Big differences found in heart and stroke risks among AANHPIgroups

Originally published by the American Heart Asociation
Reprinted by Permission

The frequency of traditional cardiovascular risk factors, such as high blood pressure and high cholesterol, and the overall risk of having a heart attack or stroke varies greatly among Asian American, Native Hawaiian and Pacific Islander populations, even though these groups are usually grouped together for research purposes, new research shows.

The findings were presented last week at the American Heart Association's Epidemiology and Prevention/Lifestyle and Cardiometabolic Health Scientific Sessions in New Orleans. They are considered preliminary until full results are published in a peer-reviewed journal.

The practice of aggregating data for these distinct groups "masks important variations in both risk factor prevalence and disease burden," lead study author Rishi V. Parikh said in a news release. Parikh is a senior research analyst at the Kaiser Permanente Northern California Division of Research in Pleasanton.

"Despite being the fastest-growing population in the U.S., existing studies about Asian subgroups remain limited by inadequate sample size and exclusion of some major disaggregated subgroups, as well as a lack of long-term follow-up," he said.

Prior research has noted differences among AANHPI subgroups, including a higher death rate from cardiovascular disease in Native Hawaiian and Pacific Islander adults compared to non-Hispanic white adults in the U.S.

In the new study – the Pacific Islander, Native Hawaiian and Asian American Cardiovascular Health Epidemiology, or PANACHE – researchers analyzed health records from 2012 to 2022 for more than 2.6 million adults in large, private health systems in California and Hawaii who were an average of 49 years old with no history of heart attack, stroke, heart failure or atrial fibrillation. About 677,500 participants self-identified as Chinese, Filipino, Native Hawaiian or other Pacific Islander, Japanese, Korean, Vietnamese, other Southeast Asian (including Thai, Laotian, Cambodian, Hmong, Burmese, Indonesian, Malaysian or Singaporean) or South Asian (including Indian, Pakistani, Sri Lankan, Bangladeshi, Nepali or Bhutanese).

Researchers compared the prevalence of traditional cardiovascular risk factors, including high blood pressure, high cholesterol, obesity, Type 2 diabetes, chronic kidney disease and smoking, among adults belonging to a single AANHPI subgroup to nearly 2 million non-Hispanic white adults in the same health system database. They also used the AHA's PREVENT risk calculator to predict the participants' 10-year risk for a cardiovascular event.



Compared to non-Hispanic white adults, all AANHPI subgroups had higher rates of diabetes and high cholesterol, and all but Native Hawaiian/Pacific Islander adults had lower rates of smoking. But there were significant variations among subgroups in the prevalence of cardiovascular disease risk factors.

High blood pressure ranged from 12% of Chinese adults to a high of 30% among Filipino adults. Chinese and Filipino adults also had the lowest (20%) and highest (33%) rates of high cholesterol, respectively. Chinese adults also had the lowest rate of Type 2 diabetes, at just 5%, compared to 14% for Native Hawaiian/Pacific Islander adults.

'High blood pressure ranged from 12% of Chinese adults to a high of 30% among Filipino adults.'

There was a wider disparity in obesity rates, which ranged from 11% in Vietnamese adults to 41% in Native Hawaiian/Pacific Islander adults, who also had the highest risk among subgroups for experiencing a heart attack or stroke within 10 years.

"At the individual patient level, our findings along with previous work suggest that regular monitoring of risk factors like blood pressure and cholesterol may be helpful for early detection of increased risk and prevention of cardiovascular disease among Asian American, Native Hawaiian and Pacific Islander populations," study co-author Dr. Alan S. Go said in the news release. Go is an associate director of the Kaiser Permanente Northern California Division of Research, Cardiovascular and Metabolic Conditions Research.

Go said a next step for the PANACHE study would be a population-based survey to describe risk factors not routinely available in an electronic health record. These could include immigration history, generational status, employment history, experiences of discrimination, acculturation, diet, physical activity, and access to health care services and other resources that may be unique to each subgroup.

The additional data, Go said, "will help us understand sources of health disparities and inform tailored cardiovascular prevention strategies for AANHPI individuals, both in the clinic and in the community."

Dr. Sadiya S. Khan said in the news release that because cardiovascular disease remains the leading cause of death for all Americans, "understanding differences among specific population groups can identify gaps in monitoring and management of risk factors, such as obesity, hypertension and Type 2 diabetes."

Khan led the writing group for the AHA's scientific statement on the PREVENT risk calculator in 2023 but was not involved in the new research. She is a preventive cardiologist at Northwestern Medicine in Chicago.

"These findings further underscore that Asian Americans represent a diverse and heterogeneous group, and research should prioritize inclusion and appropriate identification of Asian Americans and various subgroups to improve cardiovascular health for all," Khan said.

EDITOR'S NOTE: For additional commentary, news and views from an AANHPI perspective, follow me on Threads, on X or at the blog Views From the Edge.

Immigration status, racism impacts heart health of AANHPI

Numerous social and structural factors, including immigration status, socioeconomic position and racism contribute to differences in cardiovascular health and heart disease risk for Asian Americans, according to the American Heart Association. Additionally, these factors affect Asian ethnic subgroups in different ways.

This AHA scientific statement “Social Determinants of Cardiovascular Health in Asian Americans,” which was released Sept. 16, highlights the evidence for the role of social determinants of health in cardiovascular health among Asian American adults, states an article in the AHA journal Circulation.

Asian Americans are the fastest growing racial group in the United States, with a population projected to reach up to approximately 46 million by 2060. According to the US Census Bureau, Asian Americans will represent more than 10% of the total US population at that time.

However, Asian Americans remain underrepresented as participants in medical research. Previous studies have found that Asian Americans are less willing to participate in health research compared to other racial/ethnic groups. Research conducted exclusively in English may also result in underrepresentation of Asian American individuals with lower English proficiency from different Asian ethnic subgroups.

“Due to the small numbers of Asian Americans recruited in research studies, even when Asian American participants are included, they are frequently combined into a single ‘Asian’ category or grouped with Native Hawaiian and Pacific Islander communities, which results in the masking of clinically relevant differences in health among subgroups of people of Asian descent,” said Chair of the statement writing group Nilay S. Shah, M.D., M.P.H., FAHA, an assistant professor of cardiology and preventive medicine at Northwestern University’s Feinberg School of Medicine in Chicago.

As of 2021, the six largest Asian origin ethnic groups in the U.S. were Chinese, Indian, Filipino, Vietnamese, Korean and Japanese Americans. People of other Asian ethnic groups, such as Pakistani, Thai or Cambodian descent, are less often identified in research studies, limiting understanding of health status in these populations.

“Asian American ethnic groups should be individually identified, since each sub-group represents a unique population with distinct social, cultural and health characteristics," said Shaw. "There are several social factors that uniquely influence health behaviors and disease risk in individual Asian ethnic groups, including reasons for immigration, socioeconomic position and differences in health care access and utilization.”

Immigration Status and Structural Racism

Immigration policy, citizenship status and legal documentation are widely recognized as important social determinants of health for people immigrating to the US including people from Asia.

Historically, Asian American immigrants have faced structural racism and anti-Asian prejudice resulting in policies restricting immigration into the US. The 1882 Chinese Exclusion Act restricted immigration and citizenship based solely on national origin, and Executive Order 9066 led to the unjust, forced incarceration of Japanese Americans during World War II in 1942.

Differences in histories and reasons for migration and resettlement may contribute to suboptimal heart health. For example, Bhutanese, Burmese, Cambodians, Hmong, Laotians and Vietnamese people have frequently arrived in the US as refugees. Refugees are more likely to experience chronic stress due to being exposed to war, violence, hunger and trauma, which may worsen heart health. Real and perceived discrimination may also influence cardiovascular health by leading to increased stress, poor sleep habits, and other suboptimal health behaviors.

Asian Americans without documented immigration status often lack employer-based health insurance. Non-US citizens also have limited access to federal and state health insurance programs, which may contribute to disparities in health outcomes. In addition, lack of health insurance and concerns about immigration status can limit access to timely health care and may also deter individuals from seeking preventive care for cardiovascular risk factors.

Socioeconomic and Social Factors

Due to the socioeconomic diversity of Asian communities, there are substantial differences in the physical and social characteristics of neighborhoods in which Asian Americans live. The complex interplay of social determinants of health, including social support, neighborhood walkability and access to nutritious foods, influence cardiovascular health and contribute to differences across ethnic groups.

While the Asian American population overall is relatively a high-income group, there are significant differences within individual ethnic groups. In 2019, median annual household income ranged from approximately $44,000 per year in Burmese Americans to $119,000 per year among Indian Americans (compared to the average of $85,800 for all Asian Americans).

Employment status in the US is frequently related to health insurance coverage, residence in resource-rich neighborhoods and housing stability. A nationally representative survey of Asian Americans from 10 ethnic backgrounds found that adults who were employed were more likely to report having better health.

In addition, Asian Americans with less than a high school education were 73% less likely to have ideal heart health compared to those with college degrees. A potential explanation is that people employed in low-wage occupations, such as in the service and food industries, may experience greater discrimination and have fewer benefits and employee protections.

Previous research has found that food insecurity, defined as limited or uncertain access to adequate amounts of food, and nutrition security, which refers to the availability, accessibility and affordability of healthy foods, are associated with increased overweight and obesity, type 2 diabetes and cardiovascular mortality in all communities. In the wake of the COVID-19 pandemic, estimates for food insecurity increased by approximately 25% for Vietnamese American adults and 53% for Filipino American adults.

Acculturation, or the process of adapting to a different culture, also affects heart disease risk factors in people who immigrate to the US For example, greater availability and consumption of processed and fast foods and more sedentary lifestyles are known risk factors associated with higher rates of obesity.

Differences in Health Access and Literacy

Asian Americans, especially those not born in the US, often experience difficulty in accessing health care services, inadequate health communication between clinicians and patients, cultural differences in health-related beliefs and discrimination in the health care system.

Prior research suggests that gaps in health insurance coverage within some Asian American subgroups, such as Korean and Vietnamese Americans, may be attributable to high rates of employment in occupations that less often provide health insurance coverage, such as jobs in the construction, maintenance or transportation industries, working for a small business or being a small business owner.

English proficiency varies considerably among Asian ethnic groups in the US. Limited English proficiency may impact cardiovascular health by preventing patients from adequately reporting symptoms or health concerns. In addition, insufficient use of interpretation/translation services may prevent health care professionals from adequately understanding and addressing health concerns in Asian Americans with limited English proficiency.

Health literacy, or knowledge about health services, also varies across Asian American ethnic groups. Limited health literacy can negatively affect the use of preventive care and/or following medical instructions and taking medications as prescribed. Asian immigrants may also gravitate towards traditional, complementary or alternative medicine practices common in Asian countries, such as acupuncture or herbal therapies.

“All of these social determinants of health are likely interrelated, and the cumulative impact of these structural and social risk factors contributes to suboptimal cardiovascular health in Asian Americans," said Shaw. 

"There is an urgent need to understand these challenges and address them with effective prevention strategies to help improve their long-term cardiovascular health. Achieving health equity in this rapidly growing population will require multi-level interventions that target the key factors influencing cardiovascular health and account for the unique experiences within individual Asian subgroups.”

DITOR'S NOTE: For additional commentary, news and views from an AANHPI perspective, follow me on Threads, on X or at the blog Views From the Edge.