Heart disease is the top cause of death for U.S. adults. And for American Indian/Alaska Native (AI/AIN) women, the risk is particularly high during pregnancy and spans generations.
To help lower that risk, the American Heart Association (AHA) recently released its first set of scientific guidelines for cardiovascular health in American Indian/Alaska Native (AI/AN) women of childbearing age.
The guidelines address well-known risk factors: high blood pressure, LDL cholesterol levels, type 2 diabetes, obesity, and smoking. But they go beyond that to include trauma and mistrust passed down for centuries.
Jason Deen, MD, is one of the experts who wrote the new guidelines. He is a UW Medicine pediatric cardiologist who practices at Seattle Children’s Hospital and directs the Indian Health Pathway at University of Washington (UW) Medicine.
“My mother is Blackfeet, so I’m a Blackfeet descendent,” Deen says. “She talked to me at a very early age about the health care differences she saw growing up in Montana. So I got into medicine very early and was interested in working in Native health. “
During medical training in Minnesota, he recalls seeing “young Native kids with adult heart risk factors” such as obesity, high cholesterol, and high blood pressure. That was “the usual” for those patients, Deen says. And on call at night, he noticed that AI/AN adults were having cardiovascular emergencies “sometimes a decade earlier than other races,” Deen says. “In my mind, the two things were linked: that cardiac disease in young folks tracks to adulthood and leads to premature disease.”
Cardiovascular disease is the top cause of pregnancy-related death in the U.S., and American Indian/Alaska Native women have the second highest rate of maternal mortality, according to a study published in The Journal of the American Medical Association in July 2023.
Although there hasn’t been a lot of research on this group, the AHA group found several measurable targets that may make a difference. They are what the AHA calls “Life’s Essential 8”:
- Eat better.
- Be more active.
- Quit tobacco.
- Get healthy sleep.
- Manage weight.
- Control cholesterol.
- Manage blood sugar.
- Manage blood pressure.
If those sound familiar, they should. They’re “very well-known, modifiable health risk factors that need to be focused on when you're thinking about cardiovascular disease prevention,” Deen says. These factors apply to people of all backgrounds.
For AI/AN communities, there’s another layer to the guidelines. It’s about “trying to address intergenerational trauma,” Deen says, and “mistrust” in the U.S. government, physicians, and the research community.
Social Drivers of Health
Consider these facts from the AHA’s report:
- 60% of AI/AN women already have “suboptimal” heart health when they become pregnant.
- Risk factors including type 2 diabetes, high blood pressure, obesity, and smoking are common.
- Good nutrition is often out of reach.
- Statistics show a “staggering” amount of interracial violence against AI/AN women.
- Toxic stress and trauma marginalize AI/AN throughout their lives and make them vulnerable to mental and physical health problems.
“The reason American Indian/Alaska Native women have health differences is because of systemic racism,” Deen says. That affects social drivers of health including economic stability, access to health care and education, where people grow up, and their social and community context.
“There’s underlying historical trauma as well,” Deen says. “These are lingering effects from colonization. "A lot of Native communities … aren't in their ancestral homelands. They do not eat their traditional foods. There has been a loss of culture over time because of assimilation and genocide.”
He points to diet as an example. “Say a community was moved from their traditional territories to a reservation: All of a sudden, they're dependent on the colonizers for their nutrition. And that nutrition is poor. Unhealthy diet really leads to a lot of obesity that we see not only for adults, but kids as well.”
Adverse childhood experiences (ACEs) can also get passed down and ultimately affect heart health. (The CDC defines ACEs as potentially traumatic events – such as violence, abuse, and growing up in a family with mental health or substance abuse problems – that occur in childhood.)
For instance, Deen describes a common situation in which a Native grandmother might have grown up in abusive boarding schools funded by the U.S. government. More than 500 of these boarding schools operated across the U.S. between 1819 and 1969 across 38 states. At least 408 of these were federally funded, according to a U.S. government report published in 2022. The goal was “civilizing” young Native children and assimilating them into Western culture. Tens of thousands of American Indian, Alaska Native, and Native Hawaiian children were taken away from their families, often by force, and sent to these schools, where they were punished for speaking their Native languages or keeping aspects of their traditional cultures. Many suffered abuse, forced labor, and neglect in these boarding schools, according to the U.S. Department of the Interior’s Indian Affairs website. As a result, this Native grandmother would have been unable to learn about healthy parenting. She may then unwittingly have exposed her daughter to ACEs that could raise heart disease risk and eventually put her granddaughter at risk for obesity and other health conditions. “That’s an example of how colonization and the boarding school experiences affect not only that person, but subsequent generations,” Deen says.
A Different Model
Deen sees a need to switch the mindset behind the health care. “There’s a very Western model of health care: ‘There is disease; I go attack disease.’ Whereas a decolonized model of health care is more, ‘We know what’s healthy for these communities and what may prevent disease, so we’re going to focus on that.’ It’s more of a public health care model rather than an intervention-based model. It’s about getting back to the notion that health care existed way before colonization and respecting that.”
The same goes for research in Native communities, Deen says. “[It] takes a lot of relationship-building and becoming part of the community initially. It's not a model where we can say, ‘I have an idea of what I want to study in you.’ It is approaching them, saying, ‘We're from XYZ University, we want to study cardiac disease in Native women, is there someone I can talk to? What do you think your unmet needs are? Where do you think your gaps in knowledge are?’
“It's about coming to these communities without an ego, without an agenda. Then you can help them over time with their own needs assessment. It’s approaching communities and talking to decision makers, which [are] typically women elders. As in a lot of cultures across the globe, Native women are really the health care stewards of the family.
On a systemic level, there’s also a need for more Native doctors and allied health professionals, as well as more Native researchers, Deen says. On the community level, "if you focus on community intervention, and the community itself is healthier and has sustainable interventions, naturally the individual health will follow.
“I think that Native women have understood this forever,” Deen says. “There’s just a yearning to break that cycle in general. Yes, it’s great to have guidance about blood pressure and cholesterol and all those things, but we just need to change the whole unhealthy ecosystem that these populations grow in,” Deen says. “That’s really how you do it.”