Minority Populations Have An Increased Risk of Stroke
For numerous reasons minorities are often at an increased risk of stroke when compared to white Americans.
Physicians treating minority patients must understand these increased risks in order to prevent stroke before it occurs. They must understand these stroke risks in order to immediately diagnose and treat stroke once it happens. Physicians need to understand the unique risk factors minority patients face in order to comply with the “standard of care” and avoid committing medical malpractice.
If physicians do not understand the stroke risks faced by minority patients, physicians may commit medical malpractice by:
- A failure to prevent a stroke before it occurs;
- A stroke misdiagnosis;
- A failure to diagnose a stroke or a delayed diagnosis of stroke; or
- A failure to treat a stroke or a delayed treatment of stroke.
Any form of stroke malpractice can have a devastating and permanent impact on a patient.
Likewise, attorneys who represent injured patients and their families should be aware of the unique stroke risk factors of their clients. This is necessary in order to hold dangerous medical providers and hospitals responsible for medical malpractice.
African-Americans and Stroke
Stroke is the fifth leading cause of death in the United States. Someone in the U.S. has a stroke every 40 seconds. Someone dies from a stroke every 4 minutes. About 795,000 people in the United States have a stroke each year. Around 610,000 are first strokes, and around 185,000 are recurrent strokes.
According to the Centers for Disease Control (CDC), African American men are twice as likely to have a stroke and are 60% more likely to die of a stroke than white men. African Americans are also more likely to become disabled and unable to participate in everyday activities like walking, lifting or grasping objects, and socializing with others than whites after a stroke.
Why are African-Americans at Higher Risk for Stroke?
African Americans generally have similar or even lower levels of total cholesterol than white and Hispanic Americans. Experts believe that African Americans’ increased stroke risk is caused by a combination of genetic and environmental factors. These include high blood pressure (hypertension), diabetes, coronary heart disease, and a sedentary lifestyle. These are each major stroke risk factors. Many African Americans also suffer from sickle cell disease, which is an independent risk factor for stroke.
African Americans Have More Stroke Risk Factors
More than 40 percent of African Americans have high blood pressure (defined as 140/90 mmHg or more). African Americans tend to develop high blood pressure at an earlier age than their Caucasian counterparts. Not only do African Americans tend to develop high blood pressure at an earlier age, it is usually more severe and results in more complications.
African Americans are also more likely to be diagnosed with diabetes and coronary heart disease whites. According to a study in 2009, African Americans were 50% more likely to be obese than non-Hispanic whites. Black women had a 60 percent chance of being obese.
While excess weight is a risk factor for stroke, gaining weight earlier in life significantly increases the risk of stroke later in life. A 2007-2008 report showed that African American children ages 6 to 17 were already 30% more likely to be obese than non-Hispanic whites.
Obesity plays an important role in predicting stroke. Obesity is an independent risk factor for stroke. Obesity also contributes to a person developing additional risk factors for stroke, like high blood cholesterol, high blood pressure, and diabetes.
Healthy weight status in adults is usually assessed by using weight and height to compute a number called the “body mass index” (BMI). BMI usually indicates the amount of body fat. An adult who has a BMI of 30 or higher is considered obese. Overweight is a BMI between 25 and 29.9. Normal weight is a BMI of 18 to 24.9. Proper diet and regular physical activity can help to maintain a healthy weight.
African Americans Receive Less and Worse Medical Care
On a statistical basis, African Americans face greater hurdles in obtaining proper medical care and preventative treatment. African Americans are also more likely to have a lower socioeconomic status than non-Hispanic whites. As a result, African Americans may be less likely to eat healthy foods (which are often more expensive than less nutritious foods). African Americans may be less likely to have health insurance. African Americans may not receive regular medical checkups that could help detect and treat stroke risks before they escalate to dangerous levels, including diabetes, high blood cholesterol, and high blood pressure.
About one in 500 African Americans will also inherit sickle cell disease, a blood disorder that affects people of African, Caribbean, Mediterranean, Indian, and Central- and South-American descents and causes red blood cells to form into a sickle, or crescent shape. Sickle cell disease is a risk factor for stroke.
Strokes can occur when sickle cells get stuck in blood vessels and clog the flow of blood to the brain. The sickle shaped cells create a clot (also called a “thrombus”) that prevents blood from flowing to the brain causing an ischemic stroke. Carriers of sickle cell disease are also at an increased risk of suffering a hemorrhagic stroke.
Approximately 11 percent of people with sickle cell disease will suffer a stroke before the age of 20. 25 percent of individuals with sickle cell disease will have a stroke by the time they reach the age of 45.
Increased Knowledge is Increased Power
Research shows that many African Americans don’t know much about strokes, their causes, their prevention, and their treatment, despite that they are the population at the greatest risk. In 2003, the results of a large study evaluating residents near Cincinnati was published. That study demonstrated that elderly African American men lacked knowledge about stroke risk factors and warning signs.
In 2010, a study surveyed African Americans living in Mississippi about stroke symptoms. The researchers found that many people did not know how lifestyle factors (like excess alcohol consumption, lack of physical activity, diabetes, smoking, high blood pressure, and high cholesterol) contribute to stroke risk.
The study also found that many people could not identify stroke symptoms and more than half of the participants were unaware that calling 911 right away was the most appropriate way to respond to stroke symptoms. Time is critical when diagnosing and treating a stroke. Certain clot-busting medications called tissue plasminogen activator (tPA) reduce long-term disability for the most common type of stroke if given within the first 3-5 hours of symptoms, according to the American Stroke Association.
The study found that African-American communities need to better educate its members about stroke risk and that schools, churches, and the media must play a greater role in delivering this information.
African Americans and Stroke Malpractice
Doctors treating patients must understand the special risks their patients face. To avoid committing medical malpractice, physicians and other medical providers treating African Americans should understand the special risks this population faces. If physicians are negligent in understanding the risks of stroke their patients face, the doctor may commit medical malpractice by failing to prevent, treat, or diagnose a stroke.
For example, knowing that African Americans are at an increased risk of stroke because high blood pressure, obesity, and diabetes, physicians should take steps to provide medications to their patients to prevent strokes. If a physician or other medical provider does not take these steps and the patient suffers a stroke, the physician may have committed medical malpractice. Similarly, if a patient is suspected of having a stroke, the doctor and hospital must act immediately to treat the patient as soon as possible or else the doctor has likely committed medical malpractice.
Hispanic Americans and Stroke
According to the U.S. Census Bureau (the agency that measures population changes), the Hispanic population has increased by 34 percent since 1980. The term Hispanic is a generic term used to describe various cultures from a variety of countries. Even though Hispanic Americans share a language, there are many distinct subgroups: Mexican Americans (62 percent), Puerto Ricans (13 percent), Cuban Americans (5 percent), Central and South Americans (12 percent) and other Hispanics (8 percent). Almost three-quarters of all Hispanics live in California, Texas, New York, Florida, New Jersey, and Illinois.
Hispanics in the U.S. have a higher rate of stroke than other populations. Hispanics are more likely to suffer a stroke at a younger age than their Caucasian counterparts. The Northern Manhattan Stroke Study, a large stroke investigation, found that the average age for stroke in Hispanics was 67, compared to 80 for Caucasians. Stroke and heart disease are responsible for one in three deaths among Hispanic women and one in four deaths among Hispanic men.
Why are Hispanic-Americans at Higher Risk for Stroke?
The leading risk factors for stroke in the Hispanic population are:
- High blood pressure;
- Obesity; and
- Diabetes and metabolic syndrome.
High Blood Pressure
High blood pressure (a key contributor to hemorrhagic stroke) is higher in Hispanics than non-Hispanic whites. In fact, the Barrow Neurological Institute Stroke Database found that Hispanics have the highest percentage of hypertension (high blood pressure) for any group. Hypertension was found in 72 percent of Hispanics with stroke (66 percent in non-Hispanic whites).
Obesity is more prevalent among Hispanics than among non-Hispanic whites. The American Heart Association reports that 75 percent of Mexican-American men and 72 percent of women age 20 and older are overweight or obese. 29 percent of Hispanic men and 40 percent of women are obese.
Diabetes and Metabolic Syndrome
Diabetes also plays a major role in stroke prevalence among Hispanics. It is estimated that 30 percent of adult Hispanics have diabetes. As many as half of these diabetes sufferers are unaware that they have the disease. Mexican Americans and Puerto Ricans between ages 24–74 are 2.4 times more likely to have diabetes than non-Hispanic whites. Researchers estimate that 47 million Americans have metabolic syndrome. Mexican Americans have the highest rate of metabolic syndrome at 31.9 percent.
People with metabolic syndrome are at increased risk for developing diabetes and cardiovascular disease. A person has metabolic syndrome if they have three or more of the following abnormalities:
- Waist circumference greater than 40 inches in men and 35 inches in women.
- Triglyceride level of 150 mg/dL, or higher
- HDL cholesterol level less than 40 mg/dL in men and 50 mg/dL in women
- Blood pressure of 130/85 mm Hg or higher
- Fasting glucose level of 110 mg/dL or higher.
While these are the most common risk factors for stroke, other significant risk factors for stroke in the Hispanic community include:
- Alcohol consumption;
- Sedentary lifestyle;
- Lack of insurance and access to medical care; and
- Language barriers.
Several studies have shown excessive alcohol use among Hispanics. The Barrow Database found that 24 percent of Hispanics have heavy alcohol intake compared to 17 percent in non-Hispanic whites. Heavy alcohol use occurs in 40 percent of Latino men age 18–39. Excessive also consumption is a risk factor for stroke, as well as many other diseases.
A sedentary lifestyle is a risk factor for stroke. The National Health and Nutrition Examination Survey studied the activity levels of Hispanics. It found that 74% of Mexican-American women did not engage in recreational physical activity and exercise.
Lack of Insurance and Access to Medical Care
A lack of insurance and access to medical care increases the risk of stroke. This is because people without insurance often don’t receive regular checkups and preventative medicine. Hispanics are less likely than non-Hispanic whites to have health insurance (66 percent vs. 89 percent).
Language barriers and lack of transportation contribute to poor access to healthcare providers. Because of this, Hispanics are more likely to delay care, drop out of treatment when symptoms disappear and have poor rates of physician use.
Hispanic Americans and Stroke Malpractice
Doctors treating patients must understand the special risks that their patients face. To avoid committing medical malpractice, physicians treating Hispanic Americans should understand the special risks this population faces. If physicians are negligent in understanding the risks of stroke their patients face, the doctor may commit medical malpractice by failing to prevent, treat, or diagnose a stroke.
For example, hospitals and medical providers in predominantly Hispanic neighborhoods should have translators available to avoid any language barriers. Likewise, knowing that Hispanic patients are predisposed to stroke because of obesity, diabetes, and high blood pressure, physicians and hospital staff must do everything they can to reduce these stroke risks.
American Indians and Alaska Natives and Stroke
There are approximately 4.5 million American Indians and Alaska Natives in the United States, 1.5% of the population, including those of more than one race. However, they are disproportionately affected by stroke.
California has the largest population of American Indians and Alaska Natives (696,600), followed by Oklahoma (401,100), and Arizona (334,700). Alaska has the highest proportion of American Indians and Alaska Natives in its populations (20%), followed by Oklahoma and New Mexico (11% each). Los Angeles County is the county with the most American Indians and Alaska Natives (154,000).
American Indian and Alaska Native Stroke Facts
Stroke is the sixth leading cause of death Among American Indians and Alaska Natives. In 2014, stroke caused 649 deaths among American Indians and Alaska Natives.
The stroke death rate is 14 percent greater among American Indians and Alaska Natives than among all U.S. races. Counties with the highest stroke death rates for American Indians and Alaska Natives are primarily in Alaska, Washington, Idaho, Montana, Wyoming, South Dakota, Wisconsin, and Minnesota.
Diabetes has been shown to be a very important risk factor for stroke among American Indians and Alaska Natives. People with diabetes have an increased risk for heart disease but can reduce their risk. This is true of every race.
Controlling blood pressure is important to prevent stroke. Lifestyle actions such as healthy diet, regular physical activity, not smoking, and healthy weight help maintain normal blood pressure levels. Blood pressure is easily checked. If a person’s blood pressure is high, physicians can prescribe medications to lower blood pressure to a normal safe range. High blood pressure can usually be controlled with lifestyle changes and medicines.
Cigarette smoking is a risk factor for stroke. Cigarette smoking is highest among American Indians and Alaska Natives in the Northern Plains (44.1%) and Alaska (39.0%) and lowest in the Southwest (21.2%). Cigarette smoking increases the risk of high blood pressure, heart disease, and stroke. A person’s risk of stroke decreases soon after quitting. If a patient smokes, doctors should suggest programs to help quit smoking.
High blood cholesterol is a major risk factor for stroke. Preventing and treating high blood cholesterol includes eating a diet low in saturated fat and cholesterol and high in fiber, keeping a healthy weight, and getting regular exercise. Physicians should check the cholesterol levels of their adult patients at least once every five years. Physicians can prescribe medicines to help lower cholesterol.
Asian Americans & Stroke
There is no single Asian American population. Rather, the Asian American population in the United States has ancestral ties to more than 30 Asian nations and 25 Pacific Islander nations. This diversity makes it more difficult to identify comprehensive facts about stroke for this population. The fact remains that stroke continues to be a leading cause of disability and death among Asian Americans.
Among Asian Americans, 6.8% have heart disease, 4.5% have coronary artery disease, and 21.2% have hypertension. Each of these is a risk factor for stroke. 1.8% of Asian Americans have already had a stroke. Asian Americans have higher mortality rates and die at an earlier age from stroke compared to White Americans.
Asian Americans & Stroke Risk Factors
Compared to most Americans, Asian Americans are less likely to be aware of high blood pressure (hypertension), have their cholesterol levels checked, or undergo treatment for these conditions.
The data shows that there is a high rate of hypertension and stroke among Southeast Asians. Although obesity rates are low for Asian adults, Filipino adults (14%) were more than twice as likely to be obese as Asian Indian (6%), Vietnamese (5%), or Chinese (4%) adults.
Published in the Journal of the American College of Cardiology, a recent study analyzed death records for the six largest Asian-American subgroups: Asian Indian, Chinese, Filipino, Japanese, Korean and Vietnamese. Together, these subgroups make up 84% of the Asians in the United States.
After comparing U.S. death rates from 2003–2010, researchers found that stroke and high blood pressure was more common among every Asian American subgroup compared to non-Hispanic whites. Compared to whites, Asian Indians and Filipino men also had greater mortality from coronary artery disease—a condition that occurs when the heart’s arteries narrow, often due to the plaque build-up on the arterial walls.
Based on these findings, authors highlight the need to direct specific treatment and prevention efforts to reduce health disparities in the Asian-American population. If Asian Americans face greater risk of hypertension and stroke, it’s important to address these risk factors to prevent complications and improve outcomes. And with a current population of more than 18 million that is projected to reach 34 million by 2050, addressing cardiovascular risk factors in this rapidly growing population will have a meaningful impact on improving the heart health of the U.S. population.
More than 70% of Asian Americans are physically inactive.
Compared with White Americans, the risk of diagnosed diabetes is 18% higher among Asian Americans.
The highest rates of cigarette smoking are among Southeast Asians males and they start smoking early in life, putting them at greater risk for heart disease.
Native Hawaiians and Pacific Islanders and Stroke
Native Hawaiians/Pacific Islanders were four times more likely than non-Hispanic white adults to die from a stroke in 2010.
In general, Native Hawaiian/Pacific Islander adults have developed several of the high-risk factors which can lead to heart attacks and stroke, such as higher rates of obesity, hypertension and cigarette smoking.
Cerebrovascular disease can be more prevalent in some U.S. island territories. For example, the death rate from stroke is 2.7 times higher in American Samoa than in the U.S. non-Hispanic white population.
Stroke Risk Factors for Native Hawaiians and Pacific Islanders
Native Hawaiians and Pacific Islanders suffer from many of the same risk factors for stroke as other minority populations. These include:
- Heart Disease; and
Native Hawaiians/Pacific Islanders were almost four times more likely to be obese than the overall Asian American population in 2011. Native Hawaiians/Pacific Islanders were 30 percent more likely to be obese than non-Hispanic Whites in 2011
Obesity continues to be a health risk in the United States Pacific Territories. Reports from the World Health Organization indicate that in the Federated States of Micronesia, almost 83 percent of women were either overweight or obese in 2008.
National data related to heart disease for Native Hawaiians/Pacific Islanders is not available at this time for many conditions and risk factors. Local data from states with high populations of Native Hawaiians/Pacific Islanders may be useful in illustrating disparities among certain populations. Heart-related health issues vary among various Asian and Pacific Islander sub-populations.
Asian Americans, in general, have the same rate of diabetes as non-Hispanic whites. However, there are differences within the Native Hawaiian/Pacific Islander population.
From a national survey, Native Hawaiians/Pacific Islanders are 2.4 times more likely to be diagnosed with diabetes as the white population. In the state of Hawaii, Native Hawaiians are 2.2 times more likely to be diagnosed with diabetes, as compared to the white population.
In 2010, Native Hawaiians/Pacific Islanders were 30 percent more likely to have had a foot examination within the past 12 months than non-Hispanic whites.
If someone you know someone has suffered a pediatric stroke – or any stroke – it is critical that you speak with a stroke lawyer as soon as possible to evaluate your options. When it comes to stroke, not all lawyers and law firms are the same. When it comes to stroke malpractice, there is no substitute for a stroke lawyer.
- Kassim AA, Galadanci NA, Pruthi S, DeBaun MR. How I treat and manage strokes in sickle cell disease. Blood 2015; 125:3401.
- Hulbert ML, Scothorn DJ, Panepinto JA, et al. Exchange blood transfusion compared with simple transfusion for first overt stroke is associated with a lower risk of subsequent stroke: a retrospective cohort study of 137 children with sickle cell anemia. J Pediatr 2006; 149:710.
- http://www.nhlbi.nih.gov/health-pro/guidelines/sickle-cell-disease-guidelines/index.htm (Accessed on September 30, 2014).
- Yawn BP, Buchanan GR, Afenyi-Annan AN, et al. Management of sickle cell disease: summary of the 2014 evidence-based report by expert panel members. JAMA 2014; 312:1033.
- Kernan WN, Ovbiagele B, Black HR, et al. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2014; 45:2160.
- Amlie-Lefond C, Rivkin MJ, Friedman NR, et al. The Way Forward: Challenges and Opportunities in Pediatric Stroke. Pediatr Neurol 2016; 56:3.
- Strouse JJ, Lanzkron S, Urrutia V. The epidemiology, evaluation and treatment of stroke in adults with sickle cell disease. Expert Rev Hematol 2011; 4:597.
- Ohene-Frempong K, Weiner SJ, Sleeper LA, et al. Cerebrovascular accidents in sickle cell disease: rates and risk factors. Blood 1998; 91:288.
- Powars D, Wilson B, Imbus C, et al. The natural history of stroke in sickle cell disease. Am J Med 1978; 65:461.
- Adams RJ, Nichols FT. Sickle cell anemai, sickle cell trait and thalassemia. In: Handbook of Clinical Neurology, Vascular Disease Part III, Vinken PJ, Bruyn GW, Klawans HL (Eds), Elsevier, Amsterdam 1989. p.503.
- Powars D, Adams RJ, Nichols FT, et al. Delayed intracranial hemorrhage following cerebral infarction in sickle cell anemia. J Assoc Acad Minor Phys 1990; 1:79.
- Adams RJ. Neurologic complications. In: Sickle Cell Disease: Basic Principles and Clinical Practice, Embury SH, Robert P, Hebbel RP, et al (Eds), Raven Press, Ltd, New York 1994. p.599.
- Resar LM, Oliva MM, Casella JF. Skull infarction and epidural hematomas in a patient with sickle cell anemia. J Pediatr Hematol Oncol 1996; 18:413.
- Oyesiku NM, Barrow DL, Eckman JR, et al. Intracranial aneurysms in sickle-cell anemia: clinical features and pathogenesis. J Neurosurg 1991; 75:356.
- Anson JA, Koshy M, Ferguson L, Crowell RM. Subarachnoid hemorrhage in sickle-cell disease. J Neurosurg 1991; 75:552.
- Overby MC, Rothman AS. Multiple intracranial aneurysms in sickle cell anemia. Report of two cases. J Neurosurg 1985; 62:430.
- Alex George, MD, Acute Stroke in Sickle Cell Disease, UpToDate, Dec, 2016
- Mozaffarian D, et al. (2014). Heart disease and stroke statistics-2015 update. Circulation, published online December 17, 2014. DOI: 10.1161/CIR.0000000000000152. Accessed December 24, 2014.American Heart Association. What About African Americans and High Blood Pressure? Available at: http://www.heart.org/idc/groups/heart-public/@wcm/@hcm/documents/downloadable/ucm_300463.pdf. Accessed: June 4, 2011.
- American Stroke Association. Warning Signs. Available at: http://www.strokeassociation.org/STROKEORG/WarningSigns/Warning-Signs_UCM_308528_SubHomePage.jsp. Accessed: June 16, 2011.
- Centers for Disease Control and Prevention. Most Americans Should Consume Less Sodium (1,500 mg/Day or Less). Available at: http://www.cdc.gov/Features/Sodium/. Accessed: June 16, 2011.
- Centers for Disease Control and Prevention. Sickle Cell Disease: Symptoms and Treatment. Available at: http://www.cdc.gov/ncbddd/sicklecell/symptoms.html. Accessed: June 4, 2011.
- Centers for Disease Control and Prevention. Stroke Facts. Available at: http://www.cdc.gov/stroke/facts.htm. Accessed: June 4, 2011.
- Genetics Home Reference. What Is Sickle Cell Disease? Available at: http://ghr.nlm.nih.gov/condition/sickle-cell-disease. Accessed: June 4, 2011.
- National Stroke Assocation. African Americans and Stroke Brochure. Available at: http://www.stroke.org/site/DocServer/AFAM.broch.pdf?docID=581. Accessed: June 4, 2011.
- Ooi WL, Budner NS, Cohen H, Madhavan S, Alderman MH. “Impact of Race on Treatment Response and Cardiovascular Disease Among Hypertensives.” Hypertension. 1989;14:227-234.
- The Office of Minority Health. Diabetes and African Americans. Available at: http://minorityhealth.hhs.gov/templates/content.aspx?ID=3017. Accessed: June 4, 2011.
- The Office of Minority Health. Heart Disease and African Americans. Available at: http://minorityhealth.hhs.gov/templates/content.aspx?ID=3018. Accessed: June 4, 2011.
- The Office of Minority Health. Obesity and African Americans. Available at: http://minorityhealth.hhs.gov/templates/content.aspx?ID=6456. Accessed: June 4, 2011.
- The Office of Minority Health. Stroke and African Americans. Available at: http://minorityhealth.hhs.gov/templates/content.aspx?ID=3022. Accessed: June 4, 2011.
- Parra EJ, Kittles RA, Shriver MD. “Implications of Correlations Between Skin Color and Genetic Ancestry for Biomedical Research.”Nature Genetics. Oct 26 2004;36(11):S54-S60.
- Saller, Anthony, et al. “Stroke Prevention: Awareness of Risk Factors for Stroke Among African American Residents in the Mississippi Delta Region.” Journal of the National Medical Association. 2010; February. Vol. 102, No. 2. 84-94.
- Schneider AT, Pancioli AM, Khoury JC. et al. “Trends in Community Knowledge of the Warning Signs and Risk Factors for Stroke.” JAMA. 2003;289:343-346.
- Young JH, Chang YP, Kim JD, et al. “Differential Susceptibility to Hypertension Is Due to Selection During the Out-of-Africa Expansion.” PLoS Genetics. 2005;1:e82.
- U.S. Census Bureau, CB06-FF.16; September 20, 2006. http://www.census.gov/Press-Release/www/releases/archives/facts_for_features_special_editions/007489.html
- Powell O. Jose, Ariel T.H. Frank, Kristopher I. Kapphahn, Benjamin A. Goldstein, Karen Eggleston, Katherine G. Hastings, Mark R. Cullen, Latha P. Palaniappan, Cardiovascular Disease Mortality in Asian Americans, Journal of the American College of Cardiology, Volume 64, Issue 23, December 2014>DOI: 10.1016/j.jacc.2014.08.048
- CDC 2011. Summary Health Statistics for U.S. Adults :2010. Table 2. http://www.cdc.gov/nchs/data/series/sr 10/sr10252.pdf
- WHO 2011. Noncommunicable diseases country profiles 2014. http://www.who.int/nmh/publicatons/ncd profiles2014/en/index.html.
- CDC 2013. Health Behaviors of Adults: United States, 2008-2010. Figuer 6.1. http://www.cdc.gov/nchs/data/series/sr 10/sr10 257.pdf.
- Howard BV, Lee ET, Cowan LD, et al. Rising tide of cardiovascular disease in American Indians: the Strong Heart Study. Circulation. 1999;99:2389-2395.
- Indian Health Service. Trends in Indian Health, 2000-2001. Rockville, Maryland: U.S. Dept. of Health and Human Services, 2004
- Casper ML, Denny CH, Coolidge JN, Williams GI Jr., Crowell A, Galloway JM, Cobb N. Atlas of Heart Disease and Stroke Among American Indians and Alaska Natives. Atlanta, GA: U.S. Dept. of Health and Human Services, Centers for Disease Control and Prevention and Indian Health Services, 2005.
- SS Oh, JB Croft, KJ Greenlund, C Ayala, ZJ Zheng, GA Mensah, WH Giles. Disparities in Premature Deaths from Heart Disease—50 States and the District of Columbia. http://www/cdc.gov/mmwr/preview/mmwrhtml/mm5306a2.htm
- Lee ET, Cowan LD, et al. Rising tide of cardiovascular disease in American Indians: the Strong Heart Study. 1999;99:2389-2395
- CDC Surveillance for health behaviors of American Indians and Alaska Natives: findings from the Behavioral Risk Factor Surveillance System, 1997-2000. In: CDC Suveillance Summaries (August 1). MMWR 2003;52 (No. SS-7). http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5207a1.htm