7 0.5 0.8 (.35) (.42) (.42) 4.0 3.3 4.8 (.91) (1.25) (1.26) 6.5 4.1 8.6 (1.31) (1.03) (2.14) 9.0 10.0 8.2 (.89) (1.57) (1.09) Black Both sexes Male Female 4.7 4.1 5.1 (.99) (1.74) (1.37) 1.0 1.0 0.9 (.69) (1.01) (.93) 7.2 7.5 7.1 (3.05) (6.40) (3.71) 9.4 5.4 11.6 (4.29) (3.98) (6.96) 12.8 12.2 13.3 (4.33) (7.25) (4.99) *Based on a self-report that the person had been told by a doctor that he or she had diabetes, plus current or past use of diabetic therapy. **Based on the results of a 75 gram oral glucose tolerance test conducted in the morning after an overnight 10-16 hour fast in persons with no medical history of diabetes. Source: National Center for Health Statistics. Hadden W. Harris M. Diabetes and Glucose Intolerance in Adults, 20-74 Years of Age, United States, 1976-80. Washington, DC. U.S. Government Printing Office (forthcoming). Vital and Health Statistics Series 11, data from the National Health Survey From: "Stroke Report," Kuller, L. [Table 52]. Paper commissioned by the Task Force on Black and Minority Health, 1984-85 119 Black Americans TABLE 25 Five-Year Death Rates for the Multiple Risk Factor Intervention Trial Screenees(*) By Diabetes and Race CHD No. Deaths Age** deaths per 1,000 adjusted CVD No. Deaths Age** deaths per 1,000 adjusted All Cause No. Deaths Age** deaths per 1,000 adjusted Diabetics 5,245 92 17.5 13.5 128 24.4 18.9 265 *N = 356,222; excludes men with history of MI. **Adjusted to age distribution of all MRFIT Screenees. 50.5 42.3 Black Non-black 717 4,528 7 85 9.8 18.8 8.5 14.2 13 115 18.1 25.4 19.7 18.4 38 227 53.0 50.1 54.4 40.1 Non-Diabetics 350,977 1,498 4.3 4.3 2,038 5.8 5.9 5,283 15.1 15.2 Black Non-black 22,444 328,533 86 1,412 3.8 4.3 4.1 4.3 170 1,868 7.6 5.7 8.1 5.7 465 4,818 20.7 14.7 21.8 14.7 From: "Diabetes and Risk of Coronary, Cardiovascular, and All Causes Mortality: Findings for 356,000 Men Screened by the Multiple Risk Factor Intervention Trial (MRFIT). Stamler J, Wentworth D, Neaton J, Schoenberger JA, Feigal D, for the MRFIT Research Group. Circulation 70(Suppl. 2):II-161, 1984 (Abstract) Black Americans TABLE 26 HDFP: Five-Year Mortality(a) By Race, Education, and Presence of LVH(b) at Baseline For All HDFP Stratum I Participants and Those Not on Medication at Baseline - Referred-Care Males, Ages 40 to 69 Years, Entry DBF 90 to 104 mm Hg % Mortality LVH- LVH+ Crude Age-adjusted Race/education (Deaths) N (Deaths) N LVH- LVH+ LVH- LVH + All stratum I participants WM>HS (18) WM = HS (26) WM < HS (42) BM < HS (56) Participants not on medication at baseline WM > HS (13) WM = HS (21) WM < HS (22) BM65 Quetelet index 2.55 (0.01) 2.47 (0.05) 2.64 (0.02)} 2.86 (.07) Calories 1832 (31)} 1590 (76) 1297 (18)} 1182 (35) Protein 74(1)} 63(35) 51 (0.8) 49 (1.5) Fat 76 (1.5)+ 66 (3.5) 50(1.1) 45 (2.4) Carbohydrate 204 (3.8)+ 169 (12) 159 (2.5) 145 (6.7) Saturated fat 27 (0.6) 23 (1.4) 17 (0.4)* 15 (0.7) Oleic acid 29 (0.7) 25 (1.3) 18 (0.4) 17 (1.0) Linoleic acid 10 (0.2) 9 (0.7) 7.7 (0.3) 7 (0.6) Cholesterol 382 (12) 420 (31) 238 (7) 224 (21) L/O ratio 0.38 (0.01) 0.35 (0.02) 0.43 (0.01) 0.45 (0.02) Wt max 186 (1.1) 185 (2.9) 159 (1.2) 173 (3.4) Wt min 142 (0.9) 143 (1.8) 115 (0.7) 122 (2.4) Wt at 25 yr 153 (0.9) 153 (2.3) 124 (0.6) 132 (2.2) L/0 ratio ■ Linoleic acid/oleic acid ratio; Wt • weight; max « maximum; min ■ minimum, •p < 0.02; tp < 0.01; \p < 0.005 (p values adjusted for multiple comparisons). From: "Determinants of high-density lipoprotein cholesterol in blacks and whites: The second National Health and Nutrition Examination Survey", Gartside, P.S. et al. [Table III]. American Heart Journal 108(3;2):646, 1984 122 Black Americans TABLE 28 Percent Decrease in Age-Adjusted(l) Rates For 0bserved(2) and Expected(3) Coronary Heart Disease Mortality Among Persons 35-74 Years of Age, According To Race and Sex: United States Coronary heart disease mortality Race and sex Observed Expected White Men.................. Women............... Black Men................. Women............... Percent decrease 17 18 16 24 13 16 *Age adjusted by direct method to the 1976-80 National Health and Nutrition Examination Survey population. ^Percent decrease between 1973 and 1977-78. Estimated from risk factors measured in the 1971-75 and 1976-80 National Health and Nutrition Examination Surveys. NOTE: Codes for coronary heart disease are 410-413 based on the Eighth Revision International Classification of Diseases, Adapted for Use in the United States. SOURCES: National Center for Health Statistics: Data from the National Health and Nutrition Examination Survey and the National Vital Statistics System. From: "Changes in Heart Disease Risk Factors," Rowland, M. et al. [Table D]. In: Health and Prevention Profile United States: 1983, National Center for Health Statistics/PHS/DHHS. U.S. G.P.O. pub., Washington, DC 20402, page 30 123 Black Americans TABLE 29 Ratio of Non-White to White Median Income, United States, 1945-1977 Black Nonwhite Nonwhite Year families families Males Females 1945 0.56 n.a. n.a. 1946 0.59 0.61 n.a. 1947 0.51 0.54 n.a. 1948 0.53 0.54 0.49 1949 0.51 0.49 0.51 1950 0.54 0.54 0.49 1951 0.53 0.55 0.46 1952 0.57 0.55 n.a. 1953 0.56 0.55 0.59 1954 0.56 0.50 0.55 1955 0.55 0.53 0.54 1956 0.53 0.52 0.58 1957 0.54 0.53 0.58 1958 0.51 0.50 0.59 1959 0.52 0.47 0.62 1960 0.55 0.53 0.70 1961 0.53 0.52 0.67 1962 0.53 0.49 0.67 1963 0.53 0.52 0.67 1964 0.56 0.54 0.57 0.70 1965 0.55 0.54 0.54 0.73 1966 0.60 0.58 0.55 0.76 1967 0.62 0.59 0.59 0.78 1968 0.63 0.60 0.61 0.79 1969 0.63 0.61 0.59 0.85 1970 0.64 0.61 0.60 0.92 1971 0.63 0.60 0.61 0.90 1972 0.62 0.59 0.62 0.95 1973 0.60 0.58 0.63 0.93 1974 0.64 0.60 0.63 0.92 1975 0.65 0.61 0.63 0.92 1976 0.63 0.59 0.63 0.95 1977 0.61 0.57 0.61 0.88 n.a. « Not available. From "A note on the biologic concept of race and its application in ipZemiologic research", Cooper, R. [Table I]. American Heart Journal 108(3;2):720, 1984 124 Black Americans TABLE 30 Distribution of Family Income in Black and White Heads of Household, 1978(*) White Black Male Female Male Female head head head head Family income (%) (%) (%) (%) Less than $5,000 4.3 22.4 8.1 42.6 $5,000-$9,999 13.1 28.0 18.2 31.7 $10,000-$14,999 15.9 21.3 19.9 13.7 $15,000-$19,999 17.9 13.1 19.2 6.6 $20,000-$24,999 16.3 7.8 13.2 2.9 $25,000-$49,999 28.1 6.9 20.5 2.5 $50,000 and over 4.4 100.0 0.4 100.0 1.0 100.0 t Totalf 100.0 Number (thousands) 43,636 5,918 3,244 2,390 *From money income of families and persons in the United States: 1978 current population reports, p. 60, No. 123. Washington, DC, 1980, U.S. Bureau of the Census, pp. 107-109. tLess than 0.05%. ■fMay not add to 100 because of rounding. From: "Socioeconomic influences on coronary heart disease in black populations," James, S.A. [Table I]. American Heart Journal 108(3;2):670, 1984 125 Black Americans TABLE 31 Prevalence of Hypertension, Mean Per Capita Income(a), and Mean Age, Percent of Ideal Body Weight and Number of People Sharing the Income By Race, Sex, and Blood Pressure Level for Adults 18 Years or Older In Georgia, 1981 Race/Sex/BP Lev< >1 Prevalence Mean Per Mean Age Sample Size Capita Weight D, No i. of n Income People the Sharing Income White Men Normotensive0 77.9 $8221 (39, 107, 3.1) 1051 Hypertensives" 22.1 $7865 (49, 117, 3.0) 342 Controlled6 7.1 $8254 (56, 115, 2.7) 94 Mildf 13.6 $8012 (45, 117, 3.1) 216 Moderate-Seve re? 1.4 $4438 (49, 127, 2.9) 32 White Women Normotensive0 81.3 $7268 (40, 104, 3.0) 1224 Hypertensives" 17.7 $6868 (59, 119, 2.4) 313 Controlled6 11.0 $7675 (64, 116, 2.1) 175 Mildf 6.8 $5619 (51, 119, 2.7) 124 Moderate-Severe? 1.0 $6311 (50, 151, 3.4) 14 Black Men Normotensive0 69.8 $5128 (34, 103, 3.4) 430 Hypertensives" 30.2 $4279 (50, 112, 3.2) 221 Controlled6 8.6 $4670 (59, 111, 2.8) 62 Mildf 17.4 $4601 (46, 110, 3.0 129 Moderate-Seve ire? 4.3 $2196 (51, 119, 5.1) 30 Black Women Normotensive0 67.4 $4048 (34, 112, 3.3) 563 Hypertensives" 32.6 $3550 (55, 132, 3.0) 279 Controlled6 18.2 $3453 (60, 131, 2.5) 153 Mildf 10.5 $4448 (48, 130, 3.4) 100 Moderate-Severe? 3.9 $1598 (49, 145, 4.5) 26 a. b. c. d. e. f. g. Per Capita Income = Family Annual Income Divided by Number of People Sharing the Income. Weight = Percent of Ideal Body Weight. Normotensive = Diastolic Blood Pressure (DBP) Less Than 90 mm Hg and Not On Antihypertensive Medication. Hypertensive = DBP at Least 90 mm Hg and/or On Antihypertensive Medication, Controlled = DBP Less Than 90 mm Hg and On Antihypertensive Medication. Mild = DBP 90 to 104 mm Hg. Moderate to Severe = DBP at Least 105 mm Hg. j^-.---"Financial Cost as an Obstacle to Hypertension Therapy," Shulman NB Martinez B, Brogan DR, Carr AA, Miles CG (submitted for publication) 126 Black Americans TABLE 32 Hypertension Detection and Follow-Up Program: Five-Year Mortality By Race and Education - Referred-Care Males Ages 40 to 69 Years, Entry DBP 90 to 104 mm Hg (Deaths) N % Mortality Race /education Crude Ag-e-adjusted* WM> HS WM = HS WM < HS BM - CO cr Male Female WM = white males WF = white females NM = non-white males NF = non-white females From: "Coronary heart disease mortality in United States blacks, 1940- 1978: Trends and unanswered questions", Gillum, R.F. and Liu, K.C. [Figure 4]. American Heart Journal 108(3;2):731, 1984 136 Black Americans FIGURE 6 Average End-Stage Renal Disease Incidence Rates, By Primary Etiology, Race, and Sex (1973-1979 Average) Hypertensive Nephropathy Glomerulonephritis Polycystic Kidney Disease Whiter White9 Blackc Black9 From: "The Incidence of Treated End Stage Renal Disease In the Eastern United States: 1973-1979", Sugimoto, T and Rosansky, S.J. [Fig- ure 5]. American Journal of Public Health 74(1):16, 1984 137 Black Americans FIGURE 7 Five-Year Age-Adjusted CHD Mortality Rate (Per 1,000) By Diastolic Blood Pressure Level By Race in I II III IV ( < 75) (75-80) (81-85) (86-91) Diastolic Blood Pressure Quintile (mm Hg) No. Black Men: 3,602 3,734 No. White Men: 67,418 65,242 3,955 61,351 4,708 65,051 V (>91) 7,491 66,322 From: 'Total and cardiovascular mortality in relation to cigarette smoking, serum cholesterol concentration, and diastolic blood pressure among black and white males followed up for five years", Neaton, J.D. et al. [Figure 2]. American Heart Journal 108(3;2):763, 1984 138 Black Americans FIGURE 8 Mean Serun Cholesterol Levels in Quintile Strata of Body Mass Index For Adults 18-74 Years of Age By Race and Sex: United States, 1971-74. NHANES I 252 B 240 o x/i 03 > CD 228 216 o U 204 'o U 182 180 0 00 White Males White Females Black Males ~^\ Black Females 95-percent Confidence Limit 0-19 20-39 40-59 60-79 i\yy? I 1 i ■:I I 80-100 Body Mass Index Quintile Strata From: "Dietary Intake and Cardiovascular Risk Factors, Part II. Serum Urate, Serum Cholesterol, and Correlates; United States 1971-1975." National Center for Health Statistics, WR Harlan, AL Hill, RP Schmouder et al. Vital and Health Statistics, Series II, No. 227. DHHS Pub. No. (PHS) 83-1677, March 1983 139 Black Americans FIGURE 9 Five-Year Age-Adjusted CHD Mortality Rate (Per 1,000) By Serum Cholesterol Level By Race m I ( < 182) No. Black Men: 5,947 No. White Men: 62,614 II III IV (182-202) (203-220) (221-244) Serum Cholesterol Quintile (mg/dl) 4,835 4,214 4,117 65,222 64,277 66,011 V ( > 244) 4,377 67,260 From: "Total and cardiovascular mortality in relation to cigarette smoking, serum cholesterol concent rat ion, and diastolic blood pressure among black and white males followed up for five years", Neaton, J.D. et al. [Figure 5]. American Heart Journal 108(3;2):765, 1984 140 Black Americans FIGURE 10 Five-Year Age-Adjusted CHD Mortality Rate (Per 1,000) By Number Of Cigarettes Reported Smoked By Race 10 S-H o- ^ 03 c/: 3 x: :rp •4—< T) < Q •D W) Q< ffi ^^ U s- cd 35 No. Black Men: 11,748 4,730 4,905 1,168 939 No. White Men: 208,481 21,184 38,399 27,044 30,276 From: "Total and cardiovascular mortality in relation to cigarette smoking, serum cholesterol concentration, and diastolic blood pressure among black and white males followed up for five years", Neaton, J.D. et al. [Figure *]. American Heart Journal 108(3;2):767, 1984 141 Black Americans FIGURE 11 CHD Mortality Ratios for Black and White Males and Females By Amount of Cigarette Smoking Per Day 1.00 1.00 ••'■••.-Xvlv 1.48 1 20 11:11 1.59 1.59 1.94 1.92 ™ l2J 1-25 1.00 1.00 i----hm 2.07 1.65 , c, 1.83 i.ji SSS:: W B W B W B W B W B W B W B W B Never 1-9 10-19 20+ Never 1-9 10-19 20+ Smoked ^- —------^y -■-•■— Smoked ^— -- ~^y ^-- —' Cigarettes a Day Cigarettes a Day Rg. 1. CHD mortality ratios for males by amount of cigarette smoking per day, by race. 1.45 1.00 1.00 1.11 x^Xxo 1.82 1.42 III 2.16 1.78 W B W B Never 1-9 Smoked w B 10-19 Cigarettes a Day w B 20+ Fig. 2. CHD mortality ratios for females by amount of cigarette smoking per day, by race. Fig. 3. CHD mortality ratios for males by amount of cigarette smoking per day in subjects with no history of serious disease, by race. 2.47 2.44 2.07 1.46 1.00 1.00 1.17 1.51 W B Never Smoked w B 1-9 W B 10-19 Cigarettes a Day w B 20+ Fig. 4. CHD mortality ratios for females by amount of cigarette smoking per day in subjects with no history of serious disease, by race. From: "Cigarette smoking and coronary heart disease in blacks: Com- parison to whites in a prospective study", Garfinkel, L. [Figures 1-4]. American Heart Journal 108(3;2):804, 1984 142 Black Americans FIGURE 12 Quartiles in the Distribution of Body Mass Index of White and Black Males and Females, 18-74 Years, By Age: United States, 1971-74 From: "Dietary Intake and Cardiovascular Risk Factors, Part I. Blood Pressure Correlates; United States, 1971-1975." Fig. 1. National Center for Health Statistics, WR Harlan, AL Hill, RP Schmouder et al. Vital and Health Statistics, Series II, No. 226. DHHS Pub. No. (PHS) 83-1676, Feb 1983 143 Black Americans FIGURE 13 Five-Year Age-Adjusted Cerebrovascular Disease Mortality Rate (Per 1,000) By Diastolic Blood Pressure Level By Race 73 o J- JD 91) Diastolic Blood Pressure Quintile (mm Hg) Black Men: 3,602 3,734 3,955 4,708 7,491 White Men: 67,418 65,242 61,351 65,051 66,322 From: "Total and cardiovascular mortality in relation to cigarette smoking, serum cholesterol concentration, and diastolic blood pressure among black and white males followed up for five years", Neaton, J.D. et al. [Figure 3]. American Heart Journal 108(3;2):764, 1984 144 Black Americans FIGURE 14 Five-Year Age-Adjusted Cerebrovascular Disease Mortality Rate (Per 1,000) By Serum Cholesterol Level By Race ^ cd _h T3 * Vh <4—< o 5 s/i O -w < u- cd 1 Xi (V •-1 _e < ug so H «n • Black Men o White Men i ( < 182) No. Black Men: 5,947 No. White Men:62,614 II III IV (182-202) (203-220) (221-244) Serum Cholesterol Quintile (mg/dl) 4,835 65,222 4,214 64,277 4,117 66,011 V ( >244) 4,377 67,260 From: "Total and cardiovascular mortality in relation to cigarette smoking, serum cholesterol concentration, and diastolic blood pressure among black and white males followed up for five years", Neaton, J.D. et al. [Figure 6]. American Heart Journal 108(3;2):765, 1984 145 Black Americans FIGURE 15 Prevalence of Hypertension at First Screen By Years of Education DBP > or = 95 mm Hg and/or Reporting Current Use of Antihypertensive Medication 60 50 o o '—' 40 CU •D 20 rX 10 0 Whites Blacks 23.1 20.0 29.9 17.8 16.5 13.5 < 10 yrs. 10-11 yrs. 12 yrs. Some College Level of Eduation College Graduate From: Race, Education, and Prevalence of Hypertension", the Hyperten- sion Detection and Follow-Up Program Cooperative Group. Figure 1. American Journal of Epidemiology 106(5):351-361 1977 146 Black Americans FIGURE 16 Stroke Mortality For Black Males in North Carolina By County Index Of Social Disorganization, 1956-1964. 300,- 260 220 h o pg 180 1 14° o S ioo 60 20 t 34 Index of Social Disorganization 1 (low) - 5 (high) 1 2 34 5 35-44 1 2 3 IT! ::::: ■» 4 5 ■ji; :•:•: ::|i: 1 2 '3 4 5 45-54 55-64 Age 65-74 From: "The Contribution of the Social Environment To Host Resistance , Cassel, J. [Figure 3]. American Journal of Epidemiology 104(2): 115, 1976 147 Black Americans FIGURE 17 Hypertension-Related Deaths Per 10,000 By Socioecologic Stress Levels In Non-White Males Aged 45-54 in North Carolina, 1960 z < 8 X < UJ o ■ High Social Instability Index CD Low Social Instability Index HIGH LOW SOCIO-ECONOMIC STATUS Figure adapted by permission from James and Kleinbaum American Journal of Public Health 66(4):354-358, 1976 From: 'The Contribution of the Social Environment To Host Resistance", Cassel, J. [Figure 4]. American Journal of Epidemiology 104(2): 116, 1976 148 Black Americans FIGURE 18 1982 Percent of Total Persons Below the Poverty Level By Race RACE RLL BLACK SPANISH WHITE PERCENT 15 35.6 29.9 12 0.00 S.00 10 15 20 25 3£ 3S 40 PERCENT Source: U.S. Bureau of the Census From: Data source - "Current Population Survey, March 1983 , U.S. Department of Commerce, Bureau of the Census 149 Black Americans FIGURE 19 Average Annual Rate of Office Visits For Selected Diseases of the Circulatory System, By Race of Patient: United States, 1975-76 120 r _o | 100 * 80 c g 60 & 40 3 20 I II Lis m iii P i" I. 1 White ^ Black and Other ^sa. Essential Coronary Symptomatic Cerebrovascular Arterio- Benign Heart Heart Disease sclerosis Hypertension Disease Disease (430-438) (440) (401) (410-413) (427) Phlebitis Varicose Hemorrhoids and Veins of (455) Thrombo- Lower phlebitis Extremities (454) Principal Diagnosis and ICDA Code From: "Office Visits for Diseases of the Circulatory System", the National Ambulatory Medical Care Survey, United States, 1975- 1976." DHEW Publication No. (PHS) 79-1791, January 1979 150 TABLES Hispanic Americans Tables 40-42 151 Hispanic Americans TABLE 40 Five Leading Causes of Death, By Race-Ethnicity, Los Angeles, 1981 Whit e Black Asi an-Amerleans Non-Spanish-surnamed* Spanish-sum amed* Rank Japanese Chinese Korean I Diseases of Diseases of Diseases of Diseases of Diseases of Malignant heart heart heart heart heart neoplasms (42) + (27) (31) (32) (32) (25) 2 Malignant Malignant Malignant Malignant Malignant Diseases of neoplasms neoplasms neoplasms neoplasms neoplasms heart (22) (18) (21) (22) (27) (16) 3 Cerebrovascu- Accidents Cerebrovascu- Cerebrovascu- Cerebrovascu- Cerebrovascu- lar diseases (9) lar diseases lar diseases lar diseases lar diseases (9) (8) (15) (ID (10) 4 Accidents Cerebrovascu- Accidents Accidents Accidents Accidents (4) lar diseases (6) (6) (5) (5) (8) 5 Pneumonia and Chronic liver Chronic liver Pneumonia and Suicide Suicide influenza disease and disease and influenza (4) (4) (3) cirrhosis (5) cirrhosis (3) (4) *As identified on the death certificate "•"Percentage of total deaths in the specified race-ethnic group. From: "Cardiovascular Diseases in Los Angeles County, 1978-1981," Frerichs, R.R. et al. American Heart Association. Greater Los Angeles Affiliate, Inc., 1983 152 Hispanic Americans TABLE 41 Age-Adjusted Mortality Rates Among Males By Race-Ethnicity, Los Angeles County, 1979-81 Aga-adjustaa* Mortality ratat pw 100,000 aalaa population Lea Angelas County Milto Black Hispanic* A»l •n-Aaarleant i Cawsas of 4-»affc (ICD Coda N**ar) -Japanaso Qilnaaa Koraaa Al 1 ciutu 643.9 . (93,441)* 1103.9 (76.916) 1377.4 (12,324) 993.7 (3,664) 624.1 (676) 496.0 (434) 932.6 (203) Ifcjor c«r4lovaicul*r tflium (390-446) 409.7 (42,672) 936.6 (37,306) 336.2 (4,444) 441.9 (2,204) 323.2 (430) 226.1 (164) 160.0 (49) oi»••!•« of koort (390-398. 402. 404-429) 322.4 (34,769) 432.6 (30.392) 436.9 (3,332) 337.6 (1,793) 220.4 (301) 176.9 (140) 117.2 (30) IftdlMlC fc-MTt 4tftOa»a (IK)) (410-414) 201.6 (21,126) 274.0 (16,991) 223.9 (1,704) 200.4 (963) 147.7 (194) 97.9 (77) 76.1 117) Myocardial Infarction an* acuta 1* (410, 411) 99.7 (10,739) 133.7 (9.636) 106.9 (640) 96.2 (497) 74.3 (100) 49.3 (41) 24.4 (7) Ckronlc l»C (412-414) 106.1 (10.369) 136.3 (9.293) 117.0 (664) 102.2 (466) 73.3 (94) 49.6 (36) 93.6 (10) Myportonslvo 4\%—%»% (-401-404) 16.6 (2.171) 22.0 (1.610) 97.0 (499) 20.4 (106) 16.4 (25) 20.2 (16) 2.6 (1) Corokrovatcular 6l»na»ai (ttrckaa) (430-436) 61.0 (5,971) 79.4 (9.013) 94.6 (713) 63.1 (309) •6.7 (107) 59.3 (32) 55.7 CI7) Itollgnoat noaplaans (cancar) (140-206) 197.6 (19,163) 216.9 (16.199) 263.9 (2,423) 162.9 (979) 141.9 (214) 127.2 (113) 167.6 (57) Pnotaonta on4 lafluania (-460-417) 24.6 (2,269) 90.1 (1.946) 32.0 (234) 34.1 (169) 21.7 (26) 11.4 (9) 17.6 (5) Ckrenlc lliror tla-nata and cirrhosis (371) 24.3 (2.967) 31.4 (2.496) 37.0 (411) 96.3 (336) 7.4 (13) 3.4 (•) 5.9 (5) Ace1toot» and atfvorso af facts CESOO-E949) 94.9 (6.199) 66.9 (9,079) 79.6 (934) •1.6 (471) 20.0 (36) 26.6 (51) •2.9 (26) 'Olract aathotf of otjusfoont alt* Lot Angola* Cbunty population, I960, oa standard t Cansus tract* la aklc* 79f or ooro of tha population oro parsons of Sponlsfc/Mlsponlc orlf la or oascaot ♦ Ifaitnrs of 4m.«i In paranthasos 9 Incluoas assantlol fcypnrtonsloo (401), kyportonalvo knort tlsaaso (402), on4 kyportanslvo koort 4\%—m* oltkor ultk (404) or •Itkovt (403) ronol tflsaasc. From: Cardiovascular Diseases in Los Angeles County, 1978-1981", Frerichs, R.R. et al. American Heart Association. Greater Los Angeles Affiliate, Inc., 1983 153 Hispanic Americans TABLE 42 Age-Adjusted Mortality Rates Among Females By Race-Ethnicity, Los Angeles County, 1979-81 Ago-adjusted* aortalIty ratos par 100,000 fanala popalotlon Ctoiaas of daath (ICD CbOa Lot Angolas Cbunty ■tits • lack Ml span let Asian Onarleans Japanaso Oklnoao farsaa 631.0 # (06,066) 667.2 (74,699) 772.3 (9,332) •07.0 (4.396) 332.2 (690) 360.0 (533) 509.7 (136) 524.3 (46.661) 555.7 (41,-495) 564.4 (4.571) 516.7 (2.343) 106.4 (374) 171.7 (155) 121.1 (42) 236.4 (55,067) 243.6 (50.173) 176.0 (5,177) 242.4 (1.792) 119.6 C774) 100.4 (95) •1.0 US) 190.9 (21.624) 156.1 (19.717) 150.9 (1.773) 146.6 (1.099) 62.1 (160) •4.4 (39) •0.1 (16) Iff 66.6 (9,410) 70.1 (•.442) 70.9 (006) (492) (70) (32) 52.4 (9) 63.9 (12,414) •6.0 (11.279) •7.6 (963) •1.0 (607) 45.7 (90) 26.2 123) 27.6 (9) 17.2 (2.579) 19.6 (1.662) 40.2 (474) 16.6 (136) 7.9 (16) 14.4 (11) 3.6 (2) 69.4 (10.104) 71.0 (6,096) •4.6 (946) 97.6 (42») •2.0 (129) 56.4 (55) 55.4 (15) 144.0 (10.627) 194.9 (16.192) 162.9 (1.974) 113.0 (636) •0.9 (161) •2.1 (90) •6.4 (51) 17.9 (2.552) 16.4 (2.707) 19.4 1222) t9.3 (145) 9.0 (19) 11.5 (•) 16.5 (5) 12.3 11,467) 15.9 (1,234) 13.0 (197) 17.7 (125) 5.4 (7) 4.2 (5) 7.7 (4) 21.6 U.603) 0.7 (2.159) 24.6 (554) 21.0 (175) 19.1 (26) 15.2 (16) 14.0 (ID All tojor cardiovascular dliaasas (390-446) Blsaasa* of koort (390-396. -402, -404-429) IscMalc kaort dli (410-414) (IH» Myocordlol Infarction and acuta IIC (410. 411) (Tronic IIC (412-414) Hyp artansI»a dlsooao1 (401-404) QsroBrovasculor dtsaosos (strokos) (430-430) sllgnont nooploans (cancar) (140-206) lo and lafluania ) Chronic llvor Olsaaso and cirrhosis (571) Accidents and aoVerso offacts (C600-C949) •Olract oothod of odjostoont vltk los Angolan Cbooty population, 1900, oa standard tfensus tracts la ohlch 79f or ooro of tko papulation oro parsons of Span I ah/Ml span Ic orlfla or 'tkabars of Booths la paranthaoo* 'lactudos ossontlal kyportonsloo (401), kyportanslvo kaort dlsoosa (402), and kyportanslvo olthout (403) rural dlsooso. koort dlsooso olthor ultk (-404) ar From: Cardiovascular Diseases in Los Angeles County, 1978-1981", Frerichs, R.R. et al. American Heart Association. Greater Los Angeles Affiliate, Inc., 1983 154 TABLES Asian/Pacific Islander Americans Tables 50-72 155 156 Asian Americans TABLE 50 Percent of Population Completing 4 Years or More of College By Specified Race, Age, and Sex: United States, 1980 M a 1 a t e m a 1 e toco and Age Tot Percent Toi Poreent White1 25-34 years 15, 400,161 24.5 15, ,394,841 21.7 35-46 years 10, ,711.364 25.9 10, ,930,907 15.6 45-66 years 18, 618,917 18.2 20, ,292,624 9.6 65 years and over 9, 210,721 10.5 13, ,730,849 7.6 Chinese2 25-34 years 4,453 57.1 4.758 45.6 35-44 years 2,601 55.0 2,619 34.4 45-64 years 3,742 30.7 3,552 15.0 65 years and over 1,391 18.5 1.450 6.8 Japanese2 25-34 years 3,287 49.3 3.517 40.4 35-44 years 1,939 48.9 2,861 24.7 45-64 years 3,878 23.7 5.827 8.9 65 years and over 1,164 7.9 1.442 4.6 Tilipino2 25-34 years 3,374 33.2 4,832 46.3 35-44 years 2,740 47.6 3,412 53.5 65-64 years 2,015 31.9 2,911 27.9 65 years and over 1.880 8.1 982 11.2 ■I Compiled froa published census reports. 2Data oro from the 1980 Census Public Use Microdata A (52) sample, computed %ff S. Can. From: "Asian-white mortality differentials: Is there excess death?", Yu, E.S.H. et al. Paper commissioned by the Task Force on Black 157 TABLE 51 Asian Americans Percent Distribution of Employed Persons According to Major Occupational Groups For Three Asian American Groups By Nativity, And For the White Population __________Chinese__________ _________Japanese__________ __________Filipino_______ U.S. Foreign U.S. Foreign U.S. Foreign born born Total born born Total born born Total White Professional 19.9 18.3 18.7 15.5 13.7 15.0 7.4 18.4 16.3 12.8 Executive, administrative, and managerial Technical Administrative support, including clerical Sales Precision production, craft, and repair Operators, fabricators, and laborers Farming, forestry, and fishing Serv ice Private household occupat ions (W) 12.6 6.3 11.5 6.0 11.8 6.1 10.7 4.2 13.6 3.8 11.5 4.1 6.7 3.5 7.2 5.8 7.1 5.3 11.1 3.1 23.1 11.9 13.0 8.3 15.7 9.2 21.9 10.7 13.9 10.2 19.7 10.5 21.6 10.0 20.8 5.3 20.9 6.3 17.3 10.7 6.4 5.1 5.5 10.7 6.4 9.5 11.4 7.3 8.1 13.4 7.4 15.5 13.3 10.2 13.7 11.1 16.7 14.2 14.7 17.1 1.0 11.2 0.6 21.1 0.7 18.5 5.0 10.6 3.5 20.1 4.6 13.2 3.6 18.8 3.7 16.8 3.7 17.2 2.9 11.3 0.3 0.7 0.6 0.6 1.0 0.0 0.3 0.7 0.6 0.4 (6,607) (18 ,062) (24 ,669) (16, ,810) (6 ,353) (23 ,163) (4 ,219) (17 ,481) (21 ,700) (84, ,027 ,375) Source: Data for Asian Americans were computed by S. Ken from the 1980 Census Public Use Microdata A (5%) example; data for the white population are compiled from the published census reports. From: "Asian-white mortality differentials: Is there excess death?," Yu, E.S.H. et al. Paper commissioned by the Task Force on Black and Minority Health, 1984-85 TABLE 52 Asian Americans Family Income For Three Asian American Groups By Nativity, and For the White Population, 1979 Median family income Chinese U.S. born Foreign born U.S. Total born Japanese $20,955 $21,010 $22,910 $29,373 Foreign born U.S. Total born $21,195 $27,475 $21,310 Filipino Foreign born Total $24,010 $23,585 White $28,835 Percent of families with income Less than $5,000 $25,000 or more (W) 3.1 6.6 5.9 1.9 6.4 3.1 5.3 3.3 3.7 5.6 60.1 41.5 45.4 62.9 40.7 57.0 38.6 48.1 46.6 37.8 (1,981) (7,368) (9,349) (6,176) (2,209) (8,385) (1,349) (7,032) (8,381) (50,644,862) Source: data for Asian Americans were computed by S. Ken from the 1980 Census Public Use Microdata A (3%) sample; data for the white population are compiled from the published census reports. From: "Asian-white mortality differentials: Is there excess death?," Yu, E.S.H. et al. Paper commissioned by the Task Force on Black and Minority Health, 1984-85 TABLE 53 Asian Americans Mortality, U.S., 1979-1981: Excess Deaths From Heart Disease 390 to 398 402 404 to 429/Heart Disease Race - White -AfiS. Deaths _______ Male Rate/ 100,000 Ex Dth Female Cumul ZEx Dth ZCumul Rate/ Deaths 100,000 Ex 1 219 16.54 0 103 2.14 0 53 0.83 0 54 0.77 0, 111 1.34 0 176 2.05 0, 240 3.01 0, 400 5.45 0, 652 10.99 0, 1225 24.62 0, 2385 49.49 0, 4958 94.63 0. 9444 175.38 0, 15993 333.01 0. 25260 583.28 0. 37014 1044.69 0. 49236 1851.04 0. 59807 3394.17 0. 105794 7395.32 0. 313124 323.86 0. Cumul ZEx Dth ZCumul Under 1 1-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-Plus All Ages 303 Ul 55 77 188 317 498 1021 2258 4615 9218 17395 28276 38527 49198 55227 53635 46245 54353 361516 21.71 2.19 0.82 1.03 2.17 3.65 6.22 13.99 38.72 95.16 198.73 353.70 582.67 923.22 1413.08 2163.78 3249.85 5008.62 8846.47 394.30 0. 0. 0. 0. 0. 0. 0. 0. 0. 0. 0. 0. 0. 0. 0. 0. 0. 0. 0. 0. 0. 0. 0. 0. 0. 0. 0. 0. 0. 0. 0. 0. 0. 0. 0. 0. 0. 0. 0. 0. Race - Black Male Female Rate/ Rate/ Age Deaths 100,000 Ex Dth Cumul ZEx Dth ZCumul Deaths 100,000 Ex Dth Cumul ZEx Dth ZCumul Under 1 Ul 41.44 53. 53. 1.59 1.59 99 37.64 56. 56. 1.95 1.95 1-4 40 5.10 28.. 81. 7.05 2.17 40 4.20 19. 75. 5.96 2.36 5-9 12 0.96 2. 82. 0.95 2.11 16 1.27 5. 81. 5.32 2.45 10-14 23 1.71 9. 91. 10.06 2.30 22 1.68 12. 93. 17.30 2.76 15-19 71 4.75 38. 130. * 3.26 47 3.14 27. 120. * 3.56 20-24 127 9.79 80. 210. 7.48 4.15 81 5.71 52. 172. 12.00 4.53 25-29 216 19.92 149. 358. 7.30 5.06 140 11.29 102. 274. 12.57 5.95 30-34 357 40.99 235. 593. 9.72 6.24 202 19.88 147. 421. 14.89 7.53 35-39 607 91.59 350. 944. 14.31 7.90 319 40.11 232. 653. 20.12 9.67 40-44 1041 183.75 502. 1446. 18.09 9.82 570 83.27 401. 1054. 27.43 12.84 45-49 1717 333.15 693. 2138. 20.33 11.79 951 151.57 641. 1695. 32.14 16.62 50-54 2706 536.41 922. 3060. 21.30 13.62 1577 252.56 986. 2681. 36.44 20.77 55-59 3866 828.71 1148. 4208. 23.21 15.35 2326 407.87 1326. 4007. 39.29 24.61 60-64 4502 1169.11 947. 5155. 21.57 16.21 3206 660.03 1589. 5596. 43.78 28.10 65-69 5166 1557.31 478. 5633. 13.58 15.95 4236 951.40 1639. 7235. 44.17 30.63 70-74 5154 2199.75 84. 5717. 3.83 15.24 4882 1482.86 1443. 8677. 40.43 31.91 75-79 4540 2972.08 0. 5717. 0.00 15.02 5095 2171.52 752. 9429. 35.42 32.17 80-84 3345 4463.36 0. 5717. * 15.02 4304 3442.27 60. 9489. 7.80 31.54 85-Plus 3434 6482.78 0. 5717. * 15.02 5888 5557.13 0. 9489. * 31.54 All Ages 37043 295.89 5717. — 15.02 * 34003 243.30 9489. — 31.54 * ♦Percent values are not given when the base of calculation (the excess deaths from all causes for a particular age sex and racial group) is equal to zero. From: Mortality Rates, Excess Deaths. National Center for Health Statistics' Death Certificate Data Tapes for 1979, 1980 and 1981. (Tables supplied by the DHHS Task Force on Black and Minority Health.) 160 Asian Americans TABLE 53 (Continued) 390 to 398 402 404 to 429/Heart Disease Race " ■ Indian Male Female Rate/ Rate/ Age Deaths 100,000 Ex Dth Cumul ZEx Dth ZCumul Deaths 100,000 Ex Dth Cumul ZEx Dth ZCumul Under 1 5 32.28 2. 2. 3.57 3.57 4 24.48 1 1. 2.45 2.45 1-4 2 2.81 0. 2. 1.76 3.02 3 5.25 2 3. 7.94 4.09 5-9 0 0.00 0. 2. 0.00 2.73 1 0.92 0 3. 1.49 3.94 10-14 0 0.42 0. 2. 0.00 2.41 1 1.73 4. 33.83 4.74 15-19 2 1.93 0. 2. 0.00 1.31 2 2.78 5. 5.67 4.94 20-24 6 8.02 3. 5. 2.28 1.76 3 3.59 6. 2.63 4.25 25-29 8 12.45 4. 9. 3.00 2.13 3 4.73 7. 1.98 3.63 30-34 9 17.17 2. 11. 1.52 2.00 6 10.34 10. 4.83 3.89 35-39 28 68.89 12. 23. 11.40 3.57 6 13.16 0 11. 1.97 3.59 40-44 38 83.93 0. 23. 0.00 3.10 12 33.70 0 14. 6.10 3.96 45-49 45 162.30 0. 23. 0.00 2.88 14 47.53 0 14. 0.00 3.61 50-54 63 253.55 0. 23. 0.00 2.81 23 87.67 0 14. 0.00 3.41 55-59 89 412.96 0. 23. * 2.81 33 142.29 0 14. * 3.41 60-64 101 632.94 0. 23. * 2.81 49 275.47 0 14. * 3.41 65-69 113 879.58 0. 23. * 2.81 75 482.87 0 14. * 3.41 70-74 105 1182.94 0. 23. * 2.81 79 712.24 0 14. * 3.41 75-79 100 1645.08 0. 23. * 2.81 75 974.63 0 14. * 3.41 80-84 72 2506.96 0. 23. * 2.81 80 1898.88 0 14. * 3.41 85-Plus 90 3894.42 0. 23. * 2.81 113 3164.79 0 14. * 3.41 All Ages 867 123.46 23. —— 2.81 * Race - 581 • Asian 80.95 14 " 3.41 * Male Female Rate/ Rate/ Age Deaths 100,000 Ex Dth Cumul ZEx Dth ZCumul Deaths 100,000 Ex Dth Cumul ZEx Dth ZCumul Under 1 9 27.77 2. 2. * * 5 17.55 0 0. * * 1-4 4 3.13 1. 3. * * 3 2.32 0 1. * * 5-9 1 0.43 0. 3. * * 1 0.90 0 1. * * '0-14 2 1.16 0. 3. * * 2 1.47 1 2. * * 15-19 4 2.68 1. 4. * * 1 0.96 0 2. * * 20-24 8 4.88 2. 6. * * 4 2.25 0 2. * * 25-29 7 4.31 0. 6. * * 7 3.52 1 3. * * 30-34 18 10.44 0. 6. * * 9 4.29 0 3. * * 35-39 24 18.24 0. 6. * * 9 5.97 0 3. * * 40-44 45 42.03 0. 6. * * 15 13.29 0 3. * * 45-49 66 80.14 0. 6. * * 22 22.36 0 3. * * 50-54 115 185.18 0. 6. * * 32 36.41 0 3. * * 55-59 168 275.02 0. 6. * * 53 77.45 0 3. * * 60-64 178 394.49 0. 6. * * 79 150.66 0 3. * * 65-69 240 636.59 0. 6. * * 100 245.84 0 3. * * 70-74 345 1114.02 0. 6. * * 124 456.69 0 3. * * 75-79 349 1780.79 0. 6. * * 172 882.41 0 3. * * 80-84 256 2842.95 0. 6. * * 172 1427.98 0 3. * * 85-Plus 293 5631.45 0. 6. * * 302 3485.46 0 3. * * All Ages 2140 126.36 6. — * * 1111 61.50 3 . — * * 161 TABLE 54 Asian Americans Mortality, U.S., 1979-1981: Excess Deaths From Ischemic Heart Disease 410 to 414/Ischemic Heart Disease Race - White ____________________Male_____________________________________________Female_________ Rate/ Rate/ Age__________Deaths 100,000 Ex Dth Cumul ZEx Dth ZCumul_______Deaths 100,000 Ex Dth Cumul ZEx Dth ZCumul Under 1 13 0.73 0. 0. 999.00 * 7 0.53 0. 0. * * 1-4 5 0.09 0. 0. * * 3 0.06 0. 0. * * 5-9 8 0.11 0. 0. * * 5 0.08 0. 0. * * 10-14 4 0.06 0. 0. * * 3 0.04 0. 0. * * 15-19 17 0.20 0. 0. * * 8 0.10 0. 0. * * 20-24 57 0.65 0. 0. * * 22 0.25 0. 0. * * 25-29 184 2.30 0. 0. * * 42 0.52 0. 0. * * 30-34 592 8.21 0. 0. * * 122 1.66 0. 0. * * 35-39 1642 28.16 0. 0. * * 303 5.10 0. 0. * * 40-44 3586 73.94 0. 0. * * 694 13.95 0. 0. * * 45-49 7145 158.35 0. 0. * * 1507 31.27 0. 0. * * 50-54 13532 281.24 0. 0. * * 3305 63.08 0. 0. * * 55-59 22575 465.19 0. 0. * * 6655 123.58 0. 0. * * 60-64 30972 742.18 0. 0. * * 11643 242.42 0. 0. * * 65-69 39463 1133.46 0. 0. * * 18814 434.44 0. 0. * * 70-74 44224 1732.65 0. 0. * * 27883 786.98 0. 0. * * 75-79 42277 2561.64 0. 0. * * 37026 1392.00 0. 0. * * 80-84 35835 3881.15 0. 0. * * 44474 2524.00 0. 0. * * 85-Plus 40770 6635.67 0. 0. * * 76621 5356.01 0. 0. * * All Ages 283407 309.11 0. 0. * * 229135 236.99 0. 0. * * Race - Black ____________________Male_________________________ ____________________Female_______________________ Rate/ Rate/ Age__________Deaths 100,000 Ex Dth Cumul ZEx Dth ZCumul_______Deaths 100,000 Ex Dth Cumul ZEx Dth ZCumul Under 1 2 0.75 0. 0. 0.00 0.00 2 0.70 1. 1. 0.02 0.02 1-4 1 0.14 0. 0. o.u 0.01 1 O.U 0. 1. 0.13 0.03 5-9 1 0.08 0. 0. 0.00 0.01 1 O.U 0. 1. 0.29 0.04 10-14 1 0.05 0. 0. 0.00 0.01 0 0.03 0. 1. 0.00 0.04 15-19 7 0.45 4. 4. * 0.10 4 0.27 3. 4. * O.U 20-24 20 1.56 12. 16. 1.11 0.32 8 0.54 4. 8. 0.94 0.21 25-29 59 5.44 34. 50. 1.67 0.71 22 1.75 15. 23: 1.67 0.50 30-34 144 16.49 72. 122. 2.98 1.29 54 5.27 37. 60. 3.73 1.07 35-39 288 43.53 102. 224. 4.16 1.87 108 13.54 67. 127. 5.83 1.88 40-44 561 79.08 142. 367. 5.13 2.49 247 36.08 152. 278. 16.35 3.39 45-49 986 191.35 170. 537. 4.99 2.96 464 73.98 268. 547. 13.47 5.36 50-54 1805 318.12 186. 723. 4.30 3.22 854 136.77 460. 1007. 17.00 7.80 55-59 2326 498.67 156. 879. 3.16 3.21 1339 234.80 634. 1641. 16.79 10.08 60-64 2736 710.64 0. 879. 0.00 2.76 1921 395.44 743. 2384. 20.49 11.97 65-69 3229 973.30 0. 879. 0.00 2.49 2581 579.72 647. 3031. 17.43 12.83 70-74 3246 1385.46 0. 879. 0.00 2.34 2977 904.17 386. 3417. 10.81 12.57 75-79 2860 1872.06 0. 879. 0.00 2.31 3160 1346.72 0. 3417. 0.00 11.66 80-84 2096 2796.94 0. 879. * 2.31 2662 2128.92 0. 3417. 0.00 11.36 85-Plus 2124 4010.12 0. 879. * 2.31 3641 3436.08 0. 3417. * 11.36 All Ages 22293 178.07 879. -- 2.31 * 26045 143.43 3417. ~ 11.36 * ♦Percent values are not given when the base of calculation (the excess deaths from all causes for a particular age, sex, and racial group) is equal to zero. From: Mortality Rates, Excess Deaths. National Center for Health Statistics' Death Certificate Data Tapes for 1979, 1980, and 1981. (Tables supplied by the DHHS Task Force on Black and Minority Health.) 162 Asian Americans TABLE 54 (Continued) Male 410 to 414/l8chemic Heart Disease Race - Indian Female Age Deaths Rate/ 100,000 Ex Dth Cumul ZEx Dth ZCumul Deaths Rate/ 100,000 Ex Dth Cumul ZEx Dth ZCumul Under 1 0 0.00 0. 0. 0.00 0.00 0 0.00 0. 0. 0.00 0.00 1-4 0 0.00 0. 0. 0.00 0.00 0 0.00 0. 0 0.00 0.00 5-9 0 0.00 0. 0. 0.00 0.00 0 0.46 0. 0 0.20 0.34 10-14 0 0.00 0. 0. 0.00 0.00 0 0.00 0. 0 0.00 0.33 15-19 0 0.39 0. 0. 0.22 0.10 0 0.00 0. 0 0.00 0.26 -0-24 1 0.89 0. 0. 0.12 O.U 0 0.00 0. 0 0.00 0.19 25-29 2 2.71 0. 1. 0.20 0.14 0 0.53 0. 0 0.00 0.13 30-34 6 11.45 2. 2. 1.55 0.42 2 3.04 1. 1.36 0.40 35-39 15 37.29 4. 6. 3.45 0.93 2 3.87 0. 0.00 0.34 40-44 18 54.31 0. 6. 0.00 0.80 4 12.17 0. 0.00 0.29 45-49 35 126.50 0. 6. 0.00 0.75 7 24.32 0. 0.00 0.26 50-54 47 189.49 0. 6. 0.00 0.73 13 50.10 0. 0.00 0.25 55-59 68 318.25 0. 6. * 0.73 18 78.26 0. * 0.25 60-64 75 470.54 0. 6. * 0.73 31 174.96 0. * 0.25 65-69 85 664.23 0. 6. * 0.73 50 325.51 0. * 0.25 70-74 79 892.86 0. 6. * 0.73 52 473.82 0. * 0.25 75-79 70 1142.26 0. 6. * 0.73 44 578.69 0. * 0.25 80-84 47 1636.49 0. 6. * 0.73 51 1218.45 0. * 0.25 85-Plus 54 2322.23 0. 6. * 0.73 70 1975.66 0. * 0.25 All Ages 603 85.92 6. — 0.73 * 347 48.36 ~ 0.25 * Male Race » Asian Female Age Deaths Rate/ 100,000 Ex Dth Cumul ZEx Dth ZCumul Deaths Rate/ 100,000 Ex Dth Cumul ZEx Dth ZCumul Under 1 2 5.34 1. 1. * * 0 1.10 0. 0. * * 1-4 1 0.57 1. 2. * * 1 0.58 1. * * 5-9 0 0.00 0. 2. * * 0 0.22 0. * * 10-14 0 0.00 0. 2. * * 0 0.00 0. * * 15-19 0 0.00 0. 2. * * 0 0.00 0. * * 20-24 2 1.06 1. 3. * * 0 0.20 0. * * 25-29 2 1.37 0. 3. * * 1 0.33 0. * * 39-34 10 6.11 0. 3. * * 2 0.82 0. ■* * 35-39 14 10.39 0. 3. * * 4 2.52 0. * * 40-44 31 28.43 0. 3. * * 6 5.61 0. * * 45-49 53 64.44 0. 3. * * 11 11.52 0. * * 50-54 92 131.66 0. 3. * * 17 19.34 0. * * 55-59 128 208.99 0. 3. * * 33 47.44 0. * * 60-64 133 294.02 0. 3. * * 52 99.39 0. * * 65-69 189 442.55 0. 3. * * 70 173.49 0. * * 70-74 264 853.54 0. 3. * * 86 317.59 0. * * 75-79 261 1331.77 0. 3. * * 126 648.13 0. * * 80-84 188 2086.81 0. 3. * * 130 1079.29 0. * * 85-Plus 221 4258.87 0. 3. * * 224 2584.25 0. * * All Ages 1590 93.88 3. —— * * 764 42.26 1. — * * 163 Asian Americans TABLE 55 Mortality, U.S., 1979-1981: Excess Deaths From Cerebrovascular Disease 430 to 438/Cerebrovascular Disease Race - White Male Female Rate/ Rate/ Age Deaths 100,000 Ex Dth Cumul ZEx Dth ZCumul Deaths 100,000 Ex Dth Cumul ZEx Dth ZCumul Under 1 54 3.85 0. 0. * * 41 3.10 0. 0. * * 1-4 19 0.37 0. 0. * * 18 0.38 0. 0. * A 5-9 19 0.29 0. 0. * * 16 0.26 0. 0. A A 10-14 21 0.28 0. 0. * * 21 0.30 0. 0. * A 15-19 53 0.61 0. 0. * * 46 0.55 0. 0. * A 20-24 105 1.21 0. 0. * * 85 0.98 0. 0. * A 25-29 141 1.76 0. 0. * A 120 1.51 0. 0. * A 30-34 200 2.74 0. 0. * * 198 2.70 0. 0. * A 35-39 288 4.94 0. 0. * * 310 5.23 0. 0. * A 40-44 442 9.11 0. 0. * * 459 9.22 0. 0. * A 45-49 726 15.66 0. 0. * * 765 15.88 0. 0. * A 50-54 1377 27.90 0. 0. * * 1213 23.14 0. 0. * A 55-59 2244 46.24 0. 0. * * 1988 36.91 0. 0. * A 60-64 3675 88.13 0. 0. * * 3081 64.15 0. 0. * * 65-69 5846 167.90 0. 0. * * 5079 117.29 0. 0. * A 70-74 8726 341.88 0. 0. * * 8023 243.37 0. 0. * A 75-79 10734 650.37 0. 0. * ft 13389 503.38 0. 0. * A 80-84 11037 1195.41 0. 0. * * 18474 1048.42 0. 0. * A 85-Plus 13600 2213.46 0. 0. * * 33537 2344.36 0. 0. * A All Ages 59307 64.69 0. 0. * * Race - 87463 Black 90.46 0. 0. * A Male Female Rate/ Rate/ Age Deaths 100,000 Ex Dth Cumul ZEx Dth ZCumul Deaths 100,000 Ex Dth Cumul ZEx Dth ZCumul Under 1 30 11.23 20. 20. 0.59 0.59 19 7.33 11. 11. 0.39 0.39 1-4 5 0.56 2. 22. 0.46 0.58 4 0.42 0. 12. 0.13 0.36 5-9 4 0.32 0. 22. 0.20 0.56 4 0.30 0. 12. 0.48 0.37 10-14 6 0.47 3. 24. 3.12 0.62 6 0.45 2. 14. 2.92 0.42 15-19 12 6.81 3. 27. * 0.69 13 0.87 5. 19. * 0.56 20-24 15 2.72 20. 47. 1.84 0.93 34 2.41 20. 39. 4.68 1.03 25-29 52 4.83 33. 80. 1.63 1.13 65 5.28 47. 86. 5.73 1.86 30-34 94 10.83 76. 151. 2.91 1.59 89 8.75 62. 147. 6.24 2.64 35-39 155 23.45 123. 273. 5.01 2.29 124 15.59 82. 230. 7.16 3.41 40-44 229 40.36 177. 450. 6.38 3.06 196 28.58 133. 362. 9.06 4.41 45-49 346 67.08 265. 715. 7.78 3.95 312 49.71 212. 575. 10.67 5.63 50-54 224 103.79 382. 1098. 8.83 4.89 457 73.24 313. 688. 11.56 6.88 55-59 719 154.12 503. 1601. 10.18 5.84 620 108.78 410. 1297. 12.14 7.97 60-64 921 239.19 582. 2183. 13.25 6.86 805 165.64 493. 1790. 13.59 8.99 65-69 1210 364.86 653. 2836. 18.54 8.03 1208 271.37 686. 2477. 18.49 10.48 70-74 1396 505.92 595. 3431. 27.08 9.15 1590 482.81 788. 3265. 22.09 12.01 75-79 1336 874.38 342. 3774. 61.53 9.91 1699 724.22 518. 3783. 24.41 12.91 80-84 992 1323.98 96. 3870. * 10.16 1497 1197.37 186. 3969. 24.16 13.19 85-Plus 978 1845.84 0. 3870. * 10.16 2007 1893.90 0. 3969. a 13.19 All Ages 9045 72.25 3870. — 10.16 * 10750 76.92 3969. 0. 13.19 A ♦Percent values are not given when the base of calculation (the excess deaths from all causes for a particular age, sex, and racial group) is equal to zero. From: Mortality Rates, Excess Deaths. National Center for Health Statistics' Death Certificate Data Tapes for 1979, 1980, and 1981. (Tables supplied by the DHHS Task Force on Black and Minority Health.) 164 Asian Americans TABLE 55 (Continued) 430 to 438/Cerebrovascular Disease Race ■ Indian _____________________Male_______________________________________________Female______________________ Rate/ Rate/ Ag£__________Deaths 100,000 Ex Dth Cumul ZEx Dth ZCumul_______Deaths 100,000 Ex Dth Cumul ZEx Dth ZCumul Under 1 1 4.04 0. 0. 0.06 0.06 0 0.00 0. 0. 0.00 0.00 1-4 0 0.00 0. 0. 0.00 0.04 1 1.17 0. 0. 2.01 0.60 5-9 0 0.00 0. 0. 0.00 0.04 0 0.00 0. 0. 0.00 0.56 10-14 0 0.00 0. 0. 0.00 0.04 0 0.00 0. 0. 0.00 0.55 15-19 1 0.77 0. 0. 0.19 O.U 1 0.79 0. 1. 0.97 0.64 20-24 1 1.34 0. 0. 0.07 0.09 1 1.35 0. 1. 0.62 0.63 25-29 0 0.54 0. 0. 0.00 0.06 1 1.05 0. 1. 0.00 0.46 30-34 2 3.16 0. 0. 0.21 0.09 2 4.26 1. 2. 1.54 0.69 35-39 1 3.24 0. 0. 0.00 0.08 3 6.19 0. 2. 0.87 0.72 40-44 3 8.89 0. 0. 0.00 0.07 5 13.10 1. 4. 2.81 1.00 45-49 5 16.71 0. 1. 0.50 0.10 6 19.90 1. 5. 3.48 1.22 50-54 8 32.03 1. 2. 4.85 0.22 5 18.79 0. 5. 6.00 1.15 55-59 14 63.65 4. 6. A 0.67 8 32.73 0. 5. A 1.15 60-64 15 93.69 1. 6. * 0.77 10 55.84 0. 5. A 1.15 65-69 21 160.86 0. 6. A 0.77 20 127.19 2. 6. A 1.52 70-74 20 222.27 0. 6. A 0.77 17 150.90 6. 6. A 1.52 75-79 24 398.97 0. 6. A 0.77 21 274.12 0. 6. A 1.52 80-84 19 649.95 0. 6. * 0.77 20 474.72 0. 6. A 1.52 85-Plus 30 1312.56 0. 6. A 0.77 43 1217.23 0. 6. A 1.52 All Ages 164 23.31 6. ~ 0.77 A 162 22.56 6. -- 1.52 A Race - Asian _____________________Male_______________________________________________Female_____________________ Rate/ Rate/ Age__________Deaths 100,000 Ex Dth Cumul ZEx Dth ZCumul_______Deaths 100,000 Ex Dth Cumul ZEx Dth ZCumul Under 1 1 4.27 0. 0 A A 2 6.58 1. 1. A A 1-4 1 0.57 0. 0 A A 1 0.58 0. 1. A A 5-9 0 0.00 0. 0 A A 0 0.22 0. 1. A A 00-14 0 0.00 0. 0 A A 1 0.49 0. 2. A A 15-19 1 0.67 0. 0 * A 0 0.24 0. 2. A A 20-24 2 1.27 0. A A 1 0.41 0. 2. A A 25-29 2 0.98 0. A A 4 1.84 1. 2 A A 30-34 5 2.95 0. A A 3 1.65 0. 2 A A 35-39 6 4.31 0. A A 6 4.36 0. 2 A A 40-44 8 7.11 0. A A 9 7.68 0. 2 A A 45-49 15 18.12 2. A A 19 18.97 3. 5 A A 50-54 21 30.16 2. A A 22 25.41 2. A A 55-59 31 50.20 2. A A 29 42.11 4. ] A A 60-64 31 68.70 0. A A 28 53.18 0. A A 65-69 61 156.59 0. A A 39 95.38 0. A A 70-74 80 258.32 0. A A 43 157.56 0. A A 75-79 93 474.54 0. A A 65 331.76 0. A A 80-84 74 819.16 0. A A 82 678.01 0. A A 85-Plus 77 1431.62 0. A A 125 1448.16 0. A * All Ages 508 29.98 7. - A A 478 26.43 11. -- A A 165 Asian Americans TABLE 56 Mortality, U.S., 1979-1981: Excess Deaths From Hypertensive Disease 401 to 405/Hypertensive Disease Race - White _____________________Male_________________________ ______________________Female______________________ Rate/ Rate/ Age__________Deaths 100,000 Ex Dth Cumul ZEx Dth ZCumul______Deaths 100.000 Ex Dth Cumul ZEx Dth ZCumul Under 1 3 0.19 0. 0. A A 1 0.08 0. 1-4 0 0.00 0. 0. A A 1 0.02 0. 5-9 2 0.02 0. 0. A A 1 0.02 0. 10-14 1 0.01 0. 0. A A 2 0.02 0. 15-19 3 0.03 0. 0. A A 2 0.02 0. 20-24 7 0.08 0. 0. A A 5 0.05 0. 25-29 21 0.27 0. 0. A A 8 0.10 0. 30-34 35 0.48 0. 0. A A 17 0.23 0. 35-39 59 1.02 0. 0. A A 27 0.45 0. 40-44 122 2.52 0. 0. A A 57 1.15 0. 45-49 226 4.86 0. 0. A A 125 2.59 0. 50-54 444 9.03 0. 0. A A 234 4.47 0. 55-59 779 16.05 0. 0. A A 444 8.24 0. 60-64 1029 24.67 0. 0. A A 717 14.94 0. 65-69 1352 38.84 0. 0. A A 1138 26.28 0. 70-74 1511 59.20 0. 0. A A 1678 47.37 0. 75-79 1575 75.45 0. 0. A A 2277 85.60 0. 80-84 1391 150.62 0. 0. A A 2775 157.47 0. 85-Plus 1708 278.05 0. 0. A * 4529 316.61 0. All Ages 10269 11.20 0. 0. A * 14038 14.52 0. Race - Black ___________Male_______________________________________________Female Rate/ Rate/ Age Deaths 100.000 Ex Dth Cumul ZEx Dth ZCumul Deaths 100,000 Ex Dth Cumul ZEx Dth ZCumul Under 1 0 0.12 0. 0. 0.00 0.00 0 0.13 0. 0. 0.00 0.00 1-4 1 0.07 1. 1. 0.17 0.02 1 O.U 1. 1. 0.29 0.03 5-9 0 0.00 0. 1. 0.00 0.02 0 0.00 0. 1. 0.00 0.03 10-14 1 0.05 1. 1. 0.66 0.03 1 0.05 0. 1. 0.50 0.04 15-19 3 0.18 2. 3. A 0.08 1 0.09 1. 2. A 0.07 20-24 6 0.49 5. 7. 0.49 0.17 6 0.40 5. 7. 1.13 0.19 25-29 23 2.12 20. 29. 0.99 0.41 20 1.62 19. 26. 2.29 0.56 30-34 49 5.63 45. 73. 1.85 0.77 31 3.65 29. 55. 2.90 0.98 35-39 78 11.83 72. 145. 2.93 1.21 57 7.21 54. 108. 4.67 1.61 40-44 147 26.01 133. 278. 4.79 1.89 107 15.63 99. 207. 6.77 2.59 45-49 205 39.85 180. 458. 5.29 2.53 177 28.20 161. 308. 8.07 3.61 50-54 317 42.76 271. 729. 6.26 3.25 276 44.26 248. 617. 9.18 4.78 55-59 413 88.60 338. 1068. 6.85 3.90 357 62.54 310. 926. 9.18 5.69 60-64 436 113.32 341. 1409. 7.78 4.43 429 88.24 356. 1282. 9.61 6.44 65-69 487 136.81 358. 1767. 10.16 5.00 553 124.12 436. 1718. 11.74 7.27 70-74 456 193.75 318. 2085. 14.45 5.56 584 177.47 428. 2146. 12.00 7.89 75-79 365 238.73 219. 2304. 39.36 6.05 573 244.34 372. 2519. 17.54 6.59 80-84 243 323.77 130. 2434. A 6.39 429 343.40 232. 2751. 30.18 9.15 85-Plus 227 427.95 79. 2513. A 6.60 495 467.50 160. 2911. A 9.68 All Ages 3457 27.62 2513. — 6.60 A 4098 29.32 2911. -- 9.68 A ♦Percent values are not given when the base of calculation (the excess deaths from all causes for a particular age, sex and racial group) is equal to zero. From: Mortality Rates, Excess Deaths. National Center for Health Statistics* Death Certificate Data Tapes for 1979, 1980 and 1981. (Tables supplied by the DHHS Task Force on Black and Minority Health.) 0. 0. 0. 0. 0. 0. 0. 0. 0. 0. 0. 0. 0. 0. 0. 0. 0. 0. 0. 0. 166 -£ OOOOM-J93X)4>^i— ui *- *- N> i— O O O O O O O LOOOOOOO^-OOh-i— oooooooo I ulUJUJOJUlOJLOKihorOH- OOOOOOOO ******************** as ««J ***K.**-|a*******»***** 00 N H H >-*-i3i000>LnLnL>»*ars>O»— OOOOOOO IO h- £.|OCT>tO00Lnv©(-l-»L0L0*-OOOOOOOO'-a •Isio\Jo^wo*ln-»Ja»-^->N>**»»-OS2MSt; ■sjL0L000i-a"OO00v0L000L0L0--IOOOIOOO (s>00000000>-0000000000 I iototolOlotOIOIOIOH-a-a>-- i— i— i— i— i— O O I................... ******************** ******************** > OO £ ? Y 0> Ul Ul *- ■c- LO LO 1-0 l-O ►- ? Ul 1 ? Ul 1 Y Ul 1 Y Y Y 1 !•>•• Ul Ul *■ *- LO LO to to •"^ £ LO LO LO LO LO tO rs» H- >— O •— '-D Ul to h- Ha- ul oo oo ro *-• o IO LO 00 9> vO VO 0*< KJ vO Ul Ul 00 Ul O o o •- i— o o o o i-ototototoioa-orororo*- i— o i_o O u> ro O O > I" m m UjLOLoLOLOLOLorotororo OOOOOO'-O^-'OO-' o O 3 LnoJU*»-nu>L*>H-i--H-0-^,*000 -4 UJ -P* ■—' •— 3 C 10 a Ul sO i— sO Ul o-< ui >— O ui •OOOOOOOOOh-OOOOOOOOOO I totoi-oioroioroioroH-i— Aooooooo O i— O i— Ln Ln Ln ui Lo to Lo i— ►- eo vO -J to -O ui O TABLE 57 Mortality, U.S., 1979-1981: Excess Deaths From Diabetes Mellitus 250/Diabetes Mellitus Race - White _____________________Male______________________________________________ Female_______________________ Rate/ Rate/ Age__________Deaths 100,000 Ex Dth Cumul ZEx Dth ZCumul_______Deaths 100.000 Ex Dth Cumul ZEx Dth ZCumul Under 1 3 0.21 0. 0. A A 1 0.05 0. 1-4 3 0.04 0. 0. A A 5 0.10 0. 5-9 5 0.08 0. 0. A A 6 0.09 0. 10-14 7 0.10 0. 0. A A 10 0.14 0. 15-19 13 0.15 0. 0. A A 20 0.24 0. 20-24 41 0.47 0. 0. A A 38 0.44 0. 25-29 91 1.14 0. 0. A A 79 0.94 0. 30-34 151 2.07 0. 0. A A 110 1.50 0. 35-39 176 3.0! 0. 0. A A 123 2.07 0. 40-44 211 4.35 0. 0. A A 153 3.08 0. 45-49 303 6.54 0. 0. A A 242 5.02 0. 50-54 547 11.13 0. 0. A A 452 8.63 0. 55-59 907 18.68 0. 0. A A 840 15.60 0. 60-64 1319 31.61 0. 0. A A 1308 27.24 0. 65-69 1677 48.17 0. 0. A A 1927 44.50 0. 70-74 1920 75.23 0. 0. A A 2478 69.95 0. 75-79 1820 110.30 0. 0. A A 2824 106.17 0. 80-84 1461 158.20 0. 0. A A 2722 154.48 0. 85-Plus 1318 214.57 0. 0. A A 3126 218.52 0. All Ages 11973 13.06 0. 0. A A 16463 17.03 0. Race - Black ___________Male_________________________ ______________________Female Rate/ Rate/ Age Deaths 100,000 Ex Dth Cumul ZEx Dth ZCumul Deaths 100.000 Ex Dth Cumul ZEx Dth ZCumul Under 1 0 0.00 0. 0. 0.00 0.00 0 0.13 0. 0. 0.01 0.01 1-4 2 0.24 2. 2. 0.49 0.05 0 0.04 0. 0. 0.00 0.01 5-9 1 O.U 0. 2. 0.18 0.06 1 O.U 0. 0. 9.23 0.01 10-14 2 0.17 1. 3. 1.21 0.08 4 0.33 3. 3. 3.59 0.09 15-19 5 0.34 3. 6. A . 0.15 4 0.29 1. 4. A O.U 20-24 14 1.10 8. 14. 0.77 0.28 13 0.89 6. 10. 1.48 0.27 !5-29 22 2.00 9. 24. 0.46 0.33 23 1.86 11. 21. 1.32 0.45 30-34 37 4.21 19. 42. 0.77 0.44 28 2.72 12. 33. 1.26 0.60 35-39 45 7.30 28. 71. 1.16 0.59 48 6.08 32. 65. 2.77 0.97 40-44 70 12.36 45. 116. 1.63 0.79 63 9.25 42. 107. 2.89 1.31 45-49 95 18.44 61. 177. 1.80 0.98 107 17.10 76. 183. 3.61 1.60 50-54 141 27.88 85. 262. 1.95 1.17 208 33.26 154. 337. 5.68 2.61 55-59 217 46.59 130. 392. 2.63 1.43 308 53.95 219. 556. 6.88 3.41 60-64 236 61.81 116. 508. 2.65 1.60 425 87.42 292. 848. 8.06 4.26 65-69 298 89.83 138. 640. 3.92 1.83 554 124.34 356. 1204. 9.58 5.10 70-74 269 114.94 93. 740. 4.23 1.97 509 166.64 318. 1522. 8.92 5.60 75-79 240 162.35 80. 819. 14.30 2.15 465 198.17 216. 1738. 10.17 5.93 80-84 133 177.00 14. 833. A 2.19 320 255.68 127. 1864. 16.42 6.20 85-Plus 109 200.82 0. 833. A 2.19 322 303.91 90. 1955. A 6.50 All Ages 1950 15.58 833. -- 2.19 A 3442 24.83 1955. -- 8.50 A ♦Percent values are not given when the base of calculation (the excess deaths from all causes for a particular age, sex, and racial group) is equal to zero. From: Mortality Rates, Excess Deaths. National Center for Health Statistics' Death Certificate Data Tapes for 1979, 1980, and 1981. (Tables supplied by the DHHS Task Force on Black and Minority Health.) 0. 0. 0. 0. 0. 0. 0. 0. 0. 0. 0. 0. 0. 0. 0. 0. 0. 0. 0. 0. 168 00 00 Y Y £ --4 ON CTs ui Ui Y Y Y Y Y -~J O^ OS Ul Ul LO LO IO IO i— Ln i— G Ul O Ul Q Ul O I I T 1 T i I va LO LO IO to i— I— to M ^-OOOOOOOOO to H- IO IO -J o» LO IO 4> <£> LO -~l £- Ul -•JOLnLOOOOOOOOOO i—i— OOOOOOOOOOOOOOOOOO ►— OOOOOOOOOOOOOOOOOO »*»*****»*********» Os SO ****** *»******»»» oo ui as Ln Ln to 00 Ul LO >-• O >—• O I— OOOOO KJ r- >— to oo ui lo ro *-. -4 O *• -J tO •— C^LOi— OOOOOOOOO OOOOOOOOOOOOOOOOOOO OOOOOOOOOOOOOOOOOOO ****** ************* ****** ************* -fr-OOOOa-O-^JOvO'VUlUl SYYYYYYYY -aOO-^a-JOaa-U-aUlUl LO LO to IO Ul O Ul O lo lo ro to .— r- Ul »—* G £ UlLOLnOOLOH-OOiaOUlOitOh- >— «- o> IO i— LO v© to 00 O O ■- Ul Ul 0"-> Os LO o o o o LOLOLOLOLOtOtO*— LO 00 to tO IO IO I— O O I- O O O to O ►— to > 03 r- m m LO LO to t— r- O 00 r- 00 LO LO I— I— »a oo lo ►- o o 3 i— r- to >— i— a> Q. -O Ul i— i— ■—> l— o 1— IO H- t— IO IO ""J Ul i— K- 00 Ul to IO ON U> LO i— i— O IO to *- LO 00 -J to Ul 00 OOLO-aji'P-LnLOOUlLOOOOOOOOOOO LO LO Ul IO h- -.1 *- *- oo o> -o. *• f- ro i— o to I— oo ui to r- i— IO LO LO LO Asian Americans TABLE 58 Rank Order and Proportional Mortality (P.M.) of the Ten Leading Causes Of Death, According to Specified Race: United States, 1980 10 Leading Causes, United States 1. Heart Disease 2. Cancer 3. Cerebrovascular Disease 4. Accidents 5. Chronic Obstructive Pulm. Disease 6. Pneumonia and Influenza 7. Diabetes Mellitus 8. Chronic Liver & Cirrhosis Disease 9. Atherosclerosis 10. Suicide & Self-inflicted injury 1CD-9 Codes 390-398,402,404-429 140-208 430-438 E800-E949 490-496 480-487 250 571 440 E950-E959 White Chinese Japanese Pilipino Rank P.M. Rank P.M. Rank P.M. Rank P.M. 1 39.3 1 31.8 1 30.4 33.5 2 21.3 2 27.4 2 25.4 20.5 3 8.6 3 8.6 3 11.2 10.1 4 5.2 4 4.2 4 5.4 6.7 5 3.0 6 2.4 8 2.0 2.0 6 2.6 5 3.0 5 3.5 2.8 7 1.7 8 2.1 7 2.0 1.8 8 1.4 9 1.2 9 1.2 1.2 9 1.5. 10 0.9 10 1.0 10 0.6 10 1.5 7 2.2 6 2.3 8 1.5 Source: National Center for Health Statistics From: "Asian-white mortality differentials: Is there excess death?", Yu, E.S.H. et al. Paper commissioned by the Task Force on Black and Minority Health, 1984-85 170 Asian Americans TABLE 59 Age-Adjusted Race-Mortality Ratios for Specified Cause of Death United States, 1980 Causes of Death Chinese Japanese Filipino Heart Disease 0.54 Cancer 0.76 Cerehrovaacular Disease 0.76 Accidents 0.34 Chronic Obstructive Pulmonary Disease 0.50 Pneumonia and Influenza 0.81 Diabetes Mellitus 0.81 Chronic Liver Disease and Cirrhosis 0.42 Atherosclerosis 0.57 Suicide and self-inflicted injury 0.64 0.42 0.60 0.76 0.44 0.34 0.73 0.64 0.34 0.41 0.62 0.42 0.40 0.66 0.39 0.31 0.59 0.49 0.29 0.25 0.30 Note: Ratios are calculated for each specific cause of death by dividing the age-adjusted death rate of a specified ethnic group by the age- adjusted death rate of the white population Source: National Center for Health Statistics, published and unpub- lished data From: "Asian-white mortality differentials: Is there excess death?", Yu E.S.H. et al. Paper commissioned by the Task Force on Black and Minority Health, 1984-85 171 Asian Americans TABLE 60 Within-Group Sex-Mortality Ratios(l) For All Causes of Death: United States, 1980 Age White Chinese Japanese Filipino All ages, crude 1.23 1.63 1.33 3.25 Age-adjusted 2 1.82 1.75 1.65 1.96 Under 5 years 1.28 1.13 1.37 1.01 5-14 years 1.56 0.73 1.31 1.39 15-24 years 3.00 2.39 2.05 2.80 25-34 years 2.61 1.60 1.84 1.87 35-44 years 1.86 1.27 1.17 1.38 45-54 years 1.88 1.70 1.64 1.34 55-64 years 1.98 1.94 1.72 2.18 65-74 years 1.96 1.97 1.95 2.58 75-84 years 1.65 1.86 1.60 2.07 85 years and over 1.28 1.31 1.38 1.71 (1) Excludes deaths of nonresidents of the United States. Ratios are computed for each ethnic group by dividing the age-specific death rate of males by the death rates of females in that age-group (2) Age-adjusted by the direct method, using as the standard population the age distribution of the total population of the United States in 1940. Adjustment is based on ten age-groups Source: National Center for Health Statistics, published and unpub- lished data computed by the authors From: "Asian-white mortality differentials: Is there excess death?", Yu, E.S.H. et al. Paper commissioned by the Task Force on Black and Minority Health, 1984-85 172 TABLE 61 Asian Americans Five Leading Causes of Death, By Race-Ethnicity, Los Angeles, 1981 Whit e Black Asi, an-Americans Non-Spanish-surnamed* Spanish-surnamed* Rank Japanese Chinese Korean 1 Diseases of Diseases of Diseases of Diseases of Diseases of Malignant heart heart heart heart heart neoplasms (42)+ (27) (31) (32) (32) (25) 2 Malignant Malignant Malignant Malignant Malignant Diseases of neoplasms neoplasms neoplasms neoplasms neoplasms heart (22) (18) (21) (22) (27) (16) 3 Cerebrovascu- Accidents Cerebrovascu- Cerebrovascu- Cerebrovascu- Cerebrovascu- lar diseases (9) lar diseases lar diseases lar diseases lar diseases (9) (8) (15) (11) (10) 4 Accidents Cerebrovascu- Accidents Accidents Accidents Accidents (4) lar diseases (6) (6) (5) (5) (8) 5 Pneumonia and Chronic liver Chronic liver Pneumonia and Suicide Suicide influenza disease and disease and influenza (A) (4) (3) cirrhosis (5) cirrhosis (3) (4) *As identified on the death certificate. +Percentage of total deaths in the specified race-ethnic group. From: "Cardiovascular Diseases in Los Angeles County, 1978-1981," Frerichs, R.R. et al. American Heart Association. Greater Los Angeles Affiliate, Inc., 1983 Asian Americans TABLE 62 Age- and Sex-Adjusted Mortality Rates By Race-Ethnicity, Los Angeles County, 1980 ____________Age- and sex-adjusted* mortality rates per 100.000 population_______ Los Angeles _____Asian and Pacific Islanders_________ Cause of Death County White Black Hispanict Japanese Chinese Filipino Korean All causes 819.9 870.2 1038.3 814.8 Major cardiovascular diseases 409.4 429.5 472.0 390.6 Diseases of heart 313.4 331.2 353.4 307.8 Total IHD 194.0 207.7 192.5 177.7 MI and other acute IHD 90.9 97.9 88.3 82.3 Chronic IHD 103.1 109.8 104.3 95.4 Hypertensive disease 21.0 19.5 47.4 Cerebrovascular diseases 74.3 75.8 94.2 63.5 79.6 48.7 19.7 48.3 482.5 362.8 137.2 421.8 255.3 157.0 84.2 143.8 161.7 99.2 57.8 82.1 106.9 47.4 31.4 63.9 55.4 28.1 18.8 13.1 51.4 19.3 12.6 50.9 •Direct method of adjustment with Los Angeles County population, 1980, as standard. tCensus tracts in which 75 percent or more of the population are persons of Spanish/Hispanic origin or descent. From: "Cardiovascular Diseases in Los Angeles," Chapman, J. M. et al. Los Angeles, CA. American Heart Association, Greater Los Angeles Affiliate, Inc., 1983 174 Asian Americans TABLE 63 Annual Mortality Rate From Diseases of the Heart, By Sex, Among Asian And Pacific Islander Groups, Los Angeles County, 1980 *«• Boats* »er 100, ,000 poyalatloa Sax Chlaoao Filipino loroaa Halo <3S 9.3 3.* 10. » 0.0 35-M 27.3 0.0 13-• IT.5 «-$« 103.-* 10.0 T5.2 35.« 55-M 329.T 111.9 212.0 23*.0 15-T* 119.5 151.2 255.3 120.1 2T5 30««.-l 13H.2 171.2 1192.5 Total i sal* 115.1 II.0 11.» ST.9 roaalo <35 I.I 0.0 1.3 0.0 35-M t«.l 11.1 0.0 0.0 «5-5« 30.1 0.0 M.2 0.0 55-l« 123.1 iso.t 21.3 I1.T 15-T* 3M.5 213.7 200.0 2M.9 2T5 23TS.I 1119.1 «9».2 1021.3 Total foaala M7.0 ST.9 25.1 25.3 Totals aa« t - aalo •aalo 151.2 12.9 •2.1 11. 3 From: "Cardiovascular Diseases in Los Angeles", Chapman, J.M. et al. Los Angeles, CA. American Heart Association, Greater Los Angeles Affiliate, Inc., 1983 175 Asian Americans TABLE 64 Annual Mortality Rate From Total Ischemic Heart Disease, By Sex, Among Asian and Pacific Islander Groups, Los Angeles County, 1980 Booths per 100, ,000 population tos Ago Chlooao Filipino Koroaa Nolo <35 0.0 0.0 0.0 0.0 35-M 2T.3 0.0 0.0 17.5 • 5-5* 25.1 0.0 50.1 0.0 55-14 157.7 •9.2 127.2 151.0 15-71 3M.1 372.1 127.1 140.3 275 2001.3 170.1 375.7 1492.5 Total aalo 91.1 31.2 29.7 24.1 Foaalo <35 3.4 0.0 0.0 0.0 35-M 0.0 11.1 0.0 0.0 • 5-5* 0.0 0.0 44.2 0.0 55-1* 14.1 30.1 0.0 0.0 I5-T« 299.0 131.9 120.0 113.3 275 1772.2 517.7 329.5 1021.3 Total roaalo 91.1 23.1 13.5 19.0 Totals - aalo 91.7 30.9 21.2 21.4 bbS foaale From: "Cardiovascular Diseases in Los Angeles", Chapman, J.M. et al. Los Angeles, CA. American Heart Association, Greater Los Angeles Affiliate, Inc., 1983 176 Asian Americans TABLE 65 Prevalence of Stroke in Examined Cohorts As Determined By Neurologists _____Japana Hawaiib California0 Significant Age group N Rate/1,000 N Rate/1,000 N Rate/1,000 leveld Definite cases only 45-49 0 __ 0 „ 2 2.7 50-54 5 20.3 14 4.9 4 7.6 55-59 16 41.3 12 6.2 2 7.4 60-64 19 49.5 25 19.2 3 18.1 65-69 28 72.4 29 34.2 3 19.4 Total 68 46.6 80 10.7 14 7.6 Age-adjus ted 35.4 10.7 10.4 ratee NS <0.02 <0.001 <0.01 <0.01 Definite and possible cases 45-49 0 __ 1 2.0 4 5.5 50-54 7 28.5 21 7.3 5 9.6 55-59 17 43.9 18 9.3 3 11.0 60-64 23 59.9 31 23.8 3 18.1 65-69 33 85.3 41 48.4 4 25.8 Total 80 54.9 112 15.0 19 10.3 Age-adjus ted 42.5 15.0 13.0 ratee NS <0.01 <0.001 <0.01 <0.01 aIn Japan, 85% of definite and possible stroke cases were seen by the neurologist. Remaining cases diagnosed by neurologist from review of clinic records and occasionally from hospital records. bIn Hawaii, 62% of definite and possible stroke cases were seen by the neurologist. Remaining cases diagnosed by neurologist from review of clinic and hospitalization records. The latter were usually available. cIn California, 74% of definite and possible stroke cases were seen by the neurologist. Remaining cases were classified as definite stroke or no stroke on the basis of the screening test results. dChi square test with two degrees of freedom. eAge-adjusted by direct method to age structure of Hawaii cohort. From: "Epidemiologic studies of coronary heart disease and stroke in Japanese men living in Japan, Hawaii, and California: Prevalence of stroke," Kagan, A. et al. In: Cerebrovascular Diseases, Ed. P. Scheinberg, Raven Press, New York, 1976 177 Asian Americans TABLE 66 Average Annual Incidence of Definite and Possible Stroke Per 1,000 By Age i Japan 1972- 78 Hawa ii 1965- -73 Age No. of subjects No. of cases Ratet No. of subjects No. of cases Rate Test** 45-49 54 0 0.0 1825 11 1.0 NS 50-54 239 7 7.3 2766 39 2.3 ** 55-59 367 11 7.5 1569 21 2.2 *** 60-64 357 17 11.9 1306 37 4.7 *** 65-69 349 27 19.3 429 18 7.0 *** Total 1366 62 11.3 7895 126 2.7 Age adj rate' us tt ted 7.4 2.7 *** tAnnual incidence rate is calculated as follows: Japan: (No. of cases/No. of subjects) 4 (Years follow-up). Hawaii: (No. of cases/No. of subjects) 6/Years follow-up). t^X^ test of two rates between two cohorts. NS: £ > 0.10. *: £ < 0.05. **: £ < 0.01. ***: £ < 0.001. ^'Calculated by the indirect method with Hawaii as standard. From: "Epidemiologic studies of coronary heart disease and stroke in Japanese men living in Japan, Hawaii, and California: Incidence of stroke in Japan and Hawaii," Takeya, Y. and Popper, J.S. Stroke 15:15-23, 1984 178 Asian Americans TABLE 67 Number of Stroke Cases By Subtype and Certainty of Diagnosis -- Japan and Hawaii Japan Hawaii Subtype Total Defi-nite PM-Sibie Total De*. nite Pbs. sibie TgraJ 62 J8 24 126 71 55 ICH 18 12 6 34 2* 8 T-E 44 26 II 74 42 32 Unknown 0 0 0 18 3 15 From: "Epidemiologic studies of coronary heart disease and stroke in Japanese men living in Japan, Hawaii, and California: Incidence of stroke in Japan and Hawaii", Takeya, Y. and Popper, J.S. Stroke 15:15-23, 1984 179 TABLE 68 Average Annual Stroke Incidence Per 1,000 By Age and Subtype -- Definite Cases Only ________Total___________ Intracranial hemorrhage Thromboembolic stroke Japan Hawaii Japan Hawaii Japan Hawaii No. of No. of No. of No. of No. of No. of Age cases Rate cases Rate cases Rate cases Rate cases Rate cases Rate 45-49 0 0.0 6 0.55 0 0.0 2 0.18 0 0.0 3 0.27 50-54 6 6.3 22 1.3 4 4.2 10 0.60 2 2.1 11 0.66 55-59 7 4.8 13 1.4 2 1.4 3 0.32 5 3.4 10 1.1 60-64 11 7.7 21 2.7 2 1.4 9 1.1 9 6.3 12 1.5 65-69 14 10.0 9 3.5 4 2.9 2 0.77 10 7.2 6 2.3 Total 38 7.0 71 1.5 12 2.2 26 0.55 26 4.8 42 0.89 Age ad- justed rate 4.7 1.5 1.7 0.55 3.0 0.89 From: "Epidemiologic studies of coronary heart disease and stroke in Japanese men living in Japan, Hawaii, and California: Incidence of stroke in Japan and Hawaii," Takeya, Y. and Popper, J.S. Stroke 15:15-23,1984 180 Asian Americans TABLE 69 Mean Serum Cholesterol Levels At Baseline (1967-1970) For Japanese Men in Japan, Hawaii, and California (from reference 15, Table 3; mg°/0)* AGE JAPAN HAWAII CALIFORNIP 45-49 179.8 £19.4 ££3.4 50-54 182.5 £19.4 ££S. £ 55-53 181.5 £18.7 ££6. 8 60-64 182. £ £16/7 ££3. 6 65-69 180.9 £11. 1 ££4.0 A footnote to the source table notes that the values from Japan were taken from the 1967 cycle, and that diabetes was excluded from this analysis -- therefore other published values may differ slightly From: Epidemiologic studies of coronary heart disease and stroke in Japanese men living in Japan, Hawaii, and California: Distrib- ution of biochemical risk factors", Nichaman, M.Z. et al. American Journal of Epidemiology 102:491-501, 1975 181 Asian Americans TABLE 70 Case-Fatality Rates in Japanese Men 1967 - 70 1971 - 74 1975 - 78 56 - 59 yrs 37.0% 39.0% 36.0% 60 - 63 yrs 36.0% 42.0% 33.0% 64 - 67 yrs 46.0% 45.0% 45.0% From: "Trends in coronary heart disease among men of Japanese ancestry in Hawaii", Reed, D. et al. Journal of Community Health 8-149- 159, 1983 182 Asian Americans TABLE 71 Cigarette Smoking Variables Among Chinese-American Men and Women In the California Hypertension Survey, 1979 (from reference 27, table 7.5; comparison data for whites) Men Men Women Women 18-49 50+ 18-49 50+ %current regular 26.6 35.2 3.6 9.7 smokers [ 34.6 30.5 36.5 25.9 ] %current or 42.0 69.8 7.7 19.2 former smokers [ 58.0 72.6 52.2 48.7 ] average cigarettes 12.5 16.4 12.0 17.1 per day among [ 26.5 28.3 23.4 23.2 ] current smokers %of current smokers 54.3 59.0 48.0 66.5 who would like to quit [ 71.0 59.0 63.8 60.8 ] From: "ischemic heart disease risk factors in Asian Americans" Kumanyika, S.K. and Savage, D.D. Paper commissioned by the Task Force on Black and Minority Health, 1984-1985 183 Asian Americans TABLE 7 2 Cigarette Smoking Variables Among F ilipino-Amer ican Men and Women In the California Hypertension Survey, 1979 (from reference 27, table 7.5; comparison data for whites) Xcurrent regular smo-current or former smokers •aver-ag* cigarettes per day among current smokers *of current smoners Mho mouIo like to Quit L 71.0 Ken Men Women Women 18-49 50* 18-49 50+ 30.7 £1.2 12.4 16. 1 c 34. 6 30.5 36.5 £5.9 3 58.3 67. £ 32.9 £5.9 r 58.0 7£.6 52.2 48.7 3 18. £ 17. £ 15.0 1. 1 c £6.5 £8.3 £3.4 £3. £ 3 75.6 90. 8« 67.6* 13. £• c 71.0 59.0 63.8 60.8 3 Based on fewer than 20 cases From: "ischemic heart disease risk factors in Asian Americans" Kumanyika, S.K. and Savage, D.D. Paper commissioned by the Task Force on Black and Minority Health, 1984-1985 184 TABLES NATIVE AMERICANS Tables 80-83 185 Native Americans TABLE 80 Leading Causes of Death Among the U.S., All Races, 1979, and Comparable Data For Indians and Alaska Natives, 1978-1980 Percent Distribution leading Causes U.S. ALt Races U.S. Ind1 dns and ALL Races Alask a Nat 1 ves 38.3 20.8 21.1 10.1 8.9 4.8 5.5 19.5 2.6 0.9 2.4 3.8 1.7 2.9 1-6 6*0 1.5 0.7 1.4 2*6 15.1 28*0« diseases of the heart malignant neoplasms Cerebrovascular diseases ^e cIdents C0Pt> pneumonia and Influenza plabetes sellltus Chronic Liver disease and e 1 r rhos1 s •• At heros clerosls Suicide Alt other ALL CAUSES 100.0 100.0 " Chronic obstructive pulmonary disease and allied conditions ** Cirrhosis of the liver, 1978 ff Among Indians and Alaska Natives, "all other" includes 3.3% homicide, 2.6% suicide, and 2.7% deaths attributed to "certain causes of mor- tality in early infancy (1978)" From: Ischemic heart disease risk factors among American Indians and Alaska Natives", Kumanyika, S.K. and Savage, D.D. Paper commis- sioned by the Task Force on Black and Minority Health, 1984-85 186 Native Americans TABLE 81 Comparison of Mortality Rates For Indians and Alaska Natives With Those of the General Population and Other U.S. Non-White Populations In Two Time Periods For Selected Causes CAUSE OF DEATH RAT I 0 TO RATIO TO U.S. CLASSIFICATION RATE U< ,S. ALL RACES OTHER NON-WHITES Inf ant 1955 62.1* 2.4 1.5 Mortality 1979 1«.6« 1.1 0.T Tuber- 1955 57.9« 6.9 2.4 c ulos Is 1980 3.-SB 6.0 1.5 Gastro- Intest1naI 1955 15.4 .. 4.3 2.3 disease 1980 4.3«« 1.3 1.3 Ace Idents 1955 184.0«« 3.3 2.6 1980 107.3*' 2.5 2.1 Alcohol's* 196* 1980 56.6! 41.3! 7.4 5.5 not given " Deaths per 1,000 live births; from reference 2, table 3.3 if Age-adjusted deaths per 100,000 population; from ref 2, table 4.11 .tji. tt tt tt n tt tt tt tt tt tt it tt tt it tt tt tt tt table 4 13 ,,,, tt tt tt tt tt tt tt tt it tt tt it tt tt tt tt it tt table 4 7 . it it tt it n it tt n it a tt it ti ii n n it n table 4 10 From: "Ischemic heart disease risk factors among American Indians and Alaska Natives", Kumanyika, S.K. and Savage, D.D. Paper commis- sioned by the Task Force on Black and Minority Health, 1984-85 187 TABLE 82 Mortality, U.S., 1979-1981: Excess Deaths From Heart Disease Native Americans 390 to 398 402 404 to 429/Heart Disease Race - White Male Female Rate/ Rate/ Age Deaths 100.000 Ex Dth Cumul ZEx Dth ZCumul Deaths 100,000 Ex Dth Cumul ZEx Dth ZCumul Under 1 303 21.71 0. 0. * * 219 16.54 0. 0. * * 1-4 Ul 2.19 0. 0. * * 103 2.14 0. 0. * * 5-9 55 0.82 0. 0. * * 53 0.83 0. 0. * * 10-14 77 1.03 0. 0. * * 54 0.77 0. 0. * * 15-19 188 2.17 0. 0. * * 111 1.34 0. 0. * * 20-24 317 3.65 0. 0. * * 176 2.05 0. 0. * * 25-29 498 6.22 0. 0. * * 240 3.01 0. 0. * * 30-34 1021 13.99 0. 0. * * 400 5.45 0. 0. * * 35-39 2258 38.72 0. 0. * * 652 10.99 0. 0. * * 40-44 4615 95.16 0. 0. * * 1225 24.62 0. 0. * * 45-49 9218 198.73 0. 0. * * 2385 49.49 0. 0. * * 50-54 17395 353.70 0. 0. * * 4958 94.63 0. 0. * * 55-59 28276 582.67 0. 0. * * 9444 175.38 0. 0. * * 60-64 38527 923.22 0. 0. * * 15993 333.01 0. 0. * * 65-69 49198 1413.08 0. 0. * i» 25260 583.28 0. 0. * * 70-74 55227 2163.78 0. 0. * * 37014 1044.69 0. 0. * * 75-79 53635 3249.85 0. 0. * * 49236 1851.04 0. 0. * * 80-84 46245 5008.62 0. 0. * * 59807 3394.17 0. 0. * * 85-Plus 54353 8846.47 0. 0. * * 105794 7395.32 0. 0. * * All Ages 361516 394.30 0. 0. * * Race ■ 313124 Black 323.86 0. 0. * * Male Female Rate/ Rate/ Age Deaths 100,000 Ex Dth Cumul ZEx Dth ZCumul Deaths 100,000 Ex Dth Cumul ZEx Dth ZCumul Under 1 Ul 41.44 53. 53. 1.59 1.59 99 37.64 56. 56. 1.95 1.95 1-4 40 5.10 28. 81. 7.05 2.17 40 4.20 19. 75. 5.96 2.36 5-9 12 0.96 2. 82. 0.95 2.11 16 1.27 5. 81. 5.32 2.45 10-14 23 1.71 9. 91. 10.06 2.30 22 1.68 12. 93. 17.30 2.76 15-19 71 4.75 38. 130. * 3.26 47 3.14 27. 120. * 3.56 20-24 127 9.79 80. 210. 7.48 4.15 81 5.71 52. 172. 12.00 4.53 25-29 216 19.92 149. 358. 7.30 5.06 140 11.29 102. 274. 12.57 5.95 30-34 357 40.99 235. 593. 9.72 6.24 202 19.88 147. 421. 14.89 7.53 35-39 607 91.59 350. 944. 14.31 7.90 319 40.11 232. 653. 20.12 9.67 40-44 1041 183.75 502. 1446. 18.09 9.82 570 83.27 401. 1054. 27.43 12.84 45-49 1717 333.15 693. 2138. 20.33 11.79 951 151.57 641. 1695. 32.14 16.62 50-54 2706 536.41 922. 3060. 21.30 13.62 1577 252.56 986. 2681. 36.44 20.77 55-59 3866 828.71 1148. 4208. 23.21 15.35 2326 407.87 1326. 4007. 39.29 24.61 60-64 4502 1169.11 947. 5155. 21.57 16.21 3206 660.03 1589. 5596. 43.78 28.10 65-69 5166 1557.31 478. 5633. 13.58 15.95 4236 951.40 1639. 7235. 44.17 30.63 70-74 5154 2199.75 84. 5717. 3.83 15.24 4882 1482.86 1443. 8677. 40.43 31.91 75-79 4540 2972.08 0. 5717. 0.00 15.02 5095 2171.52 752. 9429. 35.42 32.17 80-84 3345 4463.36 0. 5717. * 15.02 4304 3442.27 60. 9489. 7.80 31.54 85-Plus 3434 6482.78 0. 5717. * 15.02 5888 5557.13 0. 9489. * 31.54 A-ll Ages 37043 295.89 5717. — 15.02 * 34003 243.30 9489. — 31.54 * ♦Percent values are not given when the base of calculation (the excess deaths from all causes for a particular age, sex, and racial group) is equal to zero. From: Mortality Rates, Excess Deaths. National Center for Health Statistics' Death Certificate Data Tapes for 1979, 1980, and 1981. (Tables supplied by the DHHS Task Force on Black and Minority Health.) 188 > 00 00 £ Y ? Y ? ■^ ON Ui Ui Y ? Y ? W U N N Y ? Y ? U> LO K> to >— — H H Ul H a £ o ro NO LO ui o» LO *-nO U) *-Ln ro *■ O -J 00 ON 00 Ul O^ *> Ul ro 00 -J IsJ Ul as LO ro 00 -J 00 £ Oa. LO LO vO -J 00 00 «- ON I— NJ on ui ui vo ro ro i— *■ to i— O lo O i— *- *» u> oo on i— «- i— --j, OO SO o>oooooooooooooroH-ooi— ro t*aa\ONONONONONONONONONONONONON^*U*LOUJro ************»■»•**»*** ******************** I— U> 1— H- I— I— >—Oa~l-JN>Oa--l--nO»tO^ >— lsjtors>*-OvOWls-iN>Ln-Avo-«i*-'— ro ►- lo ui a- oo ro co ui K> o Ul 00 t- vo 9i M U U< On Ul I— ON NO lo ro o i—i ro ui ro •o ro ui -j o ro ui oooooooooooo>— oo^-ooo I (^ 00 00 -~l -J S Y ? Y ? 1) 0» X M > I-* *• vO -P- On Ul «- *■ LO LO ro ro H~ i— Ul 1— a Y ? Ul 1 ? Ul 1 ? Ul 1 V Y O 1 Y •A 4B- 9 CL o-. on Ul Ul *- «■ LO OJ ro ro *— ■"a-* Oj t-O ■— i— i— 00 Ul on ui ro on *- u» ro lo ui 00 oo LOi— UION00ONI— >— i-oLoao-Jroooi-'O O oo ro o o © O »o ui ro lo ro O ■■-, ro ro *» ui rororororoi-oi-orororo LOLOU>U)U>LOU>LOLOLO ui ro ro ro ro ro O >-• >— u> ro O a— Ul rororororororororoLOLo io ■— i—a ro ro u> lo OOOOOOOOOOOOOOOOOO-— 00 On NO Ul NO 00 LO Ul NO U> Ui ro ro ui ro W N H H roONONUiLoro--— ►- LO H- i-i Ul -J *- LO -J ro i— © ui lo vo on lo ro ui oo *-oooooooooooloi— h-n-H-oroi— I *-*-*-*-*-*-*-*-*-*«h-l— -OONUI*-LOLOH- o-n l— f~ ►- Ul LO i— LO LO LO LO LO LO 00 NO On LO 00 LO LO LO LO LO LO LO *- *- on no ui oo on ro r- *— On NO NO LO Ul > 00 I" m 70 O 00 Ci *> K> to ro NO t r"> M 9 Oa to to o o H- rr 3 9 O rt- H- IB 3 PO C IS IP Q. Native Americans TABLE 83 Percent Change In Age-Adjusted Mortality (Rate Per 100,000 Population) Between 1970 and 1975 For Indians and Alaska Natives And the U.S., All Races Cause of Death Disease of the Heart Cerebr ova scuta r Art er1osc leros 1s Hypertens \ on Diabetes Mellitus Horn 1c Ide Suicide Cirrhosis of the Liver Indians and Alaska Nat1ves -12.7 -20.9 -14.4 - 5.9 -12.2 ♦ 19.4 ♦ 45.3 ♦ 7.9 U.S. rat Alt Races -U.l 0.7 -17.8 0.7 -21.4 1.5 -34.5 0.8 -17.7 2.1 ♦ 15.4 2.5 ♦ 6.8 2.1 - 6.1 4.4 1975 ratio of rate for Indians and Alaska Natives to rate for U.S., all races From: "Ischemic heart disease risk factors among American Indians and Alaska Natives", Kumanyika, S.K. and Savage, D.D. Paper commis- sioned by the Task Force on Black and Minority Health, 1984-85 190 RECOMMENDATIONS MADE BY THE SUBCOMMITTEE ON CARDIOVASCULAR AND CEREBROVASCULAR DISEASES IN BLACK AND MINORITY HEALTH A. Research Issues 1) Research in Epidemiology and Etiology Minority ethnic American groups, whether of primarily Black, Hispanic, Asian, or Native American descent, share many health problems in common as well as displaying certain unique disease characteristics. These differentials may be unique to a certain age-group, or to gender, or to the geographic location of the minority group. The etiology and epidemiology of illness in such groups warrant careful investigation, not only in cases where a clear disease burden is evident but also for diseases in which a minority subgroup displays better health than the comparable majority population. CVD-specific research recommendations include: (a) Large-scale, population-based, prospective studies of coronary heart disease (CHD) - similar to the Framingham Studies - and/or community-based studies are needed for each of the minority populations. Of the many Hispanic subgroups, Puerto Ricans and Cubans particularly warrant such research. A key component of this research would be the validation in minorities of the major established and/or suspected biological risk factors for CHD that have been identified for the white American population. These risk factors include hypertension, obesity, hypercholesterolemia, inadequate physical activity, cigarette smoking, diabetes mellitus, apolipoprotein imbalance, and echocardiographic and ECG-LVH. Another key element of such research would be the surveillance of the offspring of indexed cases so as to provide crucial information on trends for risk and for disease as well as elucidating familial contribution to CHD incidence and process. Further studies on potential differences in sudden death rates between Blacks and whites, by age and gender, are needed. (b) The investigation of the impact of other diseases, such as influenza, on CHD mortality rates in minority groups is needed. (c) The effect of changes in the cardiovascular disease classification system on assessing trends in cause-specific mortality rates in minorities needs to be better documented. (d) Research on why excess deaths due to cardiovascular disease (CVD) in Native American men occur in the 35-39 age-group, but not in.older men, is needed. The association of CHD with age is less in Native Americans than in white Americans. 191 2) Research on Risk Factors There is a need to better understand risk status, risk profiles, and trends in risk patterns for the major health priority areas, for each minority group. In large part such research can be accomplished by well-designed, epidemiologic studies and/or by case-control studies, as mentioned in 1). Certain minority subsets have a more favorable health status for certain disease or have reduced all-cause mortality. For example, in every age-group, Chinese, Japanese, and Filipino American have lower all-cause mortality rates than do white, Black, and Native Americans. Not only risk factors but also environmental factors should be examined for their contribution to increased prevalence of diabetes, infectious diseases, coronary heart disease, cancer, and for the high prenatal mortality found during the past four decades in one or more of the four minorities that are the subject of this report. CVD-specific research recommendations include: (a) Biological risk factors for CHD, identified and/or suspected for whites, need to be validated and quantified for each minority. (b) Study of the determinants of nicotine and alcohol use behaviors, cessation, and cessation maintenance in minorities is needed. (c) Investigation of whether and to what extent high HDL-levels in Black men may confer benefit with regard to CHD outcomes is recommended. (d) A more complete risk profile analysis of the Black participants in the Hypertension Detection and Follow-Up Program, and the Multiple Risk Factor Intervention Trial should be undertaken. (e) Case-control studies in Hispanics are suggested to clarify the hypothesised relationships between amount of Indian admixture and "tolerance" for noninsulin-dependent diabetes mellitus and of percentage of Black admixture as a risk factor for hypertension. (f) Better assessment of the impact of hypertension on the morbidity/mortality gap in Blacks is needed. (g) Tribal variation in diabetes mellitus, a risk factor for CHD, among middle-aged and older Native Americans needs considerably more attention and research. (h) The value of 24-hour monitoring of blood pressure, the most sensitive known measure of hypertension, in predicting subsequent CHD risk in minority groups needs to be studied. 192 3) Research on Diagnosis and Treatment Research is needed to better understand the dynamics of medical care available to Black, Hispanic, Asian, and Native Americans. Appropriate diagnosis, treatment, and follow-up predispose for a favorable outcome. CVD-specific research recommendations include: (a) Investigation is needed on how specific patterns of risk factors in minorities influence treatment decisions such as whether or not to perform angioplasty or coronary bypass surgery. (b) Studies are needed of beliefs, awareness status, and pre-hospital behavior which might delay appropriate diagnosis and treatment for individuals with symptoms of CHD in minority communities. (c) Research is needed on whether the Rose Questionnaire diagnosis of angina pectoris as an indicator of CHD is less specific for Black women than for white. (d) Effective stress-reduction and behavior modification strategies for treatment of CHD and risk factors need to be developed and validated in minority populations. Successful techniques should be taught to the deliverers as well as to the receivers of health care. (e) Do Blacks receiving dialysis for hypertension-related end-stage renal disease (ESRD) have lower death rates, after adjustment for age, than whites do? If so, why? (f) Compliance/noncompliance to antihypertensive medication regimens needs to be studied. Why do Filipino women have poorer blood pressure control than Filipino men? This is in contrast to other ethnic minority groups in the United States in which women generally have better blood pressure control than men. (g) The long-term efficacy and safety of antihypertensive medications prescribed to minorities (particularly Blacks) need to be examined. Do the metabolic, hemodynamic and side effects of treatments and their impact on CHD differ among minorities and whites? 4) Research on Nutritional Factors Research on nutritional patterns, status, needs, and health consequences must specifically address and define differences between minority and majority populations. Profiles of physiological factors, cultural food patterns, and dietary behaviors and intake all need to be studied for each ethnic/racial group by gender, by age, and by socioeconomic status. In addition, nutrition's important role in effecting positive change in minority health status needs 193 elucidation. Such research would be additional to and distinct from that which investigates nutrition's role as a component of a particular socioeconomic condition. CVD-specific research recommendations include: (a) Research to determine the relationship of obesity in Black females during and after adolescence, to high-density lipoprotein and low-density lipoprotein serum levels is needed. Development of effective weight-control programs is recommended. (b) Investigation of the links between dietary potassium, sodium, calcium and, possibly, other dietary elements and hypertension in Blacks and other minorities is needed. (c) Detailed studies of total dietary cholesterol, of serum cholesterol and triglyceride fractions, as well as dietary risk reduction information, interventions, and behaviors, are recommended for Puerto Rican, Cuban, and other Hispanic populations. (d) The effect of diet on the development of diabetes mellitus in minority populations needs further study. In particular, the recent interest in the role of upper body adiposity as a risk factor for diabetes, itself a risk factor for CHD, should be pursued more extensively and tested in all Hispanic groups, as well as in Black, Asian, and Native Americans. 5) Research on Socioeconomic Status and Acculturation Sociocultural factors play in integral role in health status, in illness development, and in the treatment process. As new waves of minority immigrants settle in the United States, they bring with them the health/disease profile prevalent in their socioeconomic group from their country of origin. Their process of acculturation as new Americans most likely occurs at differing rates, depending on their past history and new allegiances, within their different minority subgroups. They may trade poor health habits for good, or vice versa. Many factors such as physiological, socioeconomic, behavioral, familial, and racial factors as well as cultural affiliations interact in this acculturation process. Multi-discipline research is needed to investigate this with the goal of maintaining good health habits and retarding the acquisition of unhealthy habits. CVD-specific research recommendations include: (a) Investigation of socioeconomic status (SES) as a risk factor for CHD, hypertension, stroke, and hypertension-related end-stage renal disease in all minority groups is needed. What is special about the status of Asian Americans that might confer some degree of protection with regard to CHD mortality on them, despite their having an apparently moderately high-risk profile? 194 (b) Further research on the associations of social mobility and social status with CHD risk factors in minorities is needed. (c) More developmental work is needed in Native Americans to produce a valid and reliable measure of acculturation and of sociocultural indices of shifts in beliefs, values, and behavior patterns which might increase CHD risk. (d) A research hypothesis worthy of investigation is that both low acculturation and high acculturation are associated with increased mortality risk in different Asian groups. Low acculturation may confer greater risk for overall mortality perhaps due to high rates of infectious diseases and high perinatal mortality. High acculturation may increase the mortality risk from diseases associated with more developed, westernized societies, such as coronary heart disease. 6) Research on Health Care Delivery Primary medical care research is needed to investigate: -how coordination of the "traditional" health care delivery process can optimize patient outcomes -determinants of physician behavior with regard to patient interaction, follow-up, and the adoption of innovations (particularly for prevention and early detection) -health care provider attributes such as physician's ethnicity or race which could affect health service utilization by minority people, whether negatively or positively -the intersection of folk (or "nontraditional") medicine with the "traditional" health care system -the extent to which and means by which the poor and the near-poor gain access to health facilities, and how they cope with any lack of accessibility -the involvement of the community in facilitating health care access and delivery to minority people. Multi-center, multi-disciplinary case-control studies are recommended for such research. CVD-specific research recommendations include: (a) The need to monitor CHD events that occur in the community, such as sudden death; hospital admissions and discharges of patients 195 diagnosed to have CHD; and emergency room visits for chest pains and related complaints. (b) The relative effectiveness of a model such as the Trilateral High Blood Pressure, Detection, and Control Project(a) (a collaborative project by voluntary organizations in the private and public sectors, which produced a manual for instructing community organizers and volunteers on techniques and planning for setting up community-wide, community-run, blood pressure control programs); and model programs such as the State of Georgia's Statewide Antihypertensive Drug Distribution System for Indigent Hypertensives(b) (whereby as many as 32,000 state residents with hypertension, and eligible for free medical care or Medicaid, can receive low-cost antihypertensive medication) need to be evaluated in different minority communities. Successful models for community action to promote cardiovascular health should be provided to minority communities. 7) Research on Disease Prevention/Health Promotion There is an urgent need for rigorous prevention-oriented and policy-relevant research, including mental health research, commensurate with the levels of need and representation of minority populations within this country. For example, certain research shows there are serious and pervasive adjustment problems - economically, socioculturally and psychologically - affecting large segments of the Indochinese refugee population, especially the more recently arrived groups. Research to determine the components of effective disease prevention and health promotion activities targeted toward health education in minority families is needed. Methods which build on the strengths of these families and their communities, both urban and rural, especially social support characteristics should be used. CVD-specific research recommendations include: (a) Determination of effective strategies for cardiovascular health education among specific minority groups and how to facilitate the adoption of specific interventions for cardiovascular risk factors, especially among high-risk subgroups. The models of the National High Blood Pressure Education Program can be adopted and modified for other risk factors for a variety of communities. Educational and therapuetic interventions successfully developed for relatively homogeneous groups in a variety of studies should be modified for use with high-risk minority groups. Care must be taken to consider the different cultural values and attitudes towards CHD and risk factors for CHD, such as obesity, chest pain, and particular health behaviors. (a) The American Red Cross, Publications, 17 and D St NW, Washington, DC (b) Georgia Dept Human Resources, 878 Peachtree St.NE, Atlanta, GA 30309 196 8) Research on Health Policy Research is needed on the effects of subtle changes in Federal policy on the appropriateness of health care received by minority populations. For example, research is required to understand the impact of the following on provider-patient interactions and on care received: -small changes in reimbursement may lead to reduction in certain services that impact disproportionately in minority populations, or upon high-risk subsets -policy changes in direct service programs, such as the Indian Health Service, Community Health Centers, Migrant Health Centers, may lead to changes in the management, organization, and delivery of services which then affect continuity and coordination of the care offered -changes in manpower development policies may affect the availability of health care personnel to minority communities. B. Information and Education 1) Minority health information dissemination should be continued, but with special emphasis on the health needs of each minority group, by age and gender, and with attention given to the most effective approach for that minority subgroup. 2) Studies that assess the need for minority patient education in specific settings, e.g. the hospital emergency room or outpatient clinic, the church, or through home-visits by trained counselors are needed and consequent, appropriate interventions need to be designed and used. 3) The publication and updating of a list of DHHS health promotion and disease prevention materials, including patient education materials, especially directed toward specific minority groups, would be of value to practicing physicians and other health care providers. 4) Targeted health education programs should be developed for specific minorities with consideration given to techniques which will lead to community-wide activation rather than to activation of the individual. 5) Techniques are needed that will encourage earlier diagnosis, full use of all diagnostic procedures, and earlier treatment interventions so that Blacks and other minorities enter the delivery system well before an advanced disease state has developed. 197 6) There is enough general, if not specific, evidence to justify a recommendation for health promotion interventions directed toward minority groups that would reinforce a diet to lower blood cholesterol, to reduce or eliminate cigarette use, to moderate and to maintain normal body weight and blood pressure. 7) Cardiovascular risk factor educational materials that will facilitate information exchange between the primary care professional and the patient should be developed. 8) Targeted smoking prevention programs for minorities are needed. 9) Continued efforts at education, prevention, treatment and control of the hypertension-related diseases, e.g. stroke and end-stage renal disease, especially in Blacks, are needed. C. Access & Utilization 1) In addition to genetic, environmental, and behavioral factors, appropriate medical care is a major determinant of morbidity and mortality due to cardiovascular disease. Under optimal medical care conditions, for example, a patient with essential hypertension can achieve blood pressure control and reduce the risk of cardiovascular sequelae. However, with variations in physician behavior and patient care-seeking behavior, optimal medical care circumstances are difficult to achieve for large population groups, and are equally if not more difficult to achieve for most minority populations. Simultaneous attention to all the elements of interaction is necessary. 2) Continue to foster adequate access to care for minorities, with special attention given to unique medical care usage patterns and any financial barriers. 3) Studies of beliefs, awareness, and pre-hospital behavior, which might delay appropriate diagnosis and treatment for individuals with symptoms of coronary heart disease in the minority communities, are needed. 4) Though there is increasing awareness, interest, and sophistication among physicians concerning many aspects of blood pressure (BP) control, programs that attempt to enhance physicians' ability to ensure optimal follow-up of hypertensive patients and to monitor the state of BP control continue to be needed. 198 5) Continued efforts at prevention, treatment, and control of the hypertension-related diseases, e.g. stroke and end-stage renal disease are needed, especially in the Black population. D. Capacity Building in Non-Federal Sector 1) The detailing of Federal workers to minority institutions for short-term assignment is recommended. 2) The opportunity for minority non-Federal workers to come to Federal facilities for training & experience should be increased. 3) The establishment in the Federal sector of improved liaison and information dissemination programs designed not only to respond to requests from non-Federal minority groups but also to actively involve volunteers from those groups as part of an intentional network-making effort. E. Financing 1) Careful and serious consideration should be given to ways in which health care deliverers could be reimbursed for providing care in preventing disease in minorities. F. Health Professions' Development 1) The detailing of Federal workers to minority institutions for short-term assignment is recommended. 2) The opportunity for minority non-Federal workers to come to Federal facilities for training & experience should be increased. 3) Development of innovative mechanisms to attract minorities into the health care field & into health research needs to be undertaken with direct and continuing input from leaders in the minority health professions. 4) Special efforts need be made to continue to aid minority researchers and those in minority research settings to be competitive in seeking research funding. 199 5) The recommendations of this Task Force need to be presented to numerous specific health professional organizations & health professional schools. G. Leadership 1) DHHS should serve as a catalyst bringing together, on a continuing basis, concerned groups focused on specific issues, such as cholesterol, cigarette smoking, and worksite health with specific attention given to minority issues. The National High Blood Pressure Education Program could serve as a model for this activity. 2) The formation of subcommittees to major task forces or standing committees within DHHS should be considered and given the charge of maintaining awareness of minority health issues and of facilitating the implementation and monitoring of initiatives resulting from this Task Force report. In addition, DHHS should take advantage of minority health professionals, administrators, and other staff who might aid in carrying out and monitoring initiatives emanating from the Task Force report. 3) The Federal government should serve as a model of minority workplace health policies, for example, by offering preventive health services and by networking these policies with the health care provider industry. H. Data Issues 1) Substantial oversampling in the major national NCHS surveys of minorities, Blacks and Hispanics in particular, is recommended. Because such an approach for Asian subgroups and Native Americans is not feasible, other directed approaches, such as cohort studies should be considered. 2) Methods of tracking major health problems, particularly nonfatal as well as fatal ones, in minority groups are needed. The primary goal of such studies would be to obtain feedback as rapidly as possible. This would enable early recognition and treatment of adverse trends in health status. 3) The timely completion of the Hispanic HANES and the dissemination of the results is recommended to provide more reliable and valid estimates of cardiovascular disease morbidity in a large and representative sample of Mexican Americans, Puerto Ricans, and 200 Cubans. Information on the other Hispanic Americans would also be useful even though their numbers are comparatively smaller and they are widely dispersed throughout the United States. 4) Longitudinal follow-up of NHANES is recommended as well as a reduction of the examination interval from 4 to 2 years is recommended. 5) Increased analytical activities for data already collected by DHHS is recommended. These analyses should not be done to the detriment of continued collection of data. 6) Existing NCHS data bases should be examined to separate grouped data into specific minorities where feasible, namely Blacks (not Hispanics), Whites (not Hispanics), Hispanics, Puerto Rican Americans, Cuban Americans, Mexican Americans, Asian/Pacific Islander Americans, Japanese Americans, Chinese Americans, Korean Americans, Filipino Americans and Native Americans. In addition, where feasible, a breakdown of these data by urban vs. rural residency, geographic location, socioeconomic status, age, and gender is recommended. 7) Health statistics need to be developed on growing subgroups of other Asians such as Polynesians, Cambodians, Vietnamese, and East Indians. These groups constitute distinct cultural entities, and many of these populations are likely to be at disproportionate risk for a variety of illnesses due to their refugee status, endemic poverty, and/or other sociocultural factors. 8) Consideration of economic and cultural factors such as nativity, geographic area of residency, level of acculturation, and socio-economic status and mobility should be considered in analyses of data from minorities. 9) Techniques to improve collection of census data for minorities need to be developed. 10) Approaches for improving death certificate diagnosis and reporting procedures for Blacks and, presumably, other minorities need to be developed. 11) The geographic locations in which Black cohort studies of CHD incidence are performed need to be expanded. 12) Success in reducing the prevalence of substance abuse, violence, and vehicular accidents in Native American populations, which will increase life expectancy, can be expected to increase the prevalence and mortality risk from cardiovascular diseases and cancer in these groups. Therefore, it is important to monitor CHD mortality trends paying close attention to changes across tribes, regions, age and gender groups, and in Indians 201 age and gender groups, and in Indians living in rural living in rural locations vs. those who have migrated to urban centers. 13) Small group-specific cohort-controlled studies to determine more accurately the actual CHD mortality, morbidity, and risk factor status of Native Americans are recommended. Specific emphasis should be placed on monitoring these disease trends over time in the more high-risk subgroups in the major tribes. 202 REFERENCES Black Americans 1. Rice DP, Feldman JJ, White KL. The Current Burden of Illness in the United States. Institute of Medicine Occasional Paper, Number 3, October 27, 1976, Washington, DC. 2. Gillum RF. Coronary Heart Disease in Black Populations: I. Mortality and Morbidity. American Heart Journal 104(4)-.839-851, 1982. 3. 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