NANETTE K. WENGER: Good morning, everyone. I am absolutely delighted to be here, to share the podium with so many valued colleagues; but in particular, to share with you some of the information that all of us must know about the number one killer of minority women, and that is cardiovascular disease. You know, this has been a wonderful decade in terms of heart disease in women in general. There has been so much emerging information, and actually, women and heart disease has made it onto everyone's radar screen. But unfortunately, it has not been a complete radar screen because there was inadequate attention to subsets of women. Now, why is this important? We're all very familiar with the 2002 report from The Institute of Medicine, and what the Institute of Medicine tells us is that racial and ethnic minorities receive a lower quality of healthcare, even after we do all kinds of adjusting for socioeconomic status and for other healthcare variables. So these are the areas that have to be remedied as we discuss cardiovascular disease in women. And what I will do as an introduction and a background this morning is to review some of the statistics, some of the sub straights, and indeed, to try to provide some of the solutions.

First, let's look to see what are the statistics; what is the information that we have about the problem? And I want to call to our attention that fortunately, the U.S. is increasing in diversity. This relates both to women and to men. And the projections are that by 2050, half of our population will be what has previously been referred to as "racial and ethnic minorities," and at 50 percent, this will be minorities no more. But the problem that we will have to address in these days is that of the U.S. women of racial and ethnic minorities, because they are disadvantaged by health disparities—and we're all aware to how important health is to involvement in society. Now, what are the obstacles to care that we see overall for women of color? Some of them may be linguistic, some of them may be logistic, but I think the important feature is that these linguistic barriers inhibit communication. There are very many women with limited English proficiency, and in this population, we see that it's coupled with low income. We see major cultural differences, and as such, we see major different perceptions about health, about illness, and about prevention. And often, these are the ones that constitute barriers in access to care. Unfortunately, we're still living in the era of sex- and race-based stereotypes, again, limiting communication, limiting the availability of information that women get from their healthcare providers. What we have seen pervasively is difference in health status and health risk factors.

The socioeconomic issue is a very important contributor. I think we're all aware that women comprise 70 percent of the Medicaid population over 15 years of age, and we all know that if Medicaid is our health insurer, that in many venues limits access to care, limits extent of care. And that is one of the reforms that we must get in our Medicaid population. The educational characteristics, the information, becomes very important because awareness is the beginning of learning about health and the prevention of disease, about the ability to come to screening components. And what we've seen is that all of the features that I've listed for you are contributors to the greater incidence of cardiovascular disease in ethnic and minority women, and indeed, to their greater mortality. Let's look now just at a few examples. I certainly am not going to be—give you many, many details; but what I want to highlight for you is that both for White and for Black women, coronary heart disease is their overwhelming health problem. But examine the disparity in terms of the death rates for Black women from coronary disease and Black women from stroke as compared with their White sisters. What we see is that Black women have the worst mortality for coronary heart disease and stroke, both problems that are potentially preventable.

Let's now look at the leading causes of death for Hispanic or Latino men and women, and I want you to look at the side of the slide that relates specifically to women. And look at one feature: if you compare column "A," which is diseases of the heart and stroke, the Hispanic or Latino women have greater mortality than do their male peers, a very serious problem. But it's not even a composite issue. We're going to have to learn to dissect this apart because the Latino women have the lowest stroke mortality. That high column is mainly coronary heart disease, but very important is that this population has to realize that cardiovascular disease and stroke is part of their landscape of illness. As we look at the causes of death for the Asian Pacific Islanders—and again, look at the side of the slide in white that addresses the women—about an equal preponderance of disease for women and for men. But interestingly, these are the women with the lowest coronary mortality. The stroke mortality is prominent in this subpopulation. When we examine data in the same format for the American Indian and the Alaska natives, again, these are the women comparable in occurrence to the men, but they have the second-lowest stroke rate. Perhaps one of the things we're going to have to ask for is that as these columns are developed in the future, let's break out the coronary disease and the stroke because they are different in subpopulations and they may warrant different attention.

Now, let's look at an issue of awareness, and this was highlighted in the February issue of "Circulation" based on the American Heart Association's survey because we were trying to see what women across this country perceived as their leading cause of death. Perceptions become enormously important. Perceptions determine health behavior, and the importance of perception and awareness is that unless women see that cardiovascular disease is part of their illness experience, they are not going to heed any of our preventive messages and they are not going to respond to symptoms. And that is really across the lifespan. I want to remind us that the highest bar here is just above 50 percent, which means that most women in this country are not aware that heart disease is their leading killer, the White women just above 50 percent. But for the Black and Hispanic women pictured here—and these are the women with the highest mortality—their awareness is very, very limited. It is under the 30 percent level. Now, this becomes also important for those of you who represent the media because this American Heart survey showed that most women get their health information where? Where do you think? Exactly, from the media, most from magazines, next from television, with fewer than a third of women getting any of their health information from healthcare providers. And therefore, I am so excited that over the past year, so much of the media has devoted attention to cardiovascular disease in women, and particularly so that the accuracy of it has been very, very impressive. This is the way we will teach our women. This gives the media an enormous amount of responsibility.

Now, let's spend just a moment talking about the substrate for coronary heart disease and stroke, and that is the burden of coronary risk factors. Again, let's examine what has happened over time; and these bars show you what has happened over a period of 20 years. And I want to show you that we have had some accomplishments. Certainly, if you look at the center of the slide for both Black men and women, the highest prevalence of hypertension. But if you look at the second set of columns, improvement over time for White women, improvement over time for Black women. But even though the Mexican women shown here have a lower prevalence, that prevalence is increasing. That is a trend that we must reverse. Even though absolutely it's slow, prevalence is increasing. Now, that's the prevalence of blood pressure. What about awareness, treatment, and control? Awareness, much better than it was in prior years; treatment, not as good as awareness; control, not as good. Note that the control is least among the Black and Hispanic women. But when we look at the job we've done with blood pressure—this is the very last set of columns—fewer than a third of all patients with hypertension are controlled, and that is lowest in the Mexican-American population.

Let's look at smoking, and smoking bears a direct relationship to education and information in all groups. And what we see is that the White women are doing absolutely the worst for smoking, and actually, it seems that education coupled with information can decrease smoking. We still have a huge task to do. And now, what about physical activity and its relationship to the American epidemic, which is obesity and an increase in body mass index? What we tend to see, and if you look at the men to the one side of the slide and the women to the other, women have less moderate or physical activity in all subgroups than their male counterparts. But interestingly, if you look at the third column from the right of the slide, you'll see that body mass index seems particularly important for White women. The White women who are most slender have the highest physical activity level and we see an association with high body mass index and low physical activity. And we must ask which is the chicken and which is the egg? Are these individuals obese because they don't have physical activity; or, because they are obese, do they feel that physical activity is a problem and do they limit their activity? But decreased physical activity and obesity are two major problems in this country.

To very briefly summarize several other issues, let's look simply at unhealthy cholesterol levels. The fact is that for all subsets of women, about 40 percent; but what see is here that the White women seem to do worse in terms of elevated cholesterol level. For high blood pressure, the Black women seem to do worse. Almost half of all Black women have hypertension, but almost a third of all other women. And if we were to have displayed this for you by age, you will see that in all subsets of women, high blood pressure increases with aging. We've emphasized that physical inactivity is highest in the Black and Hispanic women, and about a third of Hispanic women report absolutely no leisure time physical activity. Now, some of this translates into disease because what we see is that the lack of physical activity, the increased body mass index, is associated with diabetes. We all remember that diabetes is a coronary risk equivalent. What does that mean? That means that a woman with diabetes is as likely to have a heart attack as a woman who has already had a heart attack. But importantly, diabetes is a much more powerful risk factor for women than it is for men. And here, we see that education is going to have to be very, very important because what we see is that some of the behaviors that may delay the development of diabetes seem to be less as educational level increases.

Finally, what about the solutions? What is it that we can do and what is it that we must do? Very briefly, we must increase awareness that cardiovascular disease is the leading cause of morbidity and mortality for women of racial and ethnic minorities. We must increase this awareness in their healthcare providers. Perhaps the major message is that behavior changes by women, lifestyle changes, cannot only decrease coronary risk factors, but they can decrease coronary disease. We need public education. We need increased access to screening and to healthcare. If this is very easy to say, this is very hard to accomplish. But what our goal should be is aggressive implementation of coronary risk reduction targeting in particular the high-risk women, and those tend to be the women of racial and ethnic minorities. What we have seen multiple times in this conference, and we will see it again and again, is that this is a combination of public information and education and information and education of healthcare providers. Today, for women in general and for women of racial and ethnic minorities in particular, we have the opportunity almost to change a paradigm of clinical practice, to emphasize prevention because if this is what we do, we have the potential to improve the heart health of women in general and minority women in specific. And I thank you for your attention.