Risk factors, atherosclerosis, and cardiovascular disease among Aboriginal people in Canada: the Study of Health Assessment and Risk Evaluation in Aboriginal Peoples (SHARE-AP)

doi:10.1016/S0140-6736(01)06255-9

The Lancet

Volume 358, Issue 9288, 6 October 2001, Pages 1147-1153

https://doi.org/10.1016/S0140-6736(01)06255-9 Get rights and content

Summary

Background

Little is known about the rates of cardiovascular disease (CVD), atherosclerosis, and their risk factors among Canada's Aboriginal people. To establish the relative prevalence of risk factors, atherosclerosis, and CVD, we undertook a population-based study among people of Aboriginal and European ancestry in Canada.

Methods

We randomly recruited 301 Aboriginal people from the Six Nations Reservation, and 326 people of European origin from Hamilton, Toronto, and Edmonton, Canada. Clinical CVD was defined by history or electrocardiographic findings, atherosclerosis was measured by B-mode carotid ultrasonography, and conventional and new CVD risk factors were measured using standardised methods.

Findings

Aboriginal people had significantly more carotid atherosclerosis (mean of the maximum intimal-medial thickness 0·82 (SD 0·20) mm vs 0·78 (0·20) mm, p=0·027), and had a higher frequency of CVD (18·5% vs 7·6%, p=0·00002) compared with Europeans. Aboriginal people had significantly higher rates of smoking, glucose intolerance, obesity, abdominal obesity, and substantially higher concentrations of fibrinogen, and plasminogen activator inhibitor-1. Aboriginal people had significantly higher rates of unemployment and a lower annual household income. For any given income level, Aboriginal people had higher rates of risk factors and CVD compared with the Europeans.

Interpretation

A significant proportion of Aboriginal people live in poverty which is associated with high rates of CVD and CVD risk factors. Improvement of the socioeconomic status of Aboriginal people might be a key to reduce CVD in this group.

Introduction

Although in the past 50 years the rates of deaths from acute infectious diseases has declined among Aboriginal people in Canada, their life expectancy remains much lower compared with others living in Canada.1, 2 Furthermore, although the prevalence of cardiovascular disease (CVD) has been declining in Canada, there are data to suggest that CVD rates are increasing among Aboriginal people.³ Therefore, establishing the prevalence of risk factors for atherosclerosis and CVD among Aboriginal people is important to address an impending epidemic of CVD in this group.

The Aboriginal people who participated in this study come from the Six Nations Reserve in Brant County, Ontario, Canada which is located 30 km from Hamilton, Ontario, Canada. The Six Nations Reserve took its present form of 20 000 hectares in 1847, and is home to 10 000 Aboriginal people. In a health survey by the Six Nations Health Committee in 1997, heart disease and diabetes were reported as the most frequent health disorders affecting people living on the reserve. The Study of Health Assessment and Risk Evaluation in Aboriginal Peoples (SHARE-AP) was designed to investigate the burden of atherosclerosis, CVD, and their determinants among the Six Nations people, and was a joint initiative between the Six Nations people and investigators from the neighboring McMaster University.

Section snippets

Methods

Study population

We randomly selected participants from a comprehensive list of Six Nations Band members. Their addresses and phone numbers were identified by searching local telephone directories. From this list, households were randomly selected and mailed an introductory letter, followed by up to 12 telephone calls inviting the individual with the earliest date of birth in the household to participate in the study. Individuals between 35 and 75 years who were Six Nations Band Members, who had

Results

Of 379 eligible Aboriginal people, 79% of individuals completed the health assessment between October, 1998, and May, 2000, at the Gane Yohs Community Health Centre located on the Six Nations Reserve. Of 450 eligible European-Canadian people, 326 (72%) completed the health assessment between April, 1997, and October, 1998, as previously described.¹⁴ The exact details of the recruitment of these two groups are provided in figure 1. Aboriginal people were more often deemed ineligible for

Discussion

We have shown that Aboriginal people in Canada have a higher frequency of CVD and have a greater burden of atherosclerosis compared with Canadians of European ancestry. The rates of conventional risk factors, including glucose abnormalities, abnormal lipids, hypertension, tobacco use, obesity, as well as some novel risk factors associated with the development of thrombosis, are also significantly increased among the Aboriginal people. Although these are likely to be the immediate determinants

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2022, CJC Open
Indigenous peoples in Canada are at an increased risk of cardiovascular disease compared to non-Indigenous people. Contributing factors include historical oppression, racism, healthcare biases, and disparities in terms of the social determinants of health. Access to and inequity in cardiovascular care for Indigenous peoples in Canada remain poorly studied and understood. A rapid review of the literature was performed using the PubMed/MEDLINE, Web of Science, and Indigenous Studies Portal (iPortal) databases to identify articles describing access to cardiovascular care for Indigenous peoples in Canada between 2002 and 2021. Included articles were presented narratively in the context of delays in seeking, reaching, or receiving care, or as disparities in cardiovascular outcomes, and were assessed for their successful engagement in indigenous health research using a preexisting framework. Current research suggests that gaps most prominently present as delays in receiving care and as poorer long-term outcomes. The literature is concentrated in Alberta, Manitoba, and Ontario, as well as among First Nations people, and is largely rooted in a biomedical worldview. Additional community-driven research is required to better elucidate the gaps in access to holistic cardiovascular care for Indigenous peoples in Canada. Healthcare professionals, researchers, and policymakers should reflect further upon their actions and privilege, educate themselves about historical facts and the Truth and Reconciliation Commission, tackle prevailing disparities and systemic barriers in the healthcare systems, and develop culturally safe and ethically appropriate healthcare interventions to improve the health of all Indigenous peoples in Canada.
Le risque de maladies cardiovasculaires est plus élevé chez les populations autochtones du Canada que chez les populations non autochtones. L’oppression historique, le racisme, les préjugés dans les soins de santé et les disparités quant aux déterminants sociaux de la santé sont des facteurs qui contribuent à ce phénomène. L’accès aux soins cardiovasculaires et l’équité des soins pour les personnes autochtones du Canada sont des questions peu étudiées et mal comprises. Une revue rapide de la littérature a été réalisée dans les bases de données PubMed/MEDLINE, Web of Science et Indigenous Studies Portal (iPortal) pour recenser les articles publiés entre 2002 et 2021 qui décrivent l’accès aux soins cardiovasculaires pour les peuples autochtones du Canada. Les articles retenus sont présentés de manière narrative et font état de retards dans la recherche de soins, dans l’atteinte d’un établissement de soins et dans l’obtention des soins, ou de certaines disparités quant aux résultats de santé cardiovasculaire. Ces articles ont également été évalués d’après leur intégration réussie des principes de recherche en santé autochtone à partir d’un cadre déjà établi. Selon les recherches actuelles, les écarts se manifestent principalement par des retards dans l’obtention des soins et par des résultats de santé plus défavorables à long terme. Les études publiées se concentrent surtout sur l’Alberta, le Manitoba et l’Ontario, portent principalement sur les Premières Nations et sont en grande partie abordées selon une perspective biomédicale. Des recherches plus approfondies, menées avec les communautés autochtones, sont nécessaires pour mieux comprendre les écarts dans l’accès à des soins cardiovasculaires holistiques pour les peuples autochtones du Canada. Les professionnels de la santé, les chercheurs et les décideurs politiques devraient entreprendre un processus de réflexion approfondie sur leurs actions et leurs privilèges, s’informer sur les réalités historiques ainsi que sur la Commission de vérité et réconciliation, s’attaquer aux disparités qui perdurent et aux barrières systémiques dans l’accès aux soins de santé, et mettre en place des interventions de soins culturellement sécuritaires et éthiquement adaptées, pour améliorer la santé de l’ensemble de la population autochtone du Canada.
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Primary and Secondary Cardiovascular Prevention Among First Nations Peoples With Type 2 Diabetes in Canada: Findings From the FORGE AHEAD Program
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Citation Excerpt :
This percentage is significantly higher than the ∼10% reported in the general population with T2DM from the DM-SCAN study.23 The proportion of smokers in the current study is also higher than the ∼40% documented in Indigenous communities in the Study of Health Assessment and Risk in Ethnic Groups and Aboriginal Peoples (SHARE-AP) and the CIRCLE study over a decade ago.10,22 The proportion of active smokers in FA communities was greater in FN men than women.
First Nations (FN) peoples in Canada face spiraling rates of type 2 diabetes mellitus (T2DM) and cardiovascular disease (CVD). Data on the extent of CVD risk-factor management in FN peoples with T2DM in Canada are scarce.
A T2DM registry with data from 7 FN communities in Canada was utilized to identify individuals eligible for primary and secondary CVD prevention. Proportions of individuals meeting clinical practice guideline–specified targets (hemoglobin A1c ≤7.0%; blood pressure ≤130/80 mm Hg; low-density lipoprotein ≤2 mmol/L) were calculated. Prescription of recommended cardioprotective medications (antithrombotic medication, lipid-lowering agents, renin-angiotensin-aldosterone system inhibitors, and beta-blockers) among those with CVD was assessed. χ² tests were employed to evaluate differences between CVD prevention groups and sexes.
Of the 2098 individuals in the registry, 18% had documented CVD (female: male = 1.12). Overall, <10% met all 3 clinical practice guideline targets. Attainment of hemoglobin A1c and blood pressure targets was comparable between primary and secondary CVD prevention groups, with<50% achieving targets. A greater proportion of the secondary prevention group met low-density lipoprotein targets compared to those without CVD (61.6% vs 40.9%, P < 0.01). In the secondary prevention group, beta-blockers were prescribed to only 20%, and <60% were prescribed antithrombotics, lipid-lowering medications, or agents targeting the renin-angiotensin-aldosterone system; <2% were prescribed medications from all 4 classes of cardioprotective medications.
Primary and secondary CVD prevention recommendations for individuals with T2DM are not being met for an alarmingly high proportion of FN peoples. These findings serve as an urgent call for proactive measures to reduce CVD events and related mortality in this high-risk population.
Au Canada, chez les membres des Premières Nations, le nombre de cas de diabète de type 2 (DT2) et de maladie cardiovasculaire (MCV) monte rapidement. On a peu de données sur l’importance de la prise en charge des facteurs de risque de MCV chez les membres des Premières Nations atteints de DT2 au Canada.
Un registre du DT2 comportant des données sur sept communautés canadiennes des Premières Nations a été utilisé pour repérer les personnes admissibles à la prévention primaire et secondaire de la MCV. Les proportions de personnes qui avaient atteint les cibles énoncées dans les lignes directrices de pratique clinique (HbA_1c ≤ 7,0 %; pression artérielle ≤ 130/80 mm Hg; lipoprotéines de basse densité ≤ 2 mmol/L) ont été calculées. La prescription des médicaments cardioprotecteurs recommandés (antithrombotiques, hypolipidémiants, inhibiteurs du système rénine-angiotensine-aldostérone et bêtabloquants) chez les patients présentant une MCV a été évaluée. Des tests du χ² ont été employés pour évaluer les différences entre les groupes de prévention de la MCV et les sexes.
Parmi les 2 098 personnes figurant au registre, 18 % présentaient une MCV documentée (rapport femmes:hommes = 1,12). Moins de 10 % de l’ensemble de ces personnes avaient atteint les trois cibles énoncées dans les lignes directrices de pratique clinique. Du point de vue de l’atteinte des cibles relatives à l’HbA_1c et à la pression artérielle, les groupes de prévention primaire et secondaire étaient comparables, moins de 50 % des personnes ayant atteint ces cibles. Une plus grande proportion des individus du groupe de prévention secondaire que de ceux exempts de MCV avait atteint la cible relative aux lipoprotéines de basse densité (61,6 % vs 40,9 %, p < 0,01). Dans le groupe de prévention secondaire, des bêtabloquants avaient été prescrits chez seulement 20 % des sujets et des antithrombotiques, des hypolipidémiants ou des médicaments ciblant le système rénine-angiotensine-aldostérone avaient été prescrits chez moins de 60 % des sujets; des médicaments des quatre classes de médicaments cardioprotecteurs avaient été prescrits chez moins de 2 % des individus.
Les recommandations en matière de prévention primaire et secondaire de la MCV chez les personnes atteintes de DT2 ne sont pas suivies dans une proportion alarmante des membres des Premières Nations. Les constatations faites montrent qu’on doit de toute urgence prendre des mesures proactives pour réduire le nombre de cas de MCV et la mortalité connexe dans cette population à risque élevé.
Cardiovascular Risk and Cardiovascular Health Behaviours in the Transition From Childhood to Adulthood
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The prevention and management of cardiovascular risk factors during the transition from childhood to adulthood is critically important in defining cardiovascular health trajectories. Unfortunately, many young people fall out of clinical care during this important time, leading to worsening cardiovascular risk and missed opportunities to modify future outcomes. The field of health care transition has evolved to support young people with complex health needs in developing self-management and self-advocacy skills to promote positive health outcomes despite changes in health care providers and resources. While transitional care efforts are largely focused on childhood-onset chronic illnesses such as sickle cell disease and cystic fibrosis, young people with cardiovascular risk factors such as hypertension, obesity, and dyslipidemia also stand to benefit from structured supports to ensure continuity in care and positive health behaviours. On the backdrop of the broader health care transition literature, we offer practical insights and suggestions for ensuring that young people with cardiovascular risk factors experience uninterrupted high-quality care and support as they enter the adult health care system. Starting transition preparation in early adolescence, actively engaging all key stakeholders throughout the process, and remaining mindful of the developmental underpinnings and social context of transition are keys to success.
La prévention et la prise en charge des facteurs de risque cardiovasculaire durant la transition de l’enfance à l’âge adulte jouent un rôle crucial dans la définition des trajectoires en santé cardiovasculaire. Beaucoup de jeunes cessent malheureusement d’être suivis durant cette période importante, ce qui entraîne une aggravation du risque cardiovasculaire et des occasions manquées d’améliorer les résultats futurs. Le domaine de la transition des soins de santé a évolué afin d’aider les jeunes ayant des besoins complexes en matière de santé à acquérir les compétences nécessaires pour être autonomes et s’autoreprésenter, et ce, dans le but de favoriser l’obtention de résultats de santé positifs malgré les changements de fournisseurs et de ressources de soins de santé. Les initiatives de transition des soins visent principalement les patients atteints de maladies chroniques apparaissant durant l’enfance, comme la drépanocytose et la fibrose kystique, mais les jeunes présentant des facteurs de risque cardiovasculaire comme l’hypertension, l’obésité et la dyslipidémie pourraient aussi tirer des bienfaits de programmes structurés pour les aider à continuer de recevoir les soins dont ils ont besoin et à adopter des comportements favorisant la santé. Fondées sur l’ensemble des publications traitant de la transition des soins de santé, les observations et les suggestions pratiques présentées visent à s’assurer que les jeunes présentant des facteurs de risque cardiovasculaire continuent de recevoir des soins de qualité supérieure et de l’aide lorsqu’ils passent au système de soins de santé pour adultes. La réussite de la transition repose sur trois éléments : la préparation à la transition dès le début de l’adolescence, la mobilisation active des intervenants clés tout au long du processus et le souci des fondements du développement et du contexte social de la transition.
Cesarean Delivery and Vaginal Birth After Cesarean Delivery Rates in a First Nations Community-Based Obstetrical Program in Northwestern Ontario
2020, Journal of Obstetrics and Gynaecology Canada
To examine rates of cesarean delivery (CD) and vaginal birth after cesarean delivery (VBAC) and the patient profile in a community-based obstetrical practice.
Retrospective data from 2012 to 2017 for the Sioux Lookout Meno Ya Win Health Centre (SLMHC) were compared to data from the 30 hospitals providing the same level of services (Maternity 1b: maternity care by family physicians/midwives with CD and VBAC capacity) and Ontario. SLMHC VBAC patients were then compared to the general SLMC obstetrical population. Data included maternal age, parity, comorbidities, CD, VBAC, neonatal birth weight, and Apgar scores.
The SLMHC obstetrical population differed from comparable obstetrical programs, with significantly higher rates of alcohol, tobacco, and opioid use and a higher prevalence of diabetes. CD rates were significantly lower (25% vs. 28%), and women delivering at SLMHC chose a trial of labour after CD almost twice as often (46% vs. 27%), resulting in a significantly higher VBAC rate (31% vs. 16%). Patients in the VBAC population differed from the general SLMHC obstetrical population, being older (7 years) and of greater parity. The neonates of VBAC patients had equivalent Apgar scores but lower rates of macrosomia and lower birth weights, although the average VBAC birth weight at 3346 g was equivalent to the provincial average.
The SLMHC obstetrical program has lower CD and higher VBAC rates than expected, despite prevalent risk factors typically associated with CD. Our study demonstrates that VBAC can be safely performed in well-screened and monitored patients in a rural setting with emergency CD capacity.
Examiner les taux de césarienne et d'accouchement vaginal après césarienne (AVAC) ainsi que le profil des patientes dans le cadre d'une pratique obstétricale communautaire.
Les auteurs ont comparé les données rétrospectives du Sioux Lookout Meno Ya Win Health Centre (SLMHC) de 2012 à 2017 aux données tirées de 30 hôpitaux qui offrent le même niveau de services (niveau 1b : soins de maternité prodigués par des médecins de famille et sages-femmes, dans un établissement où il est possible de réaliser des AVAC et césariennes) en Ontario. Les patientes ayant eu un AVAC au SLMHC ont ensuite été comparées à la population obstétricale générale du même établissement. Les données comprenaient l'âge maternel, la parité, les comorbidités, la césarienne, l'AVAC, le poids à la naissance et l'indice d'Apgar.
La population obstétricale du SLMHC différait des populations de programmes obstétricaux comparables; elle présentait des taux considérablement plus élevés de tabagisme et de consommation d'alcool et d'opioïdes, ainsi qu'une prévalence accrue de diabète et un taux de césarienne significativement inférieur (25 % c. 28 %). Les femmes ayant accouché au SLMHC ont choisi presque deux fois plus souvent de se soumettre à une épreuve de travail après la césarienne que les femmes des autres populations (46 % c. 27 %), ce qui a donné lieu à un taux d'AVAC considérablement supérieur (31 % c. 16 %). Les patientes de la population ayant eu un AVAC étaient plus âgées de 7 ans en moyenne et avaient donné naissance à un plus grand nombre d'enfants que les femmes de la population obstétricale générale du SLMHC. Les nouveau-nés des patientes ayant subi un AVAC avaient un indice d'Apgar égal à celui des autres populations, mais présentaient un taux inférieur de macrosomie et un plus petit poids à la naissance, même si le poids à la naissance moyen des bébés nés par AVAC, qui s'élevait à 3 346 g, équivalait à la moyenne provinciale.
Le programme obstétrical du SLMHC présente un taux de césarienne inférieur et un taux d'AVAC supérieur aux attentes, en dépit des facteurs de risque généralement associés à la césarienne. L'étude indique que l'AVAC peut être réalisé de manière sécuritaire chez des patientes dont l'état de santé a été bien évalué et qui demeurent sous surveillance, dans un établissement en milieu rural doté de la capacité de pratiquer des césariennes d'urgence.
Explaining the variability in cardiovascular risk factors among First Nations communities in Canada: a population-based study
2019, The Lancet Planetary Health
Historical, colonial, and racist policies continue to influence the health of Indigenous people, and they continue to have higher rates of chronic diseases and reduced life expectancy compared with non-Indigenous people. We determined factors accounting for variations in cardiovascular risk factors among First Nations communities in Canada.
Men and women (n=1302) aged 18 years or older from eight First Nations communities participated in a population-based study. Questionnaires, physical measures, blood samples, MRI of preclinical vascular disease, and community audits were collected. In this cross-sectional analysis, the main outcome was the INTERHEART risk score, a measure of cardiovascular risk factor burden. A multivariable model was developed to explain the variations in INTERHEART risk score among communities. The secondary outcome was MRI-detected carotid wall volume, a measure of subclinical atherosclerosis.
The mean INTERHEART risk score of all communities was 17·2 (SE 0·2), and more than 85% of individuals had a risk score in the moderate to high risk range. Subclinical atherosclerosis increased significantly across risk score categories (p<0·0001). Socioeconomic advantage (–1·4 score, 95% CI −2·5 to −0·3; p=0·01), trust between neighbours (–0·7, −1·2 to −0·3; p=0·003), higher education level (–1·9, −2·9 to −0·8, p<0·001), and higher social support (–1·1, −2·0 to −0·2; p=0·02) were independently associated with a lower INTERHEART risk score; difficulty accessing routine health care (2·2, 0·3 to 4·1, p=0·02), taking prescription medication (3·5, 2·8 to 4·3; p<0·001), and inability to afford prescription medications (1·5, 0·5 to 2·6; p=0·003) were associated with a higher INTERHEART risk score. Collectively, these factors explained 28% variation in the cardiac risk score among communities. Communities with higher socioeconomic advantage and greater trust, and individuals with higher education and social support, had a lower INTERHEART risk score. Communities with difficulty accessing health care, and individuals taking or unable to afford prescription medications, had a higher INTERHEART risk score.
Cardiac risk factors are lower in communities with high socioeconomic advantage, greater trust, social support and educational opportunities, and higher where it is difficult to access health care or afford prescription medications. Strategies to optimise the protective factors and reduce barriers to health care in First Nations communities might contribute to improved health and wellbeing.
Heart and Stroke Foundation of Canada, Canadian Partnership Against Cancer, Canadian Institutes for Health Research.

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ArticlesRisk factors, atherosclerosis, and cardiovascular disease among Aboriginal people in Canada: the Study of Health Assessment and Risk Evaluation in Aboriginal Peoples (SHARE-AP)

Summary

Background

Methods

Findings

Interpretation

Introduction

Section snippets

Methods

Results

Discussion

Clin Biochem

Thromb Res

Am J Cardiol

Lancet

Soc Sci Med

1996 Census Directory

Cardiovascular diseases in Aboriginal Canadians anadian Cardiovascular Society Consensus Paper

Can J Cardiol

Increasing rates of ischemic heart disease in the native population of Ontario, Canada

Arch Intern Med

The Study of Health Assessment and Risk in Ethnic groups (SHARE): Rationale and Design

Can J Cardiol

Enzymatic determination of total serum cholesterol

Clin Chem

A peroxidase coupled method for the colorimetric determination of serum triglycerides

Clin Chem

Simple automated determination of serum or plasma glucose by a hexokinase/glucose-6-phosphate dehydrogenase method

Clin Chem

Estimation of the concentration of low density lipoprotein cholesterol in plasma, without use of the preparative ultracentrifuge

Clin Chem

Comparison of improved precipitation methods for quantification of high-density lipoprotein cholesterol

Clin Chem

Articles
Risk factors, atherosclerosis, and cardiovascular disease among Aboriginal people in Canada: the Study of Health Assessment and Risk Evaluation in Aboriginal Peoples (SHARE-AP)