Recent Advances in Preventive Cardiology and Lifestyle Medicine Behavioral Strategies for Cardiovascular Risk Reduction in Diverse and Underserved Racial/Ethnic Groups

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 as a result of a constellation of social, environmental, biological, and systems factors.1,2 Disparities are most clearly evident for black compared with white Americans.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 3 decades.5,6 Table 1, derived from the American Heart Association (AHA) scientific statements on primordial,4 primary,5 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 a 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. As a result of a growing recognition that subclinical disease develops over many years and with various 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. The need for effective prevention strategies is especially urgent for racial/ethnic minority communities in which 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 this article. Effective, broad-based policies that affect tobacco control, nutrition, physical activity, and access to care4,8 and strategies to increase guideline concordant delivery of pharmacological and interventional cardiovascular care combined with clinician-delivered, individual-based behavioral interventions are important; however, a thorough examination of the impact of these policies is beyond the scope of this article. This article provides a brief overview of the 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.