Published online before print June 10, 2004, doi: 10.1161/01.STR.0000130427.84114.50
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(Stroke. 2004;35:1557.)
© 2004 American Heart Association, Inc.
Original Contributions |
Racial and Ethnic Disparities in Cardiovascular Risk Factors Among Stroke Survivors
United States 1999 to 2001
From the Cardiovascular Health Branch, Division of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Ga.
Correspondence to Dr Henraya F. McGruder, Centers for Disease Control and Prevention, 4770 Buford Hwy NE, Mailstop K-47, Atlanta, GA 30341. E-mail hdd8{at}cdc.gov
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Abstract |
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Background and Purpose— Stroke mortality is higher among US blacks than it is among US whites. Few studies have examined racial and ethnic differences in the prevalence of cardiovascular disease (CVD) risk factors among stroke survivors, especially among Hispanics.
Methods— Data are from 96 501 persons aged18 years or older who participated in the 1999, 2000, or 2001 National Health Interview Survey, a continuous annual household-based survey of the US population. Participants reported a history of stroke, hypertension, diabetes, myocardial infarction, and coronary heart disease. Other CVD risk factors were current smoking, overweight/obese, inadequate physical activity, and binge drinking.
Results— Stroke was reported by 2.8% of blacks, 1.3% of Hispanics, and 2.2% of whites. Among 2265 stroke survivors, blacks were 1.65-times more likely (95% CI, 1.55 to 1.75) and Hispanics were 0.73-times less likely (95% CI, 0.69 to 0.78) than whites to report hypertension. Hispanics and blacks were more likely than whites to report diabetes (P<0.05). Hispanics and blacks were less likely than whites to report total coronary heart disease (P<0.05). Overweight was 1.63-times higher among blacks (95% CI, 1.55 to 1.73) and 1.36-times higher (95% CI, 1.30 to 1.44) among Hispanics than whites. Blacks were 1.82-times more likely (95% CI, 1.71 to 1.94) and Hispanics 2.09-times more likely (95% CI, 1.98 to 2.22) than whites to report inadequate levels of physical activity. Binge drinking and smoking were less common among Hispanics and Blacks than among whites (P<0.05).
Conclusions— Racial and ethnic disparities exist in stroke prevalence and CVD risk behaviors and medical history. Targeted secondary prevention will be important in reducing disparities among Hispanic and black stroke survivors.
Key Words: stroke • racial differences • risk factors • cardiovascular disease
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Introduction |
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Stroke is the third leading cause of death in the United States, ranking behind heart disease and all forms of cancer. Stroke is also a leading cause of serious, long-term disability in the nation. According to the American Heart Association, 700 000 strokes (500 000 initial and 200 000 recurrent) occur each year, an estimated 4.7 million Americans are currently living with stroke, and in 2003 the direct and indirect costs for stroke will be
$51.2 billion.1 There are racial disparities in stroke. For example, blacks have a higher prevalence of hospitalizations for stroke than whites.2 Stroke death rates are also higher for blacks than for whites.3 A small study of 430 patients hospitalized with ischemic stroke suggested a higher prevalence of risk factors for recurrent stroke among black or Hispanic patients than among white patients.4 Finally, preventing a recurrent stroke is an important strategy for reducing stroke-related death and disability.1,5 Despite this research, little is known about racial and ethnic disparities in the general population of stroke survivors, especially among Hispanics. To examine such differences in cardiovascular disease (CVD) risk behaviors and medical history among persons in the United States living with stroke, we analyzed data from the National Health Interview Survey (NHIS) for blacks, Hispanics, and whites.
See Editorial Comment, page 1568
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Subjects and Methods |
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The NHIS is a continuous, annual, household-based survey that has been conducted by the National Center for Health Statistics since 1957.6 The survey is designed to collect self-reported information from a representative sample of the civilian, noninstitutionalized US population. Our study population included persons aged 18 years and older. Data from the NHIS for 1999, 2000, and 2001 were combined to improve the power of the study; these years have similar survey designs and data collection methods. More detailed information on the NHIS survey is available elsewhere.6
In the NHIS, a respondent was identified as having had a stroke if he or she answered "yes" to the following question, "Have you ever been told by a doctor or other health professional that you had ... a stroke?" The presence of medical history for CVD risk factors among persons with stroke was assessed by similar questions for hypertension, diabetes, myocardial infarction, and coronary heart disease. Hypertension status was assessed by the question, "Were you told on 2 or more different visits that you had hypertension, also called high blood pressure?" We defined the presence of total coronary heart disease as an affirmative answer for myocardial infarction or coronary heart disease.
The other sociodemographic variables we included in our analysis were age (18 to 64 years, 
65 years), sex (male, female), education (less than high school, high school, more than high school), poverty level (below, equal to, or above, do not know/refused), family income in the past year (<$20 000; $20 000; refused/do not know), and employment within the past 12 months (employed, not employed). In the survey, race and Hispanic origin were determined by asking separate questions concerning race, ie, "What race do you consider yourself to be?" and "Which one of these groups would you say BEST represents your race?", and concerning Hispanic origin, ie, "Do you consider yourself Hispanic/Latino?" For our study we used 3 categories for ethnicity (black, non-Hispanic; Hispanic; and white, non-Hispanic). We excluded "Asian" and "Native Hawaiians and Other Pacific Islanders" because of small numbers (n=65).
The CVD behavioral risk factors we examined were current smoking, overweight, obesity, inadequate physical activity, and binge drinking. A current smoker was defined as a person who had ever smoked at least 100 cigarettes in their lifetime and currently smokes every day or some days. Self-reported height and weight were used to calculate body mass index. Persons with body mass index 25 kg/m2 were considered overweight, and persons with body mass index 30 kg/m2 were considered obese.7 American Heart Association guidelines for primary prevention recommend that adults should perform moderate exercise for 30 minutes at least 3 days per week, or vigorous exercise for 20 minutes at least 3 days per week.4,8 In our cohort, persons with stroke who did not perform this amount of exercise were considered to have inadequate physical activity. We excluded persons who reported they were unable to perform exercise (n=83) from analyses of physical activity data. Binge drinking during the past year was defined in the NHIS as having at 5 drinks of any alcoholic beverage on any 1 occasion.
We estimated the prevalence of stroke by age group among blacks, Hispanics, and whites and examined the distribution of sex and socioeconomic characteristics among persons living with stroke for these 3 groups. The prevalence of CVD risk factors was estimated for black, Hispanic, and white adults living with stroke. Comparing blacks and Hispanics with whites, we obtained odds ratios from separate multivariable logistic regression models that controlled for age and sex. All calculations were performed using SUDAAN survey software to account for the complex multistage sampling design of NHIS and to weight the data so that estimates are representative of the US population.6 Results were age-adjusted to the year 2000 US population standard.7 Statistical significance was determined as P<0.05.
The total sample who participated in 1 of the 1999, 2000, or 2001 NHISs was 96 501. There were 2330 (2.4%) respondents who reported that they had a stroke. After exclusions for other races, the survey participants included 2265 noninstitutionalized stroke survivors (697 in 1999, 749 in 2000, and 819 in 2001).
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Results |
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The prevalence of stroke was significantly higher among persons aged 65 years and older than among persons aged younger than 65 years in each ethnic group (Table 1). A significantly greater proportion of blacks than whites in our cohort were aged younger than 65 years (Table 1). No statistically significant differences between the ethnic groups were observed by sex and employment status. In all 3 groups, only 1 in 5 persons living with stroke had been employed in the previous 12 months. Compared with whites, blacks, and Hispanics with stroke were significantly more likely to have less than a high school education, live below the poverty level, and report an annual family income of <$20 000 (Table 1). The prevalence of stroke among blacks was significantly higher than among Hispanics or whites, regardless of age or gender (Table 2).
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The most common medical history among persons living with stroke was hypertension (Table 3). The unadjusted prevalence of hypertension ranged from 79.4% (95% CI, 74.5 to 84.4) among blacks to 62.4% (95% CI, 59.6 to 65.1) among whites; the difference was statistically significant between these 2 groups (P<0.05). Blacks (32.1%; 95% CI, 26.7 to 37.4) and Hispanics (38.0%; 95% CI, 30.6 to 45.4) were significantly more likely than whites (20.8%; 95% CI, 18.5 to 23.6) to have diabetes (P<0.05). No significant differences were observed for the unadjusted prevalence of myocardial infarction or total coronary heart disease.
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Among persons living with stroke, blacks (25.6%) were significantly more likely than Hispanics or whites to be current smokers (P<0.05) (Table 3). Overall, almost two thirds of persons living with stroke were overweight, which includes obesity. The unadjusted prevalence of overweight for blacks and Hispanics was higher than for whites, although these ethnic differences did not reach statistical significance. The unadjusted prevalence of obesity was significantly higher in blacks than in whites (P<0.05). Less than 5% of persons with stroke reported that they were unable to exercise. Blacks and Hispanics were significantly more likely to have inadequate physical activity than whites (P<0.05). Overall, the prevalence of binge drinking was 6.5%. Unadjusted estimates revealed binge drinking was significantly less common among Hispanics than among whites (P<0.05).
All results from logistic regression models, which compared characteristics among blacks and Hispanics with those of whites and which controlled for age and sex, were statistically significant (Table 4). Blacks were 65% more likely and Hispanics were 27% less likely than whites to have hypertension (P<0.05). Blacks (89%) and Hispanics (47%) were more likely to have diabetes (P<0.05) and less likely to have myocardial infarction (15% and 37%, respectively; P<0.05) and total coronary heart disease (13% and 39%, respectively; P<0.05) after adjustment for age and gender. Both blacks and Hispanics were more likely than whites to report CVD risk factors of overweight, obesity, and inadequate physical activity and less likely to report current smoking and binge drinking (P<0.05).
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Discussion |
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The Healthy People 2010 objectives include eliminating racial and ethnic disparities in health as 1 of its 2 overarching goals.8 Our study revealed racial and ethnic disparities in the prevalence of stroke and in the burden of risk factors for subsequent stroke among stroke survivors. These findings echo observed racial and ethnic disparities in stroke incidence9 and mortality.1,3 For example, among persons younger than age 65 years, blacks in the Greater Cincinnati region had 2- to 4-times greater incidence rates of first-ever stroke compared with rates among whites in Rochester.9 Additionally, the 2000 overall death rate for stroke for all Americans was 60.8 per 100 000 population, but the rates for black males and females were considerably higher at 87.1 and 78.1 per 100 000. These disparities in stroke mortality are even more pronounced in middle ages: in 1997 the relative risk for stroke mortality was 4-times as high as for blacks aged 35 to 54 than for non-Hispanic whites in this same age group.10
The current study showed blacks and Hispanics with greater medical history and stroke risk behaviors when compared with whites. This finding is in agreement with other studies examining the ethnic disparities in stroke risk factor profiles. Using data from the third National Health and Nutrition Examination Survey, Qureshi et al indicated that blacks with a history of myocardial infarction and stroke have a poor CVD risk factor profile, placing them at increased risk for secondary events.11 In that study, a poor CVD risk factor profile was defined by the presence of 2 of the following characteristics: poorly controlled or undiagnosed hypertension and hypercholesterolemia, poorly controlled diabetes, active smoking, and heavy alcohol use. These findings were not accounted for by differences in education level or medical insurance status among race and ethnicity, age and sex groups, but rather, according to the authors, attitudes toward risk factor modification were a determinant of inadequate prevention of secondary events. Patient attitudes were assessed by medication compliance and current smoking status. Mistrust of health providers might explain how patient attitudes toward risk modification can affect secondary prevention. Blacks (43%) were less likely than whites (80%) to report trusting their physicians.12 The authors noted that the legacy of racial discrimination against blacks in medical research and clinical settings (eg, the Tuskegee Syphilis Study) may play a major role in persistent mistrust within this racial group.
Another study by Hajat et al examined the cerebrovascular risk factor profile among different ethnic groups in the South London, UK population.13 Findings indicated that hypertension and diabetes were more prevalent among blacks when compared with whites. Additionally, blacks were less likely to have atrial fibrillation compared with whites. The findings also showed blacks were less likely to engage in excessive alcohol intake and to be current smokers compared with whites.13 Rosamond et al found that after adjusting for prevalent hypertension and diabetes among a population of blacks and whites, ischemic stroke incidence remained statistically significant among blacks.14 We observed similar findings with blacks, in addition to Hispanics, in the current study. These findings suggest that the cerebrovascular risk factor profiles are similar for blacks residing in the US and UK. However, special attention should be paid to the risk factor profile of Hispanic stroke population. These differences among Hispanics should be considered when secondary prevention measures are formulated.
Racial and ethnic differences have also been observed in stroke hospitalization.4,15 Sacco et al found hypertension was more prevalent among blacks and Hispanics hospitalized for stroke whereas cardiac disease (eg, myocardial infarction, angina, atrial fibrillation, congestive heart failure, or any cardiac disease) was more prevalent in whites.4 In the current study, a disparity was observed between blacks and Hispanics concerning the prevalence of hypertension. Similar findings were observed in that whites were more likely to have coronary heart disease in both studies. These findings highlight the importance to understanding the stroke epidemiology of all racial or ethnic groups, especially Hispanics, and understanding the varying disparities among stroke risk factors.
To our knowledge, this study is the first to use NHIS data to estimate the prevalence of stroke as well as ethnic disparities among CVD risk factors. This study also confirms the findings of other studies concerning the elevated prevalence of stroke risk factors among blacks and Hispanics. However, this study is also subject to several limitations. First, all responses to NHIS questions are self-reported and are not confirmed by a physician or health care provider. A sensitivity of 65.8% has been reported for a single screening question for stroke similar to the one used in the NHIS.16 That study found instances of both underreporting and overreporting of self-reported stroke compared with stroke determined from medical records or neurologic examination. Second, the NHIS does not provide information concerning the timing or type of stroke. Blacks are more likely than whites to have hemorrhagic strokes,17 and persons with hemorrhagic stroke may have a higher prevalence of risk factors (eg, hypertension, smoking, and heavy alcohol intake) than persons with other types of strokes.18 Questions pertaining to other risk behaviors important in secondary prevention of CVD events, including abnormal cholesterol and dietary habits, were not assessed in the NHIS. Finally, we found racial and ethnic disparities in comorbidities among stroke survivors. These findings may be influenced by the racial and ethnic differences in stroke incidence and survival.19
Public health efforts should continue to educate the public, especially blacks and Hispanics, concerning CVD risk factors and risk modification techniques to prevent incident and recurrent stroke. Certain CVD risk factors are uncontrollable (eg, increasing age, race, ethnicity, sex, and heredity) but individuals are able to change or treat most other risk factors (eg, hypertension, smoking, diabetes, and heart disease). Continued support of targeted strategies for high-risk racial and ethnic groups within communities is also needed. The Centers for Disease Control and Prevention’s Racial and Ethnic Approaches to Community Health project (REACH 2010) works with communities to eliminate disparities in 6 priority areas, including CVD.20 This 2-phase, 5-year initiative supports community coalitions in designing, implementing, and evaluating community-driven strategies to eliminate these disparities. "Take a Loved One to the Doctor Day" is a national campaign designed to motivate individuals to seek regular medical care.21 This program focuses on the populations that tend to have the least access to health care (eg, blacks and other racial and ethnic minority groups).
Renewed efforts for secondary prevention are particularly needed. Persons with CVD and stroke report an average of 7 visits with a health care professional within the past year,12 which suggests ample opportunities for delivery of messages about secondary prevention messages4 and a general lack of implementation of secondary prevention strategies.12 One recent program to establish effective use of secondary prevention procedures and guideline use in hospitals is the "Get with the Guidelines" program sponsored by the American Heart Association. This is a quality-improvement program designed to empower the health care team to consistently treat each patient with the most updated treatment guidelines.22 The program aims to capitalize on the "teachable moment" while the patient is hospitalized, when they are most likely to make lifestyle changes. The infrastructure also needs to be in place in hospitals and outpatient settings to ensure stroke patients get appropriate acute and follow-up care.23 The greatest risk reduction for subsequent morbidity and mortality is from treating and controlling co-morbid conditions among person with stroke.24,25
Stroke has a particularly disproportionate health effect on blacks and Hispanics. Focusing public health efforts on reinforcing the importance of controlling CVD risk factors can reduce this disparity. Reducing the burden of stroke throughout the United States will require: (1) primary prevention and control of risk factors; (2) public education about signs and symptoms of stroke, the need for emergency response (eg, calling 9-1-1), and the importance of immediate transport to a primary stroke center; (3) early and appropriate evaluation and treatment of persons with acute stroke; and (4) effective secondary prevention among persons living with stroke. By creating culturally appropriate public health messages and targeted intervention strategies among persons with stroke and their health care providers, CVD risk factors, morbidity, and mortality among high-risk racial and ethnic groups may be reduced. With all these efforts in place, the racial and ethnic disparities among stroke survivors may begin to diminish.
Received March 10, 2004; accepted March 22, 2004.
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- American Heart Association. Heart Disease and Stroke Statistics—2003 Update. Dallas, TX: Am Heart Association; 2002.
- Centers for Disease Control and Prevention. Public health and aging: hospitalizations for stroke among adults aged 65 years—United States, 2000. MMWR Morb Mortal Wkly Rep. 2003; 52: 586–589.[Medline]
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- Centers for Disease Control and Prevention. State-specific mortality from stroke and distribution of place of death—United States, 1999. MMWR Morb Mortal Wkly Rep. 2002; 5: 429–433.
- Sacco RL, Kargmann DE, Zamanillo MC. Race-ethnic differences in stroke risk factors among hospitalized patients with cerebral infarction: the Northern Manhattan Study. Neurology. 1995; 45: 659–663.
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- Klein RJ, Schoenborn, CA. Healthy People 2010 Statistical notes: age-adjustment using the 2000 projected U S population. Number 20; January 2001.
- US Department of Health and Human Services. Healthy People 2010. Washington, DC: US Department of Health and Human Services; 2000.
- Broderick J, Brott T, Kothari R, Miller R, Khoury J, Pancioli A, Gebel J, Mills D, Minneci L, Shukla R. The Greater Cincinnati/Northern Kentucky stroke study: preliminary first-ever and total incidence rates of stroke among blacks. Stroke. 1998; 29: 415–421.
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