RESEARCH AND PRACTICE

Stroke Mortality Among Alaska Native People

Ronnie D. Horner, PhD, Gretchen M. Day, MPH, Anne P. Lanier, MD, MPH, Ellen M. Provost, DO, MPH, Rebecca D. Hamel, BSN, and Brian A. Trimble, MD

Although stroke has become a signicant health problem among the Alaska Native population, its epidemiology remains poorly described. This is attributable, in part, not only to the sparseness of the literature but also to its failure to consider Alaska Native people as a distinct cultural group, one among the many that comprise the American Indian/Alaska Native designation. Despite these signicant limitations, several worrying patterns are emerging. Stroke mortality appears to be signicantly elevated among relatively younger American Indians/Alaska Natives compared with US Whites of similar age.13 Other reports indicate that, compared with US White women, American Indian/Alaska Native women have greater mortality from stroke, especially from subarachnoid hemorrhages.47 Of note, data for the 1990s indicate that stroke mortality has decreased in all racial/ethnic groups except for American Indians/Alaska Natives.8 The sparseness of the epidemiological data on stroke as it relates specically to Alaska Native people hinders efforts at prevention and intervention in this unique cultural group. Stroke prevention and intervention strategies can be most effectively designed and targeted when the higher-risk populations are identied and the types of strokes and associated etiologic factors are known. We begin the process of generating a more precise epidemiology of stroke among Alaska Natives by describing their stroke mortality between 1984 and 2003 in terms of age, gender, time, and stroke type.

Objectives. We aimed to describe the epidemiology of stroke among Alaska Natives, which is essential for designing effective stroke prevention and intervention efforts for this population. Methods. We conducted an analysis of death certicate data for the state of Alaska for the period 1984 to 2003, comparing age-standardized stroke mortality rates among Alaska Natives residing in Alaska vs US Whites by age category, gender, stroke type, and time. Results. Compared with US Whites, Alaska Natives had signicantly elevated stroke mortality from 1994 to 2003 but not from 1984 to 1993. Alaska Native women of all age groups and Alaska Native men younger than 45 years of age had the highest risk, although the rates for those younger than 65 years were statistically imprecise. Over the 20-year study period, the stroke mortality rate was stable for Alaska Natives but declined for US Whites. Conclusions. Stroke mortality is higher among Alaska Natives, especially women, than among US Whites. Over the past 20 years, there has not been a signicant decline in stroke mortality among Alaska Natives. (Am J Public Health. 2009;99:19962000. doi:10.2105/AJPH.2008.148221)

population is used as the primary referent population because it provides more precise rates with which to compare the stroke mortality patterns among Alaska Native people.

Data Source
Information on cause of death and demographic characteristics was obtained from the State of Alaska Bureau of Vital Statistics, which maintains a database comprising the data elements recorded on the death certicate of any person dying in Alaska. From this database, information was collated on Alaska Natives who were indicated to be residents of Alaska and had died of stroke in the years 1984 through 2003. An Alaska Native was dened by the death certicate race codes indicating Alaska Native, Eskimo or Canadian Eskimo, Indian or Canadian Indian, Aleut, or a mixture of any of these Alaska Native groups. Among those identied as Indian, there may be a small percentage of individuals from American Indian tribes of the contiguous United States. Although the number of such individuals is unknown, they are estimated to comprise 7% to 12% of the total Alaska Indian population on the basis of detailed US census data regarding tribal afliation of Native Americans in Alaska. Overall, misclassication of deceased Alaska Natives as being of another racial/ethnic group is estimated to be less than 5%.9 For Alaska Natives, Alaskan Whites, and US Whites, we identied stroke deaths by using International Classication of Disease, 9th

Study Population
The study population was dened as all Alaska residents who self-identied as Alaska Native people. Alaska Native people comprise those individuals whose ancestors occupied the geographic area that is now the state of Alaska. Traditionally, under federal reporting systems, the Alaska Native population is classied into 3 major ethnic groups: Aleut, Eskimo, and Indian. Linguistic and cultural studies, however, document many different subgroups within the major groupings of Eskimo and Indian, including Inupiat, Yupik, Cupik, and Sugpiaq under the category Eskimo and Athabascan, Haida, Tlingit, and Tsimpsian under the category Indian. On the basis of the US Bureau of the Census enumeration for the year 2000, there were 119 499 Alaskan residents who self-identied as an Alaska Native, of whom approximately 11% were Aleut, 50% Eskimo, and 39% Indian. Although the various indigenous groups in the state differ in culture and language, their social and economic indicators are similar.

METHODS
This population-based stroke mortality study uses death certicate data on Alaska Native people who resided in Alaska during the period 1984 through 2003, and compares these data with those for White Alaska residents and the larger US White population. In that stroke mortality patterns among Alaskan Whites are virtually identical to those of the general US White population, the latter

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Revision (ICD-9)10 and ICD-1011 codes for cerebrovascular disease as the underlying cause of death (ICD-9 codes 430434 and 436438 and ICD-10 codes I60.0I69.9). In addition to examining cerebrovascular disease mortality broadly, we examined mortality for the 2 major types of stroke, dened by subsets of ICD-9 or ICD-10 codes as follows: hemorrhagic stroke (ICD-9 codes 430432 or ICD-10 codes I60I62) and ischemic stroke (ICD-9 codes 434 and 436 or ICD-10 codes I63 and I64). ICD-9 and ICD-10 codes have been shown to be highly comparable in the classication of the underlying cause of death from stroke; with ICD10 coding used as the standard, ICD-9 coding has a sensitivity of 92.6% and a specicity of 99.8%.12 Overall, the ICD-10 coding changes are estimated to have resulted in a 6% increase in the number of deaths attributable to stroke as the underlying cause, primarily from the cause of death being classied as stroke rather than pneumonia.13 For the Alaska Native population, a single source of census data was not available for the entire study period. Consequently, the Indian Health Service population estimates were used for the years1984 through1993 and the bridged 2000 Alaska Native population, as calculated by the National Cancer Institute Surveillance Epidemiology End Results (SEER) program, was used for the years 1994 through 2003.14 For both sources, the population data represent intercensal estimates. Data for the referent population were obtained from the Centers for Disease Control and Prevention Wonder Program.15,16 The age and gender distributions of all 3 populationsAlaska Natives, Alaskan Whites, and US Whitesare shown in Table 1.

TABLE 1Demographic Characteristics of Alaska Natives, Alaskan Whites, and US Whites: 19841993 and 19942003
Characteristic Alaska Natives 19841993 Annual population, mean Age, y, % 044 4564 65 Male, % Annual population, mean Age, y, % 044 4564 65 Male, % 78.8 15.7 5.5 50.3 71.1 23.3 5.6 52.5 64.0 22.5 13.6 49.3 82.9 12.5 4.6 50.5 19942003 104 079 461 579 251 337 527 80.4 15.9 3.7 53.2 67.4 19.3 13.2 48.9 83 006 425 996 207 584 145 Alaskan Whites US Whites

Note. For Alaskan Whites and US Whites, the second time period is 1994 to 2004.

Data Analysis
The fundamental measure of occurrence was the average annual age-adjusted stroke mortality rate, where the numerator was the cumulative number of strokes and the denominator the average annual population; both sums were for the specic time period (19841993 or 19942003) divided by the number of years within that time period. Age adjustment was by the direct method, using the US 2000 standard population. Mortality rates were calculated by age category, gender, stroke type, and time period. For age comparisons, we used 3 categories (< 45 years, 4564 years,

and 65 years), with age adjustment within each category according to the US 2000 standard population. The time periods (19841993 and 19942003) represented the smallest periods of time for which reasonably precise stroke mortality rates could be calculated for Alaska Natives. The change in stroke mortality rates over time was analyzed by comparing the average annual age-adjusted mortality rates from 1984 to 1993 with those from 1994 to 2003. Rate ratios were used to compare the stroke mortality rates of Alaska Natives with those of the referent populations and between time periods. To test for statistically signicant differences, condence intervals for the rate ratios were calculated.17 Rates were considered signicantly different if a ratios 95% condence interval did not overlap 1. StatsDirect software version 2.7.2 (StatsDirect Ltd, Cheshire, UK) was used to calculate the condence intervals.

RESULTS
As shown in Table 2, in both time periods, stroke mortality for Alaskan Whites was similar to that of the US White population. The overall stroke mortality rate was slightly lower for Alaskan Whites than for US Whites from 1984 through 1993 but slightly higher from 1994 through 2003. With few exceptions, Alaskan

Whites experienced a slightly lower mortality rate from hemorrhagic stroke but a slightly higher mortality rate from ischemic stroke compared with US Whites. These patterns held for men and women separately. Given these minor differences in rates, similar conclusions are drawn about stroke mortality among Alaska Native people, whether the referent population is US Whites or Alaskan Whites. Between 1984 and 1993, 220 Alaska Native residents died from cerebrovascular disease. Approximately 34% (n = 74) of these deaths were due to hemorrhagic stroke and 65% (n =142) from ischemic stroke, with the remainder having no stroke type specied. Among US Whites, 17% of cerebrovascular deaths were due to hemorrhagic stroke and 70% from ischemic stroke. Cerebrovascular disease accounted for 4% of all deaths among the Alaska Native population compared with 7% for US Whites. During the period 1994 to 2003, 318 Alaska Native residents died from cerebrovascular disease. Twenty-nine percent (n = 93) of these deaths were due to hemorrhagic stroke and 53% (n =170) from ischemic stroke. Among US Whites, 19% of cerebrovascular deaths were due to hemorrhagic stroke and 64% from ischemic stroke. Cerebrovascular disease accounted for 5% of all deaths among the

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TABLE 2Average Annual Adjusted Stroke Mortality Rates (per 100 000) Among Alaska Natives, Alaskan Whites, and US Whites, by Gender and Stroke Type: 19841993 and 19942003
Men and Women Alaska Alaska Alaskan Natives:Alaskan US Natives, Whites, Whites, RR Whites, Stroke Type Rate Rate (95% CI) Rate Alaska Natives:US Whites, RR (95% CI) Men Alaska Alaska Alaskan Natives:Alaskan US Natives, Whites, Whites, RR Whites, Rate Rate (95% CI) Rate 19841993 All Hemorrhagic Ischemic All Hemorrhagic Ischemic 71.2 16.9 46.0 74.5 15.5 44.5 64.1 9.1 46.7 60.3 9.8 39.6 1.1 (0.9, 1.3) 1.9 (1.4, 2.6) 1.0 (0.8, 1.2) 1.2 (1.1, 1.4) 1.6 (1.2, 2.1) 1.1 (0.9, 1.3) 66.2 1.1 (0.9, 1.2) 11.2 1.5 (1.2, 2.0) 46.5 1.0 (0.8, 1.2) 56.6 1.3 (1.2, 1.5) 10.9 1.4 (1.1, 1.8) 36.3 1.2 (1.1, 1.4) 67.8 12.6 47.8 71.3 10.6 37.9 72.6 8.6 52.3 0.9 (0.7, 1.2) 1.5 (0.9, 2.6) 0.9 (0.7, 1.3) 69.4 0.98 (0.8, 1.2) 11.4 1.1 (0.7, 1.7) 48.9 1.0 (0.8, 1.3) 57.7 1.2 (1.0, 1.5) 11.4 0.9 (0.6, 1.4) 36.4 1.0 (0.8, 1.4) 74.2 21.3 43.9 76.8 19.7 48.2 59.5 9.8 43.4 61.4 9.4 40.8 1.2 (1.0, 1.6) 2.1 (1.5, 3.2) 1.0 (0.7, 1.4) 1.3 (1.1, 1.5) 2.1 (1.5, 2.9) 1.2 (0.9, 1.5) 63.5 1.2 (0.96, 1.4) 11.1 1.9 (1.4, 2.6) 44.4 1.0 (0.8, 1.3) 55.1 1.4 (1.2, 1.6) 13.9 1.4 (1.1, 1.9) 35.5 1.4 (1.1, 1.7) Alaska Natives:US Whites, RR (95% CI) Women Alaska Alaska Alaskan Natives:Alaskan US Natives, Whites, Whites, RR Whites, Rate Rate (95% CI) Rate Alaska Natives:US Whites, RR (95% CI)

19942003 58.0 1.2 (0.9, 1.5) 10.8 37.1 1.0 (0.6, 1.6) 1.0 (0.8, 1.4)

Note. CI = condence interval; RR = rate ratio. For Alaskan Whites and US Whites, the second time period is 1994 to 2004. For the overall population, the rates are age and gender adjusted; for men and for women alone, the rates are age adjusted.

Alaska Native population compared with 7% for US Whites. During the period 1984 to 1993, stroke mortality among Alaska Natives was similar to that of US Whites and Alaskan Whites, with the exception of hemorrhagic stroke (Table 2, upper half). The age-adjusted mortality rate for hemorrhagic stroke was signicantly higher among all Alaska Natives (by about 50%), but the rate was almost double among Alaska Native women. During the period 1994 to 2003 (Table 2, lower half), stroke mortality, both overall and by type, was higher for Alaska Natives (for both men and women and for women only) than for US Whites, with no signicant differences between Alaska Native men and women. Stroke mortality rates were signicantly higher for the Alaska Native population than for US Whites across most age categories for the period 1994 to 2003 (Table 3). Rate ratios between the 2 populations declined with increasing age. For all strokes, however, Alaska Natives overall and Alaska Native women had signicantly higher mortality rates than US Whites in all age categories. For Alaska Native men, a signicantly elevated mortality rate was found only for the youngest age category ( < 45 years); however, the rate was statistically imprecise. For hemorrhagic strokes, a signicantly elevated rate for Alaska Natives was found only for those in the 2 younger age categories, whereas for ischemic stroke, signicantly

elevated rates were found for those aged younger than 45 years and those 65 years and older. Of note, Alaska Native men had signicantly elevated mortality for hemorrhagic strokes and for ischemic strokes only among those aged younger than 45 years; however, the rates for this age category were statistically imprecise. For women, signicantly higher mortality occurred for all age categories across stroke types, with the one exception of hemorrhagic stroke among those 65 years or older; rate imprecision was an issue only for ischemic strokes. Alaska Native men and women had statistically similar rates within age categories for all stroke types, although men had lower rates. As shown in Table 2, stroke mortality rates for Alaska Nativesoverall and for each genderchanged little between the 2 study time periods; this condition held for all strokes and for both stroke types. None of the rate ratios indicated statistically signicant changes between time periods. By comparison, the overall stroke mortality rate for US Whites declined a signicant 14% between the 2 time periods. For ischemic stroke, US Whites stroke mortality declined by 18%, 19%, and 17% for men and women, men only, and women only, respectively.

DISCUSSION
Our study, the rst to provide a detailed description of stroke mortality among Alaska

Native people, reveals several notable characteristics of the epidemiology of stroke in this population. Compared with US Whites, Alaska Natives currently have greater mortality from stroke (all strokes and hemorrhagic strokes) at relatively younger ages (< 45 years). Second, Alaska Native women are at particularly high risk of stroke-related death across virtually all age categories and stroke types. Third, stroke mortality has remained fairly constant over time for Alaska Natives, in contrast to the signicant decline in stroke mortality among US Whites. Most of the previous reports on stroke morality among Native Americans have not considered Alaska Natives as a distinct culture but rather have included them among the heterogeneous cultural groups represented within the racial designation of American Indians/ Alaska Natives.14 Since each of the cultural groups may have a different pattern in the occurrence of stroke, the use of aggregated data may obfuscate patterns within these populations that may indicate the need for different prevention and intervention strategies. By our focus on the Alaska Native population, we have undertaken an initial step toward clarifying the epidemiology of stroke in this cultural group. Of considerable interest, our study provides initial evidence that stroke mortality among Alaska Natives may be similar to that among some American Indian tribes; stroke mortality

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TABLE 3Average Annual Age-Specic Stroke Mortality Rates (per 100 000) for Alaska Natives and US Whites, by Stroke Type and Gender: 19942003
Men and Women Stroke Type All Age 044 y Age 4564 y Age 65 y Hemorrhagic Age 044 y Age 4564 y Age 65 y Ischemic Age 044 y Age 4564 y Age 65 y 1.4a 12.1
a

Men RR (95% CI) Alaska Natives US Whites RR (95% CI) Alaska Natives

Women US Whites RR (95% CI)

Alaska Natives

US Whites

6.6 33.8 496.1 5.0 17.9 65.9

1.6 20.8 403.0 1.3 10.6 60.8 0.3 8.4 270.5

4.0 (3.0, 5.4) 1.6 (1.2, 2.1) 1.2 (1.1, 1.4) 3.7 (2.6,5.2) 1.7 (1.2,2.4) 1.1 (0.8,1.5) 4.5 (2.3, 8.7) 1.4 (0.9, 2.3) 1.2 (1.01, 1.4)

5.5a 25.5 490.8 3.7a 10.2a 46.8a 1.5a 11.5

a

1.7 23.4 406.5 1.2 11.0 64.5 0.3 10.3 268.4

3.2 (2.0, 5.0) 1.1 (0.7, 1.7) 1.2 (0.97, 1.5) 3.0 (1.7,5.4) 0.9 (0.5,1.9) 0.7 (0.4,1.4) 4.4 (1.8, 10.8) 1.1 (0.6, 2.1) 1.0 (0.8, 1.4)

7.7 42.0 494.0 5.7 42.2 65.6 1.3a 12.7a 352.7

1.5 18.3 395.9 1.3 12.7 58.5 0.3 6.7 267.8

5.0 (3.4, 7.4) 2.3 (1.6, 3.2) 1.2 (1.0, 1.5) 4.2 (2.4,7.3) 3.3 (2.2,5.1) 1.1 (0.6,2.0) 4.5 (1.7, 12.1) 1.9 (1.0, 3.5) 1.3 (1.1, 1.6)

323.9

271.7

Note. CI = condence interval; RR = rate ratio. For US Whites, the study period is 1994 to 2004. For the overall population, the age-specic rates are gender adjusted. a Based on fewer than 20 stroke deaths.

patterns similar to those identied here are reported for American Indian residents of Montana.4 It remains to be determined whether the numerous cultural groups that comprise the Alaska Native population have stroke mortality patterns similar to those found for Alaska Natives in general. Understanding the epidemiology of stroke among Alaska Natives is essential for developing effective prevention and intervention strategies to reduce the burden of stroke in this population. We have begun the process of identifying the characteristics of those individuals within the Alaska Native population who are at higher risk of death from stroke and the types of stroke for which the risk is elevated. Notably, Alaska Natives aged younger than 45 years and Alaska Native women of all ages are at signicantly greater risk of stroke mortality than their White counterparts. This elevated risk is found for hemorrhagic stroke and appears to occur for ischemic stroke as well, although the mortality rates for ischemic stroke in those aged younger than 65 years are based on too few stroke deaths to yield statistically precise rates. The observed age, gender, and time effects suggest that the etiologic factors are more prevalent among younger individuals than among older individuals and more common among women.

An explanation for the observed occurrence of stroke among Alaska Native people may reect the substantial lifestyle changes that have been occurring in this cultural group over the last several decades, specically those related to the shift from a subsistence diet to a more Westernized diet. Younger Alaska Natives have been moving away from the traditional diet, which is associated with better cardiovascular health.18,19 These dietary changes are associated with an increasing prevalence of overweight, glucose intolerance, and hypertension.20,21 Hypertensiona risk factor for both ischemic and hemorrhagic strokesand factors associated with elevated blood pressure such as overweight may therefore be the focal points for intervention. As a mortality study, our ndings are subject to a number of limitations inherent to the use of death certicate data. Using stroke as the underlying cause of death may yield conservative mortality rates compared with a proposed strategy of including any death where stroke is indicated to be a related cause, whether direct or otherwise.22 Misclassication of stroke type is also a recognized limitation of death certicate data. Although such misclassication may yield underestimates of the true rates for stroke types, this should not affect the comparison of racial/ ethnic populations unless there is differential

misclassication of stroke type by the decedents race/ethnicity. Misclassication of the decedents race/ethnicity is yet another potential limitation of our data6; however, for the broad category of Alaska Native, ethnic misclassication has been reported to be minimal in Alaska death les.9 Still another limitation is the relatively small number of stroke deaths on which the mortality rates for Alaska Natives are based. This presents the challenge of low statistical power ` -vis the referent for assessing differences vis-a population, differences between men and women or other subgroups of the population, and changes over time. It must also be recognized that the denominators for the rates in the 2 time periods are from different sources, which may account, in part, for variations in the rates. It is uncertain to what extent this is a factor, but the differences appear to be relatively small and unlikely to substantially inuence the observed rates. When we compared stroke mortality rates for the years for which both Indian Health Service and SEER population data were available (19901993), the rates based on the denominators from each of these sources were statistically similar: 70.9 (per 100 000) versus 68.1 for men and women, 61.9 versus 60.4 for men only, and 77.6 versus 74.1 for women only, respectively. Finally, the change in coding from ICD-9 to ICD-10 may

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yield higher rates because of the potential of the latter codes to identify approximately 6% more deaths as being caused by stroke; however, this effect should apply to the referent groups as well as to Alaska Natives. With due regard for the inherent limitations to this investigation, we believe these ndings advance current knowledge regarding the epidemiology of stroke among Alaska Natives, providing an initial departure point for studies of potential strategies for stroke prevention and intervention in this population. j

2. Ayala C, Greenlund KJ, Croft JB, et al. Racial/ethnic disparities in mortality by stroke subtype in the United States, 19951998. Am J Epidemiol. 2001;154: 10571063. 3. Neyer JR, Greenlund KJ, Denny CH, et al. Prevalence of strokeUnited States, 2005. MMWR Morb Mortal Wkly Rep. 2007;56:469474. 4. Ayala C, Croft JB, Greenlund KJ, et al. Sex differences in US mortality rates for stroke and stroke subtypes by race/ethnicity and age, 19951998. Stroke. 2002; 33:11971201. 5. Harwell TS, Oser CS, Okon NJ, Fogle CC, Helgerson SD, Gohdes D. Dening disparities in cardiovascular disease for American Indians: trends in heart disease and stroke mortality among American Indians and whites in Montana, 19912000. Circulation. 2005;112: 22632267. 6. Schumacher C, Davidson M, Ehrsam G. Cardiovascular disease among Alaska Natives: a review of the literature. Int J Circumpolar Health. 2003;62:343362. 7. Galloway JM. Cardiovascular health among American Indians and Alaska Natives: successes, challenges, and potentials. Am J Prev Med. 2005;29(5 suppl 1):1117. 8. Keppel KG, Pearcy JN, Wagener DK. Trends in racial and ethnic-specic rates for the health status indicators: United States, 199098. Health People 2000 Stat Notes. 2002;(23):116. 9. Indian Health Service. Adjusting for Miscoding of Indian Race on State Death Certicates. Rockville, MD: Public Health Service, Dept of Health and Human Services; 1996. 10. International Classication of Diseases, Ninth Revision. Geneva, Switzerland: World Health Organization; 1980. 11. International Classication of Diseases, 10th Revision. Geneva, Switzerland: World Health Organization; 1992. 12. Richardson DB. The impact on relative risk estimates of inconsistencies between ICD-9 and ICD-10. Occup Environ Med. 2006;63:734740. 13. Anderson RN, Rosenberg HM. Disease classication: measuring the effect of the 10th Revision of the International Classication of Diseases on cause-ofdeath data in the United States. Stat Med. 2003;22: 15511570. 14. National Cancer Institute. Surveillance Epidemiology End Results (SEER) database [limited access]. Mortalityall COD, aggregated with state, total US (19902005) race recode (W, B, AI, API); Mortalityall COD, aggregated with state, total US (19692005) race recode (W, B, Other). Available at: www.seer.cancer.gov. Accessed October 25, 2007. 15. Centers for Disease Control and Prevention, National Center for Health Statistics. Compressed Mortality File 19992004. CDC WONDER on-line database, compiled from Compressed Mortality File 19992004, Series 20, No. 2J, 2007. Available at: http://wonder.cdc. gov/cmf-icd10.html. Accessed November 6, 2007. 16. Centers for Disease Control and Prevention, National Center for Health Statistics. Compressed Mortality File 19791998. CDC WONDER on-line database, compiled from Compressed Mortality File CMF 19681988, Series 20, No. 2A, 2000 and CMF 19891998, Series 20, No. 2E, 2003. Available at:

http://wonder.cdc.gov/cmf-icd9.html. Accessed November 6, 2007. 17. Armitage P, Berry G, Matthews JNS. Statistical Methods in Medical Research. 4th ed. Oxford, England: Blackwell Science; 2002. 18. Nobmann ED, Ponce R, Mattil C, et al. Dietary intakes vary with age among Eskimo adults of northwest Alaska in the COCADAN Study, 20002003. J Nutr. 2005;135:856862. 19. Bersamin A, Luick BR, King IB, Stern JS, ZidenberCherr S. Westernizing diets inuence fat intake, red blood cell fatty acid composition, and health in remote Alaskan native communities in the Center for Alaska Native Health Study. J Am Diet Assoc. 2008;108: 266272. 20. Murphy NJ, Schraer CD, Thiele MC, et al. Dietary change and obesity associated with glucose intolerance in Alaska Natives. J Am Diet Assoc. 1995;95:676682. 21. Murphy NJ, Schraer CD, Thiele MC, et al. Hypertension in Alaska Natives: association with overweight, glucose intolerance, diet and mechanized activity. Ethn Health. 1997;2:267275. 22. Brown DL, Al-Senani F, Lisabeth LD, et al. Dening cause of death in stroke patients: The Brain Attack Surveillance in Corpus Christi Project. Am J Epidemiol. 2007;165:591596.

About the Authors

Ronnie D. Horner is with the Department of Public Health Sciences, University of Cincinnati Academic Health Center, Cincinnati, OH. At the time of the study, Gretchen M. Day and Anne P. Lanier were with the Ofce of Alaska Native Health Research, Alaska Native Tribal Health Consortium, Anchorage. Ellen M. Provost is with the Alaska Native Epidemiology Center, Alaska Native Tribal Health Consortium, Anchorage. At the time of the study, Rebecca D. Hamel and Brian A. Trimble were with the Division of Neurology, Department of Internal Medicine, Alaska Native Medical Center, Anchorage. Correspondence should be sent to Brian A. Trimble, MD, Neurology Service, Alaska Native Medical Center, 4315 Diplomacy Dr, Anchorage, AK 99508 (e-mail: btrimble@ anthc.org). Reprints can be ordered at http://www.ajph.org by clicking the Reprints/Eprints link. This article was accepted January 26, 2009.

Contributors
R. D. Horner and G. M. Day contributed to the study design, data analysis and interpretation, and drafting and revision of the article. A. P. Lanier was responsible for the study concept and contributed to the design, data interpretation, and drafting and revision of the article. E. M. Provost and B. A. Trimble contributed to data interpretation and to drafting and revision of the article. R. D. Hamel helped to draft and revise the article.

Acknowledgments
This work was performed as part of the ofcial duties of A. P. Lanier, E. M. Provost, B. A. Trimble, G. M. Day, and R. D. Hamel as employees of the Ofce of Alaska Native Health Research, Alaska Native Epidemiology Center and the Alaska Native Medical Center, all a part of the Alaska Native Tribal Health Consortium. The Alaska Native Epidemiology Center receives support through a cooperative agreement with the US Indian Health Service.

Human Participant Protection

This project was reviewed by the Alaska Native Tribal Health Consortium and was deemed not to constitute research with human subjects.

References
1. Harris C, Ayala C, Dai S, Croft JB. Disparities in deaths from stroke among persons aged <75 yearsUnited States, 2002. MMWR Morb Mortal Wkly Rep. 2005;54:477481.

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