Approaches to reducing cardiovascular disease risk and stress effects in underserved populations

Abstract

Background: While the past decade has shown a decrease in mortality and morbidity due to cardiovascular disease (CVD), it remains the leading cause of death for both men and women in the US. The burden of CVD has been demonstrated to disproportionately affect underserved populations. The course and development of CVD has been shown to be affected by modifiable risk factors such as physical inactivity, poor nutrition, smoking, and the psychosocial risk factors of depression, anxiety and stress. Objective: This study sought to explore approaches to reducing cardiovascular disease risk and stress effects in underserved populations; Latina and African American women, and individuals living in a rural population in New Ulm, MN. Method: The first purpose of this dissertation was to describe the results from a secondary data analysis utilizing 2009 and 2011 screening data from the Heart of New Ulm Project (HONU) project. Secondly, we present the results of our recently published literature review that explored the use of motivational interviewing as a technique to reduce CVD risk among African American and Latina women. Results: Women reported higher levels of stress and had higher levels of C-reactive protein (CRP) compared to men at baseline. Men had a significantly higher diastolic blood pressure (DBP) and systolic blood pressure (SBP) and reported more physical activity (PA) and a greater history of heart disease compared to women at baseline. No significant difference was found between change in stress level and changes in SBP, PA or CRP for men; however change in stress level was associated with a change in SBP for women. The covariates of body mass index (BMI) and age demonstrated significant associations with the outcome variables for women; among men, smoking, BMI and education had significant association on the outcome measures.None of the community health promotion events were shown to have a direct effect on any of the outcome variables of interest. The female-specific, SBP model demonstrated a borderline significant indirect effect of stress in 2009 via PA and stress in 2011 on SBP in 2011. The female specific, less than moderate PA (< mod PA) and the greater than moderate PA (> mod PA) models both demonstrated significant indirect effects of stress in 2009 via PA and stress in 2011 on < mod PA and > mod PA, respectively. Additionally, stress for females in 2011 was associated with increased CRP in 2011. The male-specific models demonstrated a significant indirect effect of stress in 2009 on > mod PA and < mod PA in 2011 via PA and stress in 2011, respectively. We found that the use of MI in populations of African American and Latina women demonstrated that MI can be an effective technique to reduce CV risk (Witt et al., 2012). It was shown that positive effects were attained in increasing fruit and vegetable consumption, decreasing hypertension/lowering SBP, achieving weight loss goals, and improving knowledge of CVD risk modification among those receiving motivational interviewing. Conclusion: The results from this study provide compelling evidence that future work exploring the effects of stress on modifiable risk factors for CVD in underserved populations, particularly physical activity and blood pressure is warranted. The work presented here demonstrate that while the effects of stress on the outcomes of interest were small, more intensive, targeted interventions with individuals experiencing elevated stress may produce more substantive effects in mediating the relationship between stress and physical activity and blood pressure. The small effect sizes found in this study may be due to in part, to the lack of intensity of the interventions delivered via HONU programming and may also be attributed to the fact that the HONU interventions did not specifically have a stress reduction component. Use of behavioral interventions such as motivational interviewing have demonstrated efficacy in supporting positive behavior change and could be used as an adjunct component in CVD risk reduction interventions at the population level, particularly among underserved populations. The key is to deliver the intervention consistently and in a culturally appropriate manner.Recommendations for Future Research:Behavior change programs delivered at the population level and future CVD prevention programming in settings such as New Ulm should continue to build upon the lessons learned from community based projects like HONU, the Minnesota Heart Health Program (MHHP), Pawtucket, and the North Karelia Project. Additionally, more work is needed to determine how to support long-lasting behavior change using techniques such as motivational interviewing and ensure that the modifiable risk factors for CVD are addressed. Targeted interventions that address stress among those experiencing the highest levels of stress may prove to have the most impact in mitigating the effect of stress on other modifiable behaviors. As the results from behavior change interventions have demonstrated, uptake of healthy lifestyle and health promoting behaviors and adhering and maintaining those behaviors are a universal problem, regardless of race and sex. Use of behavioral interventions such as motivational interviewing have demonstrated efficacy in supporting and sustaining positive behavior change and could be used as an adjunct component in CVD risk reduction interventions at the population level, particularly among underserved populations. Developing and implementing targeted interventions that clearly address stress reduction among those at risk for CVD is warranted.