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• W2075956739 abstract "HomeCirculationVol. 125, No. 1Behavioral Strategies for Cardiovascular Risk Reduction in Diverse and Underserved Racial/Ethnic Groups Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBBehavioral Strategies for Cardiovascular Risk Reduction in Diverse and Underserved Racial/Ethnic Groups Eileen M. Stuart-Shor, Kathy A. Berra, Mercy W. Kamau and Shiriki K. Kumanyika Eileen M. Stuart-ShorEileen M. Stuart-Shor From the University of Massachusetts Boston, College of Nursing and Health Sciences (E.M.S., M.W.K.); Beth Israel Deaconess Medical Center, Boston, MA (E.M.S.); Stanford University School of Medicine, Palo Alto, CA (K.A.B.); and University of Pennsylvania Perelman School of Medicine, Philadelphia (S.K.K.). Search for more papers by this author , Kathy A. BerraKathy A. Berra From the University of Massachusetts Boston, College of Nursing and Health Sciences (E.M.S., M.W.K.); Beth Israel Deaconess Medical Center, Boston, MA (E.M.S.); Stanford University School of Medicine, Palo Alto, CA (K.A.B.); and University of Pennsylvania Perelman School of Medicine, Philadelphia (S.K.K.). Search for more papers by this author , Mercy W. KamauMercy W. Kamau From the University of Massachusetts Boston, College of Nursing and Health Sciences (E.M.S., M.W.K.); Beth Israel Deaconess Medical Center, Boston, MA (E.M.S.); Stanford University School of Medicine, Palo Alto, CA (K.A.B.); and University of Pennsylvania Perelman School of Medicine, Philadelphia (S.K.K.). Search for more papers by this author and Shiriki K. KumanyikaShiriki K. Kumanyika From the University of Massachusetts Boston, College of Nursing and Health Sciences (E.M.S., M.W.K.); Beth Israel Deaconess Medical Center, Boston, MA (E.M.S.); Stanford University School of Medicine, Palo Alto, CA (K.A.B.); and University of Pennsylvania Perelman School of Medicine, Philadelphia (S.K.K.). Search for more papers by this author Originally published3 Jan 2012https://doi.org/10.1161/CIRCULATIONAHA.110.968495Circulation. 2012;125:171–184IntroductionCardiovascular 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.1,3Despite 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.5,6Table 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.Table 1. Established Metrics and Strategies for Prevention of Cardiovascular Disease in AdultsTargeted Risk FactorIdeal CV Health Definition Primordial Prevention GoalsPrimary Prevention GoalsSecondary Prevention GoalsStrategySmokingNever or quit >12 mo agoComplete cessation; no exposure to environmental tobacco smokeComplete cessation; no exposure to environmental tobacco smokeAsk about tobacco use at every visit.Advise every tobacco user to quit.Assess the smoker's willingness to quit.Assist the smoker in making a plan for quitting and provide counseling.Arrange follow-up, referral, and/or pharmacotherapy.Urge avoidance of environmental exposure.Dietary pattern4–5 components of the primary metricsAn overall healthy eating patternAn overall healthy eating patternBalance calorie intake and physical activity to achieve or maintain a healthy body weight.Fruits and vegetables: ≥4.5 cups/dConsume a diet rich in vegetables and fruits.Fish: 2 or more 3.5-oz servings per week (preferably oily fish)Choose whole-grain, high-fiber foods.Fiber-rich whole grains (≥1.1 g fiber per 10 g carbohydrate): 3 or more 1-oz-equivalent servings per dayConsume fish, especially oily fish, at least twice a week.Sodium: <1500 mg/dLimit intake of saturated fat to <7% of energy, trans fat to <1% of energy, and cholesterol to<300 mg/d.Sugar-sweetened beverages: ≤ 450 kcal (36 oz)/wkMinimize intake of beverages and foods with added sugars.Secondary metricsChoose and prepare foods with little or no salt.Avoidance of trans fat and saturated fatConsume alcohol in moderation if at all.Nuts, legumes, and seeds: ≥4 servings per weekWhen eating food prepared outside the home, follow the AHA Diet and Lifestyle Recommendations.Processed meats: 0 or ≤ 2 servings per weekSaturated fat: <7% of total energy intakePhysical activity≥150 min/wk moderate intensity, ≥75 min/wk vigorous intensity, or a combinationAt least 30 min of moderate-intensity physical activity on most (preferably all) days of the week30 min, 7 d/wk (minimum, 5 d/wk)For all patients, assess risk with a physical activity his to ry 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 min 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 d per weekBody mass index<25 kg/m2Achieve 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 and ≤ 35 inches in womenBody mass index, 18.5 to 24.9 kg/m2;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.Waist circumference: <40 inches in men and <35 inches in womenIf 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 mellitus is present<140/90 mm Hg or<130/80 mm Hg if patient has diabetes mellitus or chronic kidney diseaseFor 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 mellitus): as tolerated, add blood pressure medication, treating initially with β-blockers and/or angiotensin-converting enzyme inhibitors, with the addition of other drugs such as thiazides as needed to achieve goal blood pressure.Cholesterol<200 mg/dLPrimary 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 mellitus.LDL-C <100 mg/dL; if triglycerides are [mtequ]200 mg/dL, non–HDL-C should be <130 mg/dLFor 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.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%.For lipid management: assess fasting lipid profile in all patients and within 24 h 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 [mtequ]100 mg/dL, initiate LDL-lowering drug therapy; if on-treatment LDL-C is [mtequ]100 mg/dL, intensify LDL-lowering drug therapy (may require LDL-lowering drug combination); if baseline LDL-C is 70–100 mg/dL, it is reasonable to treat to LDL-C <70 mg/dL; if triglycerides are 200–499 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, niacin (after LDL-C–lowering therapy), or 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 treating LDL-C to goal after triglyceride-lowering therapy; achieve non–HDL-C <130 mg/dL if possible.Other targets for therapy: triglycerides >150 mg/dL and HDL-C <40 mg/dL in men and <50 mg/dL in womenType 2 diabetes mellitusFasting plasma glucose <100 mg/dLNormal fasting plasma glucose (<110 mg/dL) and near-normal hemoglobin A1c (<7%)Hemoglobin A1c <7%First-step therapy 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 the patient's primary care physician or endocrinologist.CV indicates cardiovascular; LDL-C, low-density lipoprotein cholesterol; CHD, coronary heart disease; and HDL-C, high-density lipoprotein cholesterol. Information adapted from American Heart Association guidelines for primordial prevention,4 primary prevention,5 secondary prevention,6 and diet and lifestyle recommendations.7The 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.BackgroundRacial/Ethnic Minority PopulationsUS 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) and separate people who report Hispanic ethnicity from those who do not (eg, Mexican American or Hispanic versus non-Hispanic black and non-Hispanic white).9 The need for separate consideration of Asian10 and 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. Many more data are available for black Americans and, more recently, Mexican Americans than for other racial/ethnic minorities.11 In addition, because of the heterogeneity in demographic and cultural variables and 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 compared with Mexican or Cuban Americans. Asians from India or Pakistan may have different CVD risk profiles compared with those from China or Japan.1,10This article focuses on race/ethnicity because 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, including environment, access to care, lifestyle patterns, and perhaps ancestry, influence the health of individuals in socially constructed racial/ethnic categories.12,13 Biological differences in glucose and lipid metabolism and the metabolism of several cardiac medications for racial/ethnic groups have been reported and may contribute to poorer outcomes.14,15 As summarized below, racial/ethnic differences in CVD risk also vary by sex.9Disparities in CVD Health StatusHypertension 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 with 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.11An estimated 47% of Americans ≥20 years of age have total blood cholesterol levels ≥200 mg/dL.11 Mexican American women and men have higher rates of dyslipidemia (51% and 49%, respectively) 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% and 42%, respectively),11 once identified, they are less likely to be controlled11 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 subgroups), and AI/AN are not available and are needed.1Addressing obesity and diabetes mellitus is also critical for reducing overall CVD risk, as addressed in 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 4 decades; however, increasing obesity and type 2 diabetes mellitus 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 ≥25 kg/m2 (80% and 75%, respectively). AI/AN populations are the most likely to be diagnosed with diabetes mellitus (15%), with high prevalence noted for black and Mexican American women (13%), black men (13%), and Native Hawaiians and other Pacific Islanders26 (12%) compared with white men and women (7%). Of particular concern in relation to global risk, the prevalence of ≥2 CVD risk factors was highest among black Americans and AI/AN (49% and 47%, respectively), although information on Hispanic/Latinos, Asian Americans, and Native Hawaiians and other Pacific Islanders is less complete than for blacks, whites, and Mexican Americans.1The recently released American Heart Association (AHA) science advisory on CVD 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 body mass index 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 because Asians have higher rates of diabetes mellitus than would be expected based on their body mass index levels.30 This same issue may apply to measures of high waist circumference, a well-established risk factor for insulin resistance and type 2 diabetes mellitus.31The 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 FactorsCigarette 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% and 18%, respectively). Among racial/ethnic groups, AI/AN had the highest prevalence (24%), black Americans and whites had similar rates (21% and 22%, respectively), and Hispanics and Asians had the lowest rates (16% and 10%, respectively).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 of whites.33,34 Black and Hispanic smokers are less likely than whites to be asked about smoking habits or offered tobacco-cessation interventions35,36 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% 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% and 66%, respectively) than white respondents, Asians, and Native Hawaiians and other Pacific Islanders (57%, 60%, and 61%, respectively).11 Although reported using a different metric, Hispanics are also relatively inactive; only 25% 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 achieved38; this makes it imperative to implement successful strategies to improve health behaviors in diverse groups.A Framework for Addressing Disparities in Health CareDespite 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, 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 Institute of Medicine 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 initiative, Finding Answers: Disparities Research for Change39 builds on the Institute of Medicine work. This work acknowledges that the social determinants of health, including poverty, education, and access to care, are significant barriers to equitable care40,41 and must be addressed to eliminate disparities42 and that these factors may be beyond the scope and control of providers.39 This initiative proposes a framework for providers and healthcare 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.43Behavioral Interventions to Prevent CVD or to Reduce Cardiovascular RiskAs 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 require specific strategies for lifestyle change and adherence to medical therapies across all racial/ethnic populations.3,11Interventions That Target Smoking CessationA 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 dependence,37 but 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%, and 22%, respectively) to smoke mentholated cigarettes, which have been shown to enhance smoking initiation and to 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 attempts to quit 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 with non-Hispanic whites but are also less likely to receive smoking-cessation advice, culturally/linguistically tailored services, or pharmacotherapy interventions49,51 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 on smoking behavior are needed in the understudied AI/AN, Asian, and Native Hawaiians and other Pacific Islanders populations.52Robles and colleagues53 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. 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 were 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 6 months; thus, booster sessions are important for sustained change.53 One prospective observational study (n=1782) evaluated the effectiveness of nicotine replacement (patch) on cessation rates among the 5 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 AI/AN (10%, 12%, and 9%, respectively).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 that combined a counseling intervention (8 brief cognitive-behavioral/motivational counseling sessions either in person or telephonically) in combination with sustained-release bupropion47 or transdermal nicotine patch55 yielded 6-month quite rates of 21% and 17%, respectively, for blacks. Combining open-label bupropion, 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 3 racial/ethnic groups included in the study; however, black Americans benefitted to a lesser extent than Hispanics and whites (38%, 41%, and 60%, respectively).56The use of clear, direct advice from healthcare 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, postintervention behavioral counseling, electronic tracking, and medication cost reimbursement, were 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 it remains incumbent on clinicians to use best-practice strategies.Behavioral Strategies to Improve Physical Activity and Heart-Healthy NutritionLifestyle 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; 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 h" @default.
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• W2075956739 title "Behavioral Strategies for Cardiovascular Risk Reduction in Diverse and Underserved Racial/Ethnic Groups" @default.
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