Behavioral Strategies for Cardiovascular Risk Reduction in Diverse and Underserved Racial/Ethnic Groups

Introduction

Cardiovascular disease (CVD) is the leading cause of death and disability in the United States across all racial/ethnic groups.¹ Much of the burden of CVD morbidity and mortality is associated with modifiable lifestyle risk factors. A disproportionate share of the burden of CVD and metabolic/vascular risk factors falls on racial and ethnic communities due to a constellation of social, environmental, biological and systems factors.^{1, 2} Disparities are most clearly evident for black Americans as compared to whites.¹ Available data for other racial/ethnic minority populations indicate disparities for certain CVD risk factors or outcomes.^{1, 3}

Despite widespread awareness among clinicians of primary and secondary CVD prevention goals and the potential for improving clinical outcomes by integrating lifestyle risk reduction interventions into practice, the application of these interventions is far from optimal.⁴ Therapeutic goals for primary and secondary prevention have been well established over the last three decades.^{5, 6} Table 1, derived from the AHA scientific statements on primordial,⁴ primary⁵ and secondary⁶ risk reduction and diet and lifestyle recommendations,⁷ delineates targeted goals and risk reduction strategies across the spectrum of prevention. Primary prevention seeks to avoid a first occurrence of CVD among individuals at risk through smoking cessation; management of blood pressure (BP), lipids and glucose; weight control, and dietary and physical activity counseling.⁵ Secondary prevention aims for intensive and comprehensive management of risk factors in those with established CVD and is associated with improved survival and reduction in recurrent events.⁶ Secondary prevention benchmarks for lipid management are lower than for primary prevention, but BP, smoking, dietary and physical activity goals are the same. Based on a growing recognition that subclinical disease develops over many years and with varying levels of risk, the necessity to broaden the focus of CVD prevention to include primordial prevention, the avoidance of adverse levels of risk factors in the first place, is now recognized.⁴ Including primordial prevention in the risk reduction paradigm necessitates promoting health behaviors that have been associated with decreased CVD morbidity across the lifespan and with a population focus.

Table 1.

Established metrics and Strategies for Prevention of CVD in adults

Targeted Risk Factor	Ideal CV Health Definition* Primordial Prevention Goals	Primary Prevention Goals	Secondary Prevention Goals	Strategy
Smoking	Never or quit > 12 mo ago	Complete cessation. No exposure to environmental tobacco smoke.	Complete cessation. No exposure to environmental tobacco smoke.	Ask about tobacco use at every visit. Advise every tobacco user to quit. Assess the smoker's willingness to quit. Assist the smoker to make a plan for quitting and provide counseling. Arrange follow-up, referral and/or pharmacotherapy. Urge avoidance of environmental exposure.
Dietary Pattern	4 – 5 components of the primary metrics Fruits and vegetables; ≥ 4.5 cups per day Fish: ≥ two 3.5-oz servings per week (preferably oily fish) Fiber-rich whole grains (≥ 1.1 g of fiber per 10 g of carbohydrate); ≥ three 1-oz-equivalent servings per day Sodium: < 1500 mg per day Sugar-sweetened beverages; ≤ 450 kcal (36 oz) per week. Secondary metrics Avoidance of trans fat and saturated fat Nuts, legumes, and seeds: ≥ 4 servings per week Processed meats: none or ≤ 2 servings per week Saturated fat: < 7% of total energy intake.	An overall healthy eating pattern.	An overall healthy eating pattern.	Balance calorie intake and physical activity to achieve or maintain a healthy body weight. Consume a diet rich in vegetables and fruits. Choose whole-grain, high-fiber foods Consume fish, especially oily fish, at least twice a week Limit your intake of saturated fat to <7% of energy, trans fat to <1% of energy, and cholesterol to < 300 mg per day Minimize your intake of beverages and foods with added sugars. Choose and prepare foods with little or no salt If you consume alcohol, do so in moderation. When you eat food that is prepared outside of the home follow the AHA Diet and Lifestyle Recommendations.
Physical activity	≥ 150 min/wk moderate intensity or ≥ 75 min/wk vigorous intensity or combination	At least 30 min of moderate-intensity physical activity on most (and preferably all) days of the week.	30 minutes, 7 days per week (minimum 5 days per week)	For all patients, assess risk with a physical activity history and/or an exercise test, to guide prescription. For high risk patients, consult physician before initiating vigorous exercise program. For all patients, encourage 30 to 60 minutes of moderate-intensity aerobic activity, such as brisk walking, on most days of the week, supplemented by flexibility training and an increase in daily lifestyle activities. Encourage resistance training at least 2 days per week.
Body Mass Index	< 25 kg/m2	Achieve and maintain desirable weight (body mass index 18.5–24.9 kg/m2). When body mass index is ≥25 kg/m2, waist circumference at iliac crest level ≤40 inches in men, ≤35 inches in women.	Body mass index: 18.5 to 24.9 kg/m2 Waist circumference: men <40 inches, women <35 inches	Assess body mass index and/or waist circumference on each visit and consistently encourage weight maintenance/reduction through an appropriate balance of physical activity, caloric intake, and formal behavioral programs when indicated to maintain/achieve a body mass index between 18.5 and 24.9 kg/m2. If waist circumference (measured horizontally at the iliac crest) is ≥35 inches in women and ≥40 inches in men, initiate lifestyle changes and consider treatment strategies for metabolic syndrome as indicated. For overweight/obese persons, reduce body weight by 10% in first year of therapy.
Blood Pressure	<120/80	<140/90 mm Hg; <130/85 mm Hg if renal insufficiency or heart failure is present; or <130/80 mm Hg if diabetes is present.	<140/90 mm Hg or <130/80 mm Hg if patient has diabetes or chronic kidney disease	For all patients: Initiate or maintain lifestyle modification—weight control; increased physical activity; alcohol moderation; sodium reduction; and emphasis on increased consumption of fresh fruits, vegetables, and low-fat dairy products. For patients with blood pressure ≥140/90 mm Hg (or ≥130/80 mm Hg for individuals with chronic kidney disease or diabetes): As tolerated, add blood pressure medication, treating initially with ß-blockers and/or ACE inhibitors, with addition of other drugs such as thiazides as needed to achieve goal blood pressure.
Cholesterol	< 200 mg/dL	Primary goal: LDL-C <160 mg/dL if ≤1 risk factor is present; LDL-C <130 mg/dL if ≥2 risk factors are present and 10-y CHD risk is <20%; or LDL-C <100 mg/dL if ≥2 risk factors are present and 10-y CHD risk is ≥20% or if patient has diabetes. Secondary goals: (if LDL-C is at goal range): If triglycerides are >200 mg/dL, then use non-HDL-C as a secondary goal: non-HDL-C <190 mg/dL for ≤1 risk factor; non-HDL-C <160 mg/dL for ≥2 risk factors and 10-y CHD risk ≤20%; non-HDL-C <130 mg/dL for diabetics or for ≥2 risk factors and 10-y CHD risk >20%. Other targets for therapy: triglycerides >150 mg/dL; HDL-C <40 mg/dL in men and <50 mg/dL in women.	LDL-C <100 mg/dL If triglycerides are ≥200 mg/dL, non-HDL-C should be <130 mg/dL	For all patients: Start dietary therapy. Reduce intake of saturated fats (to <7% of total calories), trans-fatty acids, and cholesterol (to <200 mg/d). Adding plant stanol/sterols (2 g/d) and viscous fiber (>10 g/d) will further lower LDL-C. Promote daily physical activity and weight management. Encourage increased consumption of omega-3 fatty acids in the form of fish or in capsule form (1 g/d) for risk reduction. For lipid management: Assess fasting lipid profile in all patients, and within 24 hours of hospitalization for those with an acute cardiovascular or coronary event. For hospitalized patients, initiate lipid-lowering medication as recommended below before discharge according to the following schedule: LDL-C should be <100 mg/dL If baseline LDL-C is ≥100 mg/dL, initiate LDL-lowering drug therapy. If on-treatment LDL-C is ≥100 mg/dL, intensify LDL-lowering drug therapy (may require LDL-lowering drug combination). If baseline LDL-C is 70 to 100 mg/dL, it is reasonable to treat to LDL-C <70 mg/dL. If triglycerides are 200 to 499 mg/dL, non-HDL-C should be <130 mg/dL. Further reduction of non-HDL-C to <100 mg/dL is reasonable. Therapeutic options to reduce non-HDL-C are: ◦ More intense LDL-C–lowering therapy, or ◦ Niacin (after LDL-C–lowering therapy) ◦ Fibrate therapy (after LDL-C–lowering therapy) If triglycerides are ≥500 mg/dL, therapeutic options to prevent pancreatitis are fibrate or niacin before LDL-lowering therapy; and treat LDL-C to goal after triglyceride-lowering therapy. Achieve non-HDL-C <130 mg/dL if possible.
Type 2 Diabetes	Fasting plasma glucose < 100 mg/dL	Normal fasting plasma glucose (<110 mg/dL) and near normal HbA1c (<7%).	HbA1c <7%	First-step is vigorous modification of other risk factors (eg, physical activity, weight management, blood pressure control, and cholesterol management as recommended above). Second-step therapy is usually oral hypoglycemic drugs: sulfonylureas and/or metformin with ancillary use of acarbose and thiazolidinediones. Third-step therapy is insulin. Treat other risk factors more aggressively (eg, change BP goal to <130/80 mm Hg and LDL-C goal to <100 mg/dL). Coordinate diabetic care with patient's primary care physician or endocrinologist.

Information adapted from AHA Guidelines for primordial prevention,¹¹ primary prevention,⁵ secondary prevention,⁶ and diet and lifestyle recommendations.⁷

The need for effective prevention strategies is especially urgent for racial/ethnic minority communities where the prevalence of risk factors is high and control of these risk factors remains low. This review examines evidence-based strategies to facilitate integration of established lifestyle risk reduction interventions in diverse and underserved racial/ethnic groups and offers practical approaches to achieve primary and secondary prevention in these populations. By focusing on behavioral strategies that target the individual and that can be implemented by the clinician at the point of service we have, by definition, limited the scope of the paper. Effective broadly based policies that affect tobacco control, nutrition, physical activity and access to care^{4, 8} as well as strategies to increase guideline concordant delivery of pharmacologic and interventional cardiovascular care are important in combination with clinician-delivered individually based behavioral interventions; but a through examination of the impact of these policies are beyond the scope of this paper.

This paper provides a brief overview on disparities in CVD health status, lifestyle risk factors and health care. Successful CVD risk reduction strategies targeted to lifestyle behaviors are then described with a focus on research that demonstrates benefit in racial/ethnic minorities. General issues related to cultural competence and cultural tailoring are also discussed.

Background

Racial/ethnic Minority Populations

U.S. health statistics typically use categories based on “race” (African American or black; white, American Indian/Alaska Native (AI/AN), Asian Americans, and Native Hawaiians and Other Pacific Islanders (NHOPI), and also separate people who report Hispanic ethnicity from those who do not (e.g., Mexican American or Hispanic vs. non-Hispanic black and non-Hispanic white).⁹ The need for separate consideration of Asian¹⁰and Pacific Islander¹¹ populations is now recognized, given the heterogeneity of CVD Risk profiles and demographic characteristics within each of these broader categories; thus, the use of a single Asian/Pacific Islander category is decreasing. Data for black Americans and, more recently, Mexican Americans, are much more available than data for other racial/ethnic minorities.¹¹ In addition, because of the heterogeneity in demographic and cultural variables as well as CVD risk factors in the broader ethnic minority categories generally, data reported for aggregate categories may be misleading and generalities from data for a single subgroup are imprecise. For example, Puerto Ricans may have different CVD risk profiles when compared with Mexican or Cuban Americans. Asians from India or Pakistan may have different CVD risk profiles compared to those from China or Japan.^{1, 10}

This paper focuses on race/ethnicity since these designations identify groups known to suffer a disproportionate burden of CVD, but acknowledges the heterogeneity within these groups and the limitations of these socially constructed categories.¹ We recognize that race and ethnicity are complex concepts that elude simple, discrete categorization and that many factors influence the health of individuals in socially constructed racial/ethnic categories including environment, access to care, lifestyle patterns and perhaps ancestry.^{12, 13} Biological differences in glucose and lipid metabolism as well as the metabolism of several cardiac medications for racial/ethnic groups have been reported and may also contribute to poorer outcomes.^{14, 15} As summarized below, racial/ethnic differences in CVD risk also vary by gender.⁹

Disparities in CVD Health Status

Hypertension is a leading preventable cause of premature death in the United States and is a major contributor to the disparate burden of CVD borne by racial/ethnic minorities, particularly Black Americans. Once diagnosed with high BP, racial/ethnic minorities are less likely to achieve adequate control and more likely to experience end-organ damage.^{11, 16, 17} Although more data are available for Black Americans, high rates of hypertension have been noted for American Indians¹⁸ and Asian American populations.¹⁹ Mexican Americans have lower rates of hypertension compared to other racial/ethnic subgroups (although this may be more a function of undetected disease than true prevalence) but once diagnosed they are the least likely to be controlled.¹¹

An estimated 47% of Americans age 20 and older have total blood cholesterol levels of 200 mg/dL or higher.¹¹ Mexican American women and men have higher rates of dyslipidemia (51%, 49%) than their white counterparts and they are less likely to be aware¹¹ or controlled.²⁰ Although black American men and women are less likely to experience dyslipidemia (40%, 42%)¹¹ once identified they are less likely to be controlled,¹¹ or prescribed lipid-lowering therapy²¹ than their white counterparts. Data on awareness, treatment and control for Hispanics other than Mexican Americans, Asian Americans (including Asian sub-groups) and AI/AN are not available and are needed.¹

Addressing obesity and diabetes are also critical for reducing overall CVD risk, as addressed in other AHA statements.^22–24 Downward shifts in population levels of cholesterol, BP and smoking account for nearly half of the decline in age-standardized CVD deaths over the past four decades, however increasing obesity and type 2 diabetes offset this trend and contribute to the persistent national CVD and stroke burden.^{4, 25} Black women and Mexican American men¹¹ are the most likely to have a (body mass index) BMI ≥25 (80%, 75%). AI/AN are the most likely to be diagnosed with diabetes (15%), with high prevalence noted for Black and Mexican American women (13%), black men (13%) and NHOPI²⁶ (12%) compared to white men and women (7%). Of particular concern in relation to global risk, the prevalence of two or more CVD risk factors was highest among Black Americans and AI/AN (49%; 47%), although information on Hispanic/Latinos, Asian Americans, and NHOPI is less complete than for blacks, whites and Mexican Americans.¹

The recently released American Heart Association (AHA) science advisory on cardiovascular disease in Asian Americans points to the need to collect more data on this heterogeneous racial/ethnic group.¹⁰ The authors note the rapid growth of the Asian American population and that only recently have subgroups of Asian Americans been included in national health surveys. Of particular importance, the thresholds for certain risk factors in Asian descent populations may differ from typical definitions.²⁷ Studies suggest that Asians with lower BMI compared with whites may have a similar proportion of body fat,²⁸ and lower thresholds defining obesity have been identified.^{10, 29} This information has relevance to clinical care since Asians have higher rates of diabetes than would be expected based on their BMI levels.³⁰ This same issue may apply to measures of high waist circumference, a well established risk factor for insulin resistance and Type2 Diabetes.³¹

The value of preventing and controlling these CV factors is well established and the disparities, as presented, are substantial. Thus, strategies to effectively reduce risk in these high risk groups are of critical importance.

Disparities in CVD Lifestyle Risk Factors

Cigarette smoking continues to be a leading cause of preventable morbidity and mortality in the United States.³² The overall prevalence of active smokers among American adults is 21%; men are more likely to smoke than women (23%, 18%). Among racial/ethnic groups AI/AN had the highest prevalence (24%), Black Americans and whites had similar rates (21%, 22%), and Hispanics and Asians had the lowest rates (16%, 10%).^{11, 32} Black Americans suffer a higher burden of health consequences of smoking, particularly lung cancer and cardiovascular disease, despite the fact that their smoking prevalence is similar to that in whites.^{33, 34} Black and Hispanic smokers are less likely than whites to be asked about smoking habits or offered tobacco-cessation interventions^{35, 36} despite the fact that they have higher health consequences of cigarette use.³⁷ Few studies included Native Americans despite their high smoking rates.

Regular physical activity is essential to promote and maintain health. However current estimates indicate that only 33 percent of Americans meet current physical activity recommendations.¹¹ The lack of physical activity is associated with preventable morbidity and mortality,³⁸ and differences in levels of physical activity are observed by race/ethnicity. American Indians and blacks were more likely to report not engaging in vigorous activity (68%, 66%) than white respondents, Asians and NHOPI (57%, 60%, 61%).¹¹ Although reported using a different metric, Hispanics are also relatively inactive; only 25 percent report regular leisure-time physical activity.¹¹ Increasing physical activity is an important intervention target in both primary and secondary prevention of CVD and is associated with reductions in BP, lipid profiles, blood sugar and weight as well as maintaining healthy weight and sustaining weight loss once achieved;³⁸ this makes it imperative to implement successful strategies to improve health behaviors in diverse groups.

A Framework for Addressing Disparities in Health Care

Despite the plethora of studies documenting racial/ethnic disparities in cardiovascular health and the national goal of eliminating health disparities, these disparities persist. The Institute of Medicine (IOM), in its seminal report Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare, did much to raise public consciousness about disparities in health care and proposed a framework for conceptualizing the sources of disparities.² They defined disparities as racial/ethnic differences that are not explained by the underlying condition or patient preferences. The IOM suggested that understanding and addressing institutional (systems), provider (clinical encounter), and patient-level variables which lead to differences in the quality of healthcare received by minorities is critical to finding effective solutions.

The Robert Wood Johnson Foundation (RWJF) initiative, Finding Answers: Disparities Research for Change³⁹ builds on the IOM work. They acknowledge that the social determinants of health including poverty, education and access to care are significant barriers to equitable care,^{40, 41} and must be addressed to eliminate disparities,⁴² these factors may be beyond the scope and control of providers.³⁹Finding Answers proposes a framework for providers and health care organizations to understand disparities solutions and posits that positive interactions between patients and providers, in a system that acknowledges individual characteristics, community values, and societal norms can lead to improved processes of care which in turn lead to improved outcomes.⁴³

Behavioral Interventions to Prevent CVD or Reduce Cardiovascular Risk

As noted previously, although considerable published data support the effectiveness of primary and secondary prevention of CVD risk factors on reducing all cause cardiovascular morbidity and mortality across all racial/ethnic populations^{5–8, 44, 45} achievement of risk reduction has not been optimal, particularly for racial/ethnic minority populations. Achieving CVD risk reduction and ultimately reducing death and disability from cardiovascular diseases requires specific strategies for lifestyle change and adherence to medical therapies across all racial/ethnic populations.^{3, 11}

Interventions that target smoking cessation

A complex constellation of biological, social, environmental and psychological factors influences smoking prevalence and dependence on tobacco. There is no uniform characterization that predicts initiation or the degree of dependence³⁷ however there are compelling racial/ethnic group differences in smoking behaviors that make culturally tailored smoking cessation interventions a priority. Blacks are more likely than Hispanics or Whites (69%, 29%, 22%) to smoke mentholated cigarettes which have been shown to enhance smoking initiation and inhibit quitting.^{33, 46} Black Americans smoke fewer cigarettes per day, however, the favored brands are higher in tar and nicotine. They also make more quit attempts per year but are less likely to quit successfully compared with non-Hispanic White smokers.^{33, 34, 47–50} Hispanic Americans are less likely to be heavy smokers compared to non-Hispanic Whites but are also less likely to receive smoking cessation advice, culturally/linguistically tailored services or pharmacotherapy interventions,^{49, 51} and have low quit rates.⁵² Little has been reported about smoking preferences and behaviors and the influence of cultural practices in relation to smoking in the AI/AN populations, although they have the highest prevalence of active smoking and low quit rates.^{33, 52} More data about smoking behavior is needed in understudied AI/AN, Asians and NHOPI populations.⁵²

Robles and colleagues systematically reviewed smoking-cessation pharmacotherapies in diverse populations and concluded that pharmacotherapy, including nicotine replacement (gum, patch, nasal spray) and/or sustained release bupropion, is effective in achieving smoking cessation in racial/ethnic populations.⁵³ The majority of these studies were done in blacks; data are less available for AI/AN, Hispanic and Asian populations.⁵³ Quit rates with pharmacotherapy was attenuated in blacks who smoked within 30 minutes of awakening, smoked menthol cigarettes and had higher levels of salivary cotinine. These individuals may need higher doses of pharmacotherapy even if they are light smokers. Another consideration is that quit rates were attenuated at six months; thus, booster sessions are important for sustained change.⁵³ One prospective observational study (n=1,782) evaluated the effectiveness of nicotine replacement (patch) on cessation rates among the five major racial/ethnic groups using Medicaid claims data and a survey (response rate 58%). Although there were no statistically significant between group differences in 30-day cessation rates (p=0.14) there was a trend for Asians (18%) to have better quit rates than whites, blacks or NI/NA (10%, 12%, 9%).⁵⁴ These studies in combination suggest that smoking-cessation pharmacotherapy may be beneficial for individuals in racial/ethnic minority populations but that between-group differences persist.

Combining culturally/linguistically-tailored cognitive-behavioral counseling with tobacco-cessation medication has been found to increase rates of smoking cessation in minority populations. Studies which combined a counseling intervention (eight brief cognitive-behavioral/motivational counseling sessions either in-person or telephonically) in combination with sustained-release bupropion⁴⁷ or transdermal nicotine patch,⁵⁵ yielded 6 month quite rates of 21% and 17% respectively for blacks. Combining open-label buproprion, the nicotine patch and individual counseling in an 8 week intervention resulted in an impressive overall quit rate of 53%. Of note, the intervention was effective for all three racial/ethnic groups included in the study; however Black Americans benefitted to a lesser extent compared to Hispanics and whites (38%, 41%, 60% respectively).⁵⁶

The use of clear, direct advice from health care providers to stop smoking continues to be the single most influential way to achieve smoking cessation in most patient populations and when provider education is linked to system-wide change, cessation rates improve.^{55, 57–59} Adding smoking status as a vital sign to the clinic assessment process increased the proportion of providers who asked about smoking status, advised patients to quit and arranged follow-up.⁵⁹ Clinic-wide initiatives including; culturally/linguistically tailored behavior change stage-specific provider-delivered cessation advice and techniques, signed contracts, waiting room posters about cessation, written information, follow-up letters, post-intervention behavioral counseling, electronic tracking, and medication cost reimbursement was associated with greater reduction in smoking across racial/ethnic groups.⁶⁰ Overall, given the significant disparities in smoking prevalence, cessation rates and smoking-related morbidity and mortality experienced by racial/ethnic populations, it is encouraging to note that smoking cessation interventions can be effective in these underserved populations and remains incumbent upon clinicians to utilize best-practice strategies.

Behavioral strategies to improve physical activity and heart healthy nutrition

Lifestyle behaviors, including physical activity and dietary habits, are influenced by a complex constellation of personal and environmental factors. Cultural norms, values, beliefs and practices contribute to shaping behavior and are important considerations in effective interventions to modify diet and exercise behaviors in diverse underserved racial/ethnic groups.⁶¹ Considerable interpersonal variation exists within any racial/ethnic subgroup however; thus, personally tailored interventions within the cultural context appear to be most successful.⁶¹ Environmental factors such as lack of access to healthy affordable food or safe, affordable places to exercise exert a significant influence on healthy lifestyle behaviors. The AHA has several guidelines relevant to policy remedies to address the inequities in neighborhood resources supportive of following a healthy lifestyle.^{4, 8}

A 2010 AHA Scientific Statement provides an extensive review of behavioral interventions to modify adverse physical activity and dietary lifestyle changes and provides insights into effective strategies for increasing physical activity and heart healthy nutrition.⁶¹ Of the 73 randomized trials reviewed, 25 permitted inferences about the success of the intervention in racial/ethnic minority participants. Most of these randomized trials examined interventions in Black Americans (n=17) and Hispanics (n=8) with no trials having a sufficiently large sample of Asian Americans or American Indians to support inferences about these groups. Although the between-group effect sizes tended to be small (0.00 to 0.33),⁶¹ such modest changes can reflect clinically significant improvements in a substantial proportion of participants.⁶²

Strategies to change physical activity and dietary intake targeted at individuals typically incorporate cognitive-behavioral techniques that focus on modifying the way an individual views situations, appraises the meaning of the situation, and makes choices.^{63, 64} Common cognitive-behavioral techniques shown to be effective generally and in minority populations include goal setting, self-monitoring, feedback and reinforcement, self-efficacy enhancement, incentives, modeling, problem solving, relapse prevention and motivational interviewing.⁶¹ Goals can be identified by either the participant^{61, 65, 66} and/or provider^{61, 67, 68} and should be specific (measurable), realistic but challenging and attainable in the specified time frame.⁶¹ Self-monitoring, developing an awareness of daily lifestyle habits and areas where these behaviors conflict (or concur) with desired behavior, can include simple strategies like handwritten diaries, or more technology based approaches such as on-line electronic logs, and is associated with positive lifestyle change.^{69, 70} The frequency and timing of behavioral interventions vary widely among studies. However, evidence does suggest that multiple sessions are more effective than single-session interventions.^{61, 66, 67, 70, 71} Little research is available about the optimal number and timing of visits, but expert opinion suggests that 12 weeks in necessary to achieve behavior change,⁶⁴ and that follow-up should be assessed at 6 weeks, then at 6, 9 and 12 months and every 6 months thereafter.⁶¹ Several studies demonstrating dietary or physical activity changes that were sustained over twelve months in minority populations typically had follow-up contacts over at least 4 months.^{61, 68}

Changing behavior is a complex process which takes place over time and necessitates the individual being able to problem solve and deal with relapses. Interventions that promote the individual's ability to identify barriers to successful behavior change, identify problems as they arise and to identify and engage potential solutions is important in both achieving goals and maintaining success.^{61, 65, 66, 72} When lapses occur, the ability to utilize these problem solving techniques to monitor and adjust their behavior (relapse prevention) is associated with continued success.^{61, 66, 72} Feedback and reinforcement, which allow providers to guide the individual through the process of changing behavior by highlighting progress toward goals and the consequences of non-adherence and supporting relapse prevention, are frequently incorporated in successful behavior change interventions.^{61, 66, 68} Self-efficacy, the individual's perceived ability to make a desired change (e.g. to incorporate the lifestyle changes into their life),^{61, 73} has been associated with positive behavioral outcomes.^{61, 68} Modeling a behavior entails incorporating a demonstration of the behavior in the intervention. Examples might include cooking-demonstrations or observing peers engaging in this behavior. Studies that utilize modeling report favorable outcomes.^{61, 68, 74, 75} In addition, motivational interviewing has captured the interest of clinicians recently and is associated with favorable adherence to dietary and physical activity recommendations.^{61, 76, 77} Motivational interviewing acknowledges the individual's role and responsibility in making healthy choices and participating in their care. It challenges the individual to “own” his or her goals and choices and recognize that change is an evolving process where people both move forward toward goals (progress) and fall back on old patterns (relapse) but that success is within their reach. Motivational interviewing challenges the provider to relinquish ownership of the “truth” and to become a reflective listener.^{78, 79} Interventions that target the delivery of services have been studied and include both group and individual approaches. Behavioral interventions embedded in group sessions and including didactic education and the cognitive-behavioral counseling strategies mentioned above have been associated with positive outcomes.^{61, 66–70, 72, 74, 80–84} Individualized behavioral counseling provided by health care professionals allows the provider to tailor the message to the individual's particular needs and has been shown to be effective.⁶¹ However, for underserved racial/ethnic groups, individual counseling may be less effective⁶⁸ compared to group interventions.^{61, 69, 71}

Strategies to reduce hypertension

Several large hypertension trials have demonstrated that culturally tailored care which utilizes both systems (access to care) and individual strategies (behavioral and pharmacologic) can effectively lower BP among members of racial/ethnic minority populations;^{44, 85–90} and that these changes can be sustained over time.⁹¹ The International Society on Hypertension in Blacks published a consensus statement which asserts that with early and aggressive guideline-concordant treatment that is culturally and linguistically tailored, blacks can achieve the same level of BP control as their non-Hispanic white counterparts.⁹² Thus the onus is on providers to treat individuals early and to goal using evidence-based culturally/linguistically appropriate strategies.

Dietary pattern change, sodium reduction, and weight reduction may be particularly important for BP control in black Americans and other minority populations.^{44, 86–88, 93, 94} The Dietary Approaches to Stop Hypertension (DASH) study evaluated the BP lowering effects of an eating plan that was high in fruits and vegetables and low in saturated fat in a study cohort of hypertensive and non-hypertensive adults that was two-thirds minority.⁸⁵ Sodium intake and body weight were held constant. Black Americans in particular and other minorities enrolled in the study achieved systolic BP reductions better than or similar to whites.⁹⁵ A subsequent study, DASH-Sodium, evaluated the combined effects of the DASH diet and sodium reduction and reported benefits in BP lowering for Black Americans as well as other demographic subgroups.^{87, 94} The PREMIER trial tested a multi-component lifestyle intervention (group and individual counseling about weight loss, reduced sodium intake, increased physical activity and limited alcohol consumption with specific attention to cross-cultural issues) compared to the same intervention enhanced with the DASH diet or advice only.^{88, 93} PREMIER demonstrated that multiple lifestyle changes can be undertaken concomitantly and lead to a significant BP reduction; that a more intensive intervention produced greater BP reductions than less frequent counseling;⁹³ and that a multicomponent intervention is achievable and effective in diverse groups including minorities, women and the elderly.

Self-monitoring is effective in improving BP control.⁹⁶ In a recent trial that enrolled a significant proportion of Black Americans (49%), usual care was compared to bi-monthly culturally-tailored nurse counseling via telephone, thrice weekly home BP monitoring alone, or a combination of bi-monthly phone counseling and home BP monitoring. While each of the three interventions demonstrated improved BP control, the combination of home BP monitoring and culturally-tailored telephone counseling led to significant reductions in systolic BP (4 mmHg) at 24 months.⁹⁷

Davis and colleagues from the RWJF Disparities initiative conducted a systematic review of interventions that improve hypertension care in racial/ethnic communities and found 62 trials that enrolled at least 50 percent minority individuals between 1995 and 2006.³⁴ They concluded that culturally tailored lifestyle interventions which target individuals, including nutrition counseling^{85, 88, 91, 98, 99} and exercise^{100, 101} are effective in lowering BP in minorities and that sodium restriction yields the greatest benefit in lowering BP in hypertensive Black Americans. Of note, all of these trials incorporated cultural tailoring (including linguistic/literacy needs) of individual and group interventions, a necessary first step in designing effective cross-cultural interventions.^102–104

Although individual level interventions are effective, Davis and colleagues concluded that the greatest gain can be attained from organization-level interventions, such as clinic-reorganization and nurse-led multidisciplinary teams.¹⁰⁵ Care coordination based on a team approach to care has been shown to be effective. This approach views health care professionals, patients, and community resources as integral members or components of the health care team and may be particularly important in busy clinics serving low income populations where quality care is adversely affected by space, staffing, revenue, and other constraints.¹⁰⁶ Interventions that focused on improving the quality of care processes, including individual tailoring of physician, nursing, pharmacist and nutritionist services were effective in improving rates of BP control in both whites and blacks in an academic family practice clinic¹⁰⁷ and an urban public hospital¹⁰⁸ although sustaining the intervention was challenging. Interventions that included nursing^109–113 and community health workers^{110, 111} were found to be effective. Hill and colleagues demonstrated that even in young urban black men (a hard to reach/treat sub-group) BP can be reduced over time with an educational/ behavioral/ pharmacologic intervention provided by a nurse practitioner/community health worker/physician team.¹¹¹ They noted, as did other researchers,^{110, 114} that utilizing principles of community based participatory research where the community is invited to be part of designing and implementing the intervention, integrating a community health worker within the team, and placing services in the community of the study participants were important contributors to the success of the intervention.

Strategies to reduce hyperlipidemia

Davis and colleagues reviewed 14 dyslipidemia intervention studies that enrolled a sufficient number of racial/ethnic and underserved populations to make inferences and concluded that interventions that target the individual and/or the health care system can be effective in improving lipid profiles.¹⁰⁵ In a randomized, modified cross-over trial Ard and colleagues demonstrated that a program based on a modified Duke Rice Diet and which included culturally-sensitive recipes, addressed attitudes about exercise and included family members in the weight loss efforts engineered a 3% reduction in total cholesterol. The control group did not show significant reduction.⁹⁸ Another trial that focused on nutrition counseling randomized African American men and women to either a self-help or full-instruction behaviorally-oriented nutrition counseling intervention (reductions in intake of dietary fat, cholesterol and sodium) designed to be suitable as an adjunct to usual physician care. Food cards and an illustrated nutrition guide for self-paced learning were introduced during an initial research clinic visit, with periodic brief counseling sessions with a nutritionist (baseline and every 4 months). The full-instruction group attended four group classes taught by a nutritionist and received a video and 12-part audioseries program and workbook in addition to the food cards and nutrition guide. Twelve month follow-up demonstrated an average 7 to 8 percent reduction in total cholesterol in both the self-help and full-instruction groups, with the largest reductions in those who reported greater use of the counseling materials.⁸³

Interventions that target the provider and health care organization have also been shown to improve lipid profiles in racial/ethnic and underserved populations. In one trial that enrolled primary care clinicians from community health centers, clinicians were randomized to treat their dyslipidemic patients (40% blacks, 11% AI) using usual care, or a structured intervention. The intervention consisted of a structured assessment and treatment program (brief dietary assessment and three 5- to 10-minute dietary counseling sessions given by the primary care clinician, referral to a local dietitian if the low-density lipoprotein cholesterol (LDL-C) remained elevated at 4-month follow-up, and a prompt for the clinician to consider lipid-lowering medication based on the LDL-C at 7-month follow-up). Total cholesterol and LDL decreased more in the intervention group than the control group although the changes were modest.¹¹⁵ Jenkins and colleagues examined whether a quality improvement initiative (performance reports, chart prompts of eligible patients, evidence-based treatment recommendations) could improve lipid outcomes in a sample of African American and white patients. Following implementation of the QI initiative the charts of 2,860 dyslipidemic patients treated by six clinicians over a one-year period were examined and improvement in total cholesterol and HDL were observed for both groups.¹⁰⁷

Strategies to reduce multiple risk factors in low income minority populations

Racial/ethnic minorities are more likely to have multiple risk factors and clustering of risk factors is associated with higher risk of premature morbidity and mortality.^{3, 11, 116} Data are accumulating that multidisciplinary, multi-component interventions effectively reduce overall risk in underserved minority populations. A randomized clinical trial evaluating a nurse and dietitian-led case management intervention for CVD risk reduction was undertaken within a large county health care system.¹¹⁷ Participants were low income men and women, primarily racial/ethnic minorities with multiple risk factors. Intensive lifestyle change and evidence-based medical therapies for elevated risk factors formed the basis of the case-management interventions, which was delivered by Spanish speaking nurses and dietitians in the county health clinic and was additive to usual primary care. In addition, participants in the study were referred to community exercise facilities, including senior centers, to improve adherence to physical activity recommendations. The primary outcome measure was change in Framingham risk score (FRS). At 16 months of follow up, mean FRS was significantly lower for the patients in case management versus usual care after adjusting for baseline FRS. Change in systolic and diastolic BP was the main contributor to the reduction seen in the FRS. Although the overall changes were modest, they were clinically significant. The authors concluded that a culturally/linguistically competent multidisciplinary, multi-component intensive case management intervention for CVD risk reduction in low income predominately racial/ethnic minorities is an effective strategy in managing overall CVD risk.¹¹⁷

In an earlier study by Haskell, multiethnic patients seen for primary care in predominately free clinics were recruited to a randomized trial evaluating case management for CVD risk reduction. The disease management program was delivered by Spanish speaking nurses and dietitians, supervised by physicians, and included comprehensive lifestyle changes and medications. Significant changes in BP, blood lipids, fasting blood glucose, self reported measures of physical activity, and heart healthy nutrition were found at 12 month follow-up. These changes were attributed to improved use of and access to recommended medications, health education, and adherence to both lifestyle and pharmacologic therapies.¹¹⁴

Embedding the intervention in the community and explicitly addressing barriers to chronic disease management has been found to be effective in improving BP, lipids and smoking. Becker and colleagues enrolled Black American adults with a family history of CVD to participate in an enhanced primary care (EPC) group or an urban community-based multi-component CVD risk reduction intervention (CBC). In the CBC group a nurse practitioner provided disease management and a dietitian provided individual lifestyle counseling at a convenient site selected by the community of interest. Participants received their CV and smoking cessation medications free of charge at any pharmacy and were able to attend bi-weekly sessions at the YMCA led by the community health worker. Both groups achieved significant reductions in LDL and BP at 1 year compared to baseline. The CBC group however was two times more likely to achieve LDL and BP goals. They also reported significant reductions in smoking status for the CBC group compared to the EPC group. These data suggest that when access to essential services (medications, supports for lifestyle change) are held constant, Black Americans can achieve treatment goals and that community based, nurse practitioner/community health worker care may improve outcomes.¹¹⁰ Five year follow-up demonstrated that the difference between the two groups was attenuated, with the CBC group demonstrating some regression toward baseline and the EPC group continuing to improve, however compared to baseline, the positive changes in LDL, BP and smoking observed for both groups were preserved.¹¹⁸ These studies and others suggest that implementation of a multi-disciplinary, multi-factorial approach to CVD risk reduction embedded in the community of interest is effective in low income medically underserved patients.

Many of the interventions discussed thus far (physical activity, nutrition) also impact weight, body mass index (BMI) and glucose control however a comprehensive review of this literature is outside the scope of this paper. In a rigorous systematic review of the diabetes heath disparities literature, Peek and colleagues concluded that interventions that target patients (culturally/linguistically tailored interventions, peer-support, one-on-one interventions [but not on-line interventions]) providers (treatment guidelines, provider education, computer decision-support reminders/prompts, in-person feedback and problem-based learning), and health organizations (electronic medical records, nurse-led multidisciplinary care management teams, databases, rapid HbA1c testing) can achieve meaningful improvement in diabetes outcomes. They assert that we currently have the collective knowledge and skill necessary to apply these strategies in racial/ethnic and underserved populations.¹¹⁹

Careful attention was paid to strategies to address the needs of racially/ethnically diverse populations enrolled in both the PREMEIR¹⁰³ and Diabetes Prevention Program (DPP).¹²⁰ Both of these studies demonstrated significant weight loss and enrolled a sufficient number of minority individuals to make inferences about effects in racial/ethnic subgroups. Examples of cultural tailoring from these trials include: matching race/ethnicity of patient-provider in some cases, ability to tailor the goals/information based on the needs of the individual, linguistic competence, adapting recipes and cooking demonstrations to be ethnically appropriate, multiple methods of self-monitoring, flexibility, and racial/ethnic tailoring of physical activity recommendations.¹⁰⁴ Seidel and colleagues demonstrated that the DPP intervention can successfully be translated into an urban medically underserved community with significant reductions in weight (47% lost ≥ 5% of body weight and 26% lost ≥7%) and other metabolic endpoints. They modified the rigorous DPP intervention (6 months of weekly 1:1 sessions delivered by highly trained professionals) to be more aligned with the realities of practice in an underserved community. The modified intervention included 12 weekly 90-minute group sessions over 12–14 weeks, group classes led by a dietitian and exercise specialist, healthy food choices, emphasis on fat intake and use of a pedometer to encourage increases in physical activity.¹²¹

Translating evidence to practice: a mandate for effective cross-cultural care

Effective cross-cultural care is important to successfully implement CVD risk reduction strategies across all racial/ethnic groups. This is particularly important given the observed disparities in CVD outcomes for racial/ethnic minorities. In order to engage with patients in ways that are culturally competent, providers need to have an awareness of their own cultural values and beliefs, knowledge of the patients' views and experiences, and the requisite skills to deliver culturally/linguistically appropriate interventions.^{104, 122} The language barriers faced by non-English speaking individuals need to be considered and literacy needs to be assessed to address the needs of those individuals with low educational attainment.⁶¹ For lifestyle behavior changes, cultural competence includes recognition that the patient must incorporate clinical guidance into his or her daily routines for fundamental behavioral and social process such as eating and the ability to motivate and facilitate this process. This can be very different from facilitating adherence to medication regimens. Table 2 outlines some of the cross cultural considerations that should be kept in mind when providing prevention counseling to individuals or groups. Additional resources for acquiring cultural and linguistic competencies are available from HRSA¹²³ and the Office of Minority Health.¹²⁴ Acquisition of cross cultural skills however is not simple, nor does it follow a cook-book approach. It requires time, patience and a commitment to meeting the needs of each person as a unique individual.

Table 2.

Applying cross cultural principles in individual or group behavioral/lifestyle counseling for prevention

Issues	Applications
Core issues relate to both provider and patient knowledge, attitudes, and behavior and include communication styles, trust, prejudice, patient, autonomy and family dynamics, the role of the practitioner (expert vs partner), traditions, customs and spirituality.	In general, respect the uniqueness of each individual. Establish a relationship based on respect, empathy and curiosity. Assess decision-making preferences and the role of family. Employ strategies for identifying and bridging different styles of communication. Offer prevention services in a manner compatible with the person's cultural health beliefs and practices and preferred language. Be aware of issues of mistrust and prejudice and the impact of race/ethnicity on clinical decision-making.
The meaning of illness and wellness varies among cultures. Cultural influences contribute to the person's understanding of prevention as well as views on weight, physical activity, or a heart healthy diet.	Ask questions to elicit the patient's understanding of CVD, his or her own risk factors, and clinical recommendations, and outlook on self-care. For example, What do you think caused the problem? How? What worries you the most? What kind of treatment do you think you should receive? What can you do to improve your health? Establish their views on treatment and goals with an emphasis on behavior change.
Patient motivation for and adherence to behavioral change recommendations is strongly influenced by the social contexts of their day-to-day life, social support, previous experience with the health care system, and resources for change	Assess supports for change (family, friends, environment); resources including access to healthy affordable places to exercise and purchase healthy food; literacy/language. Determine previous experiences with changing lifestyle behaviors. Utilize translators as needed and provide verbal and written information that is appropriate for cultural, linguistic and literacy needs. Identify community based behavior change programs and other resources that may assist the patient in meeting his or her goals.
Bringing the patient perspective and clinician perspective together requires negotiation	Strive for collaboration. Consider both your perspective and the patient's perspective and come to a mutual understanding about what will work for this person in relation to the lifestyle recommendations detailed in Table 1. Negotiation can be facilitated by empathy, reflective listening, the ability to roll with resistance and focusing on self-efficacy.

Adapted from the HRSA document Transforming the Face of Health Professions Through Cultural and Linguistic Competence Education¹²³ as well as the Office of Minority Health National Standards on Culturally and Linguistically Appropriate Services (CLAS)¹²⁴ and selected readings.^105,122

It is often challenging for health care providers to recognize that personal, professional and organizational cultures have a significant impact on care. By definition, health care providers bring expert, disease-specific knowledge to the patient/provider interaction and this often informs the providers' expectations of patient behaviors (adherence) irrespective of how the patient might embrace and/or follow that advice.^{104, 125} Negotiating care based on both provider and patient expectations is critical to successful outcomes and it is the responsibility of the provider, not the patient, to find a way to bridge these differences and create win-win scenarios.¹²²

Summary and Conclusions

Within the broad spectrum of strategies needed to address disparities in CVD, behavioral strategies that can be effectively implemented in clinical settings have a critical role. The literature reviewed in this paper provides a menu of options for facilitating behavioral CVD risk reduction in diverse, underserved racial/ethnic groups. Several themes have emerged. It is clear that interventions need to be culturally and linguistically tailored and individualized, with an understanding that that racial/ethnic groups are not monolithic. Multi-component, multidisciplinary teams, often led by a nurse, appear to be the most effective in addressing multiple risk reduction. Including community health workers on the multidisciplinary team is an important addition to address the needs of individuals living in under-resourced areas. Efforts that target providers and the way they deliver behavioral interventions are important to achieve sustained, system-wide improvement in outcomes.

Going forward it will be important for published reports of successful interventions to provide more detailed information about the specifics of the intervention so that the intervention can be disseminated and translated into practice. Often the nuances of these interventions; information important to successful implementation, are lost. It is also important for research studies, including large clinical trials, to include more diverse subjects so that racial/ethnic subgroup comparisons can be made. Oversampling racial/ethnic minorities, including under-studied subgroups in the Asian, Hispanic and American/Indian/Alaska Native communities is necessary so that inferences can be made to these populations.

Recently the AHA released its strategic impact goal; “By 2020, to improve the cardiovascular health of all Americans by 20% while reducing deaths from cardiovascular diseases and stroke by 20%”.⁴ If, as a country, we are to meet this ambitious goal, clinicians and health care organizations will need to implement strategies to reduce CVD risk in racial/ethnic and underserved populations that bear a disproportionate burden of disease. To meet this goal we will be challenged to broaden our prevention perspective beyond primary and secondary prevention to include primordial prevention across the lifespan; a challenge that will necessitate cardiologists collaborating with clinicians from primary care, nursing, nutrition, pharmacy, family medicine, pediatrics and exercise science. Although this paper has focused predominantly on behavioral risk reduction strategies in high risk individuals; it is estimated that the majority of CVD and stroke events occur in individuals with average or only mildly elevated levels of risk, which is where the majority of the population lies.^{4, 126, 127} To achieve the greatest reduction in risk, population wide approaches to CVD risk in understudied racial/ethnic minority communities will be necessary in addition to the individual-level interventions described in this paper.