Curr Cardiovasc Risk Rep (2016) 10:25

DOI 10.1007/s12170-016-0507-4

RACE AND ETHNIC DISPARITIES (M. ALBERT, SECTION EDITOR)

Americans of Arab Descent and Cardiovascular Risk

Jassim Al Suwaidi 1

# Springer Science+Business Media New York 2016

Abstract Data about cardiovascular risk factors among

Americans of Arab descent (AA) is limited. This article aims
to provide an up-to-date review of cardiovascular risk factors
and diseases among AA living in the United States (US). We
summarize the limited existing data about the prevalence of
the various cardiovascular risk factors and diseases among
AA and compare that to Arabs living in Arab countries. We
also outline challenges of conducting cardiovascular research
among AA. In conclusion there is paucity of data about cardiovascular risk factors and diseases among AA. The current
study suggests the urgent need for better ways to identify AA
in the US and the development of large prospective studies on
determinants of cardiovascular health including potential factors such as acculturation.
Keywords Cardiovascular risk factors . Cardiovascular
disease . Americans of Arab descent . Diabetes mellitus .
Arabs . Middle East

Introduction
Cardiovascular diseases (CVD) are the commonest causes of
mortality for both men and women in the United States (US)
today [1]. Ethnic disparities among minorities in the US such

This article is part of the Topical Collection on Race and Ethnic

Disparities
* Jassim Al Suwaidi
Jha01@hmc.org.qa; jalsuwaidi@hotmail.com
1

Department of Adult Cardiology, Heart Hospital, Hamad Medical

Corporation (HMC), P.O Box 3050, Doha, Qatar

as African Americans are recognized in regard to cardiovascular risk factors and outcome [2]. CVD is highly prevalent
among Arab individuals in the Middle East and its prevalence
is expected to continue to rise and is more likely to occur at
younger age when compared to other communities [3]. We
and others [3, 4, 5, 6, 7] have recently shown that Arabs
with cardiovascular disease have higher prevalence of diabetes mellitus and metabolic syndrome when compared with
other ethnicities. Furthermore, we also described potentially
unique Bcultural^ CVD risk factors such as waterpipe
Bhookah^ smoking [8, 9] and khat (amphetamine-like)
chewing [10] that have not being adequately, studied previously in the literature.
Americans of Arab decent are ethnic minorities who are
residents of the United States (US) and trace their ancestral,
linguistic, or cultural heritage to one of 22 Arab countries [11].
Arabs may be defined as pan-ethnicity of people of various
origins, religious background and historic identities, they
share one or more of the followings; a linguistic, cultural,
political or genealogical grounds and includes minorities such
as Chaldeans, Assyrians, Berbers, Turkomans, Druze, etc.
Herein we review the literature about the obstacles of
conducting cardiovascular research among AA. We also summarize the available evidence about cardiovascular risk factors, CVD and mortality rates among AA.

Background of Arab Americans of Arab Descent

Arab immigration to the US mainly occurred in three waves.
The first began in 1875 and was comprised largely of Syrians
and Lebanese. After the World War II, the 2nd wave of Arab
immigration occurred which differed substantially from the
first wave: the majority came fleeing post-war political upheavals in Egypt, Syria, and Iraq. The 3rd wave of Arab

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Curr Cardiovasc Risk Rep (2016) 10:25

Page 2 of 6

immigration began in 1965. The 1990s witnessed an immense

increase in the number of Arab immigrants to the US: it was
estimated that the AA population grew by 65% between 1990
and 2000 [11] (http://www.aaiusa.org/who-are-arabamericans). More expected to occur as a consequence of the
events that accompanied Bthe Arab spring^.
AA were estimated to be around 3.5 million in the US
during the 2001 census. Contrary to popular assumptions or
stereotypes, the majority of Americans of Arab Descent are
native-born, and nearly 82% of Arabs in the U.S. are citizens.
Approximately 94% of AA (compared to 80% of the general
US population) in the US live in metropolitan areas.
Metropolitan Los Angeles, Detroit, and New York are home
to one-third of the population. Michigan is the state with the
highest concentration of AA of any US state (at about 1%)
and, while the state of California has the largest absolute population of AA in the US. More than 80% of AA in the US are
American Citizens [11] (http://www.aaiusa.org/who-are-arabamericans).

Challenges to Study Cardiovascular Diseases

Among AA
The first challenge is the fact the US Office of Management
and the Budget has classified Arabs as Caucasians in health
care data thus limiting the ability of researchers to extract data
for this ethnic subgroup [12]. Michigan is the only state
which collects data about Arab ancestry in vital registry files,
and therefore presents a unique opportunity to analyze
population-based data among AA, hence most of the published research so far originated from this area, however it is
possible that the health of AA in Michigan differs significantly
from the health of AA in other areas in the US, for example
although national data show that AA are on average more
affluent and educated than the general US population, this is
not the situation among AA living in Michigan, moreover,
ethnic minorities who live in localities with high concentrations of members of their ethnic group are protected against
adverse health outcomes.
Second: Arabs even in their original countries are not one
homogenous ethnicity but rather originate from several different ethnicities which complicates the issue of cardiovascular
risk factor research among AA further. A recent genetic study
conducted among 168 self-reported Qatari nationals revealed
the diversity of origin of Arabs in this small population. The
study showed three main different origins of Qatari nationals:
Arabs, Persians, and Africans [13]. This observation may be
generalized to the majority of other Arab countries and this
observation needs to be accounted for when studying CVD
risk factors among AA.
Third: the cultural and dietary diversities among Arabs
need to be accounted for when studying cardiovascular risk

factors, for example waterpipe smoking (WPS) is more prevalent among Syrians, Lebanese, and Egyptian men and women, while Khat chewing is more common among Yemeni and
Somalian men where is it usually taken daily during their
cultural gathering.

Methods
This review assesses the current knowledge about cardiovascular risk factors and CVD among AA and will encompass the
peer-reviewed literature to-date. The review was restricted to
those studies that assessed cardiovascular risk factors of AA
living in the US, with occasional comparison to studies conducted in the Arab world.

Results
There are a very limited numbers of studies most of which
were cross-sectional analysis or retrospective in design and to
the best of our knowledge there are no prospective studies that
evaluated cardiovascular risk factors among AA. More importantly most of these studies are not recent.
Diabetes Mellitus
Numerous population-based studies in the Middle East have
demonstrated increasing incidence of diabetes mellitus (DM)
among the Arab population. The reported prevalence of diabetes was as high as 22% in Saudi Arabia and United Arab
Emirate, while in North African Arab countries the prevalence
ranged between 7 to 10% [4].
Several studies assessed the prevalence and determinants
of DM and related endocrine diseases among AA in the US
[1417]. Jaber et al [14] reported a 15.5% prevalence of DM
in women and 20.1% in men using a convenience sample in
Michigan (542 participants). The combined rate of impaired
glucose tolerance (IGT), impaired fasting glucose (IFG), and
DM was 32.3% in women and 49.8% in men. Higher rates of
dysglycemia were associated with older age, being male, obesity, and having central obesity. Interestingly, 50% of those
with DM had not been previously diagnosed.
Kridllie et al [15] studied the epidemiology of diabetes and
its risk factors among Chaldean (population coming primarily
from Iraq and are Catholic) Americans. The study was conducted in Detroit, Michigan and included 234 participants (85
men and 149 women) with a mean age of 51 years, 50% of
whom migrated to the US at 40 years of age. The overall
prevalence of DM was 26% (24% for men and 28% for women) and the prevalence increased with increasing age in both
sexes; 45% of individuals where previously undiagnosed. The
investigators reported higher compared prevalence of DM

Curr Cardiovasc Risk Rep (2016) 10:25

among this population when compared to that reported among

other ethnicities in the US (Non-Hispanic whites (9%),
African-Americans (10%), and Hispanics (11%) using data
from NHANES III. In contrast to the above studies, Dallo
and Borrell [16] reported lower prevalence of DM among
AAs (n=429) compared to non-Hispanic Whites (n=79,228)
using data from the National Health Interview Survey (NHIS)
that was conducted between 2000-2003 (4.8% versus 6.9%).
For individuals 46 to 85 years old, the prevalence of DM was
higher for AAs (12.7%) compared to non-Hispanic Whites
(11.7%, P<. 0001). The study was limited by the fact that it
was a self-reported study. In another self-reported survey conducted on 321 individuals living in the metropolitan
Washington, DC area the prevalence of DM was 5.9 [17].
Two studies [14, 18] assessed the determinants of diabetes
and related health indicators among AAs. Jaber et al [18]
studied the relationship between dysglycemia and acculturation (the process of adaptation to the dominant culture) in 520
AAwho were born in the Middle East by assessing a variety of
markers and scales that measure integration into American
Society. The investigators reported less acculturated Arab
were generally at greater risk for DM than those with greater
acculturation. In men, dysglycemia was associated with older
age at immigration, unemployment, speaking Arabic with
friends, being less active in Arabic organizations, more frequent consumption of Arabic food, and less integration into
American society. In women, dysglycemia was associated
with being raised in rural areas in the Middle east, older age
at immigration, longer length of stay in the US, not being
employed outside the home, less than a high school education,
and not being able to read Arabic or English. Dallo and Borrell
[17] reported a negative association between the length of stay
in the US and the prevalence of DM.
Finally, Berlie et al [19] evaluated the quality of careassessed by adherence to American Diabetes Association
(ADA) guidelines among 53 AAs with a diagnoses of type
II DM. AA had higher lipid control but worse blood pressure
control than the general public. Pharmacotherapy among AA
was less aggressive than recommended by the ADA.

Metabolic Syndrome
The 2008 age-standardized prevalence rates of overweight
and obesity in adults aged 20 years or older in Arab countries
are alarmingly high. The prevalence is highest in high-income
Arb countries, for example 66-75% of the adult population
and 25-40% of children and adolescents are estimated to be
overweight and obese in the Gulf Arab countries. It should be
noted that very high levels of obesity were also reported in
some middle-income Arab countries. This obesity epidemic
among Arabs is attributed to dietary habit and physical inactivity, 70% of the population in the Gulf were physically

Page 3 of 6 25

inactive. Physical inactivity was higher among Arab women

when compared to men [5].
Three studies evaluated the prevalence of obesity and metabolic syndrome among AA (22-4). Jaber et al [20] in a crosssectional, population-based study reported 23% prevalence of
metabolic syndrome by the ATP III definition and 28% by the
WHO definitions. The prevalence rose significantly with increasing age in both sexes. Age-specific rates were similar for
men and women aged 20-49 years but significantly higher in
women 50 years of age. Low HDL cholesterol concentration
was the most common component of the metabolic syndrome
in both men and women.
Hatahet & Fungwe [21] studied the prevalence of obesity
(BMI>30) among Arab, African-American, and Caucasian
American women (128 AAs, 322 African American and 283
Caucasian) in Michigan. AAs were approximately 10 years
younger than the other two groups. The prevalence of obesity
was highest among African American (55%) when compared
to AA (29%) and Caucasian women (24%). AA women had
higher levels of triglyceride levels and lower HDL levels
when compared to the other two groups.
Abou-Mediene and Shamo [22] conducted a screening survey for obesity among AAs children in two elementary
schools in Michigan in 2003. The sample included 158 students (90 girls and 68 boys), ages were between 11 and 13
years old. Of boys 31% and of girls 24.5% were overweight
and 17.6% of boys and 15.5% of girls were obese. These data
followed the same trend of reports in other ethnic groups in the
US.

Hypertension
The prevalence of hypertension in the Middle East which
Moltag and colleagues reported was similar to rates observed
in North America (28%) but less than in Europe (44%) [6].
Dallo and Borrel [16] using data from the NHIS reported a
13.4 % prevalence of hypertension among AA, which was
significantly lower when compared to non-Hispanic Whites
(24.9%, P<. 0001). There were no associations between country of birth and hypertension. Dallo and James [23] reported a
16% prevalence of hypertension in a community probability
sample of 130 Chaldean-AA women (35-45 years of age) in
Michigan in 1998. In this study, the strongest predictors of BP
were BMI and waisthip ratio, both of which were inversely
correlated with age, education, English language preference,
employment outside the home, and parental school involvement. Jamil et al [24] in a self-reported study showed high
prevalence of hypertension among Chaldean Arabs (21.8%)
and other AA (19.6%) when compared to African Americans
(12.5%). In a self-reported survey, Shara et al reported 16.3%
prevalence of hypertension among a young group of 321 participants (mean age 45.36 years) [17].

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Page 4 of 6

Tobacco Use
Tobacco use is not synonymous to cigarette smoking and includes other modalities of tobacco use such as cigar smoking,
water-pipe Bhookah^ smoking, and tobacco chewing [8, 25].
In the Arab Middle East countries, the 2008 age-standardized
prevalence of daily cigarette smoking in adults aged 15 years
varied widely from 3.4% in Oman to 37.6% in Lebanon. In all
countries, men reported smoking more than did women, and
the largest disparities were in Egypt, Algeria, Morocco, and
Libya [5].
Cigarette smoking was higher and quitting rates were
lower among AA adults when compared with national
data reported in two earlier studies [12]. Several studies
evaluated cigarette smoking among AA adolescents. The
Rice et al [26] study included 1455 9th grade students,
89% of them were identified as Arab American. Of the
youths 57% reported being born in the Middle East with a
mean time in the US of 6 years. AA youth were less likely
to smoke cigarettes regularly (1% vs. 5%), in the last 30
days (2% vs. 9%) or experiment with smoking when compared to non-Arab youth (9% vs. 27%). Similar observations were reported by Weglicki et al [27] when they
studied 1872 youths (14-18 years old) attending community high schools using the Tobacco Use History
Questionnaire (THUQ). Islam and Johnson [28] conducted a survey on 480 (7th to 12th ) grade students, the overall prevalence of susceptibility to smoking, experimentation (ever smoking), 30 day, and current smoking was
50%, 45%, 18%, and 12%, respectively.

Water-Pipe Smoking
Water-pipe smoking (WPS) is a centuries-old method of tobacco use in the Middle East and the Indian subcontinent.
WPS is also increasing among young people in the Arab
countries in part because it is commonly an accepted cultural
practice with prevalence estimates between 6% and 35% of
those aged 13-15 years [8, 9].
Anecdotal reports indicate that WPS has become a global
phenomenon in recent years, in the US; 5-17% of some adolescent populations may be current WPS [8, 9]. Eisenberg et al
[29], reported a nearly 50% lifetime prevalence rate and a 20%
past 30-day use rate among first-year college students at
Virginia Commonwealth University. Moreover, nearly 300
new water-pipe cafes opened in the US between 1999 and
2004, mostly in college towns [30].
Two studies evaluated the prevalence of WPS among AA
youth; Rice et al [31] and Wiglicki et al [27] reported high use
of WPS among AA youth and more so when compared to
non-Arab American youth. The investigators concluded the
need of further research of WPS among both Arab and non-

Curr Cardiovasc Risk Rep (2016) 10:25

Arab Americans as well as to design culturally-based interventions to mitigate WPS and its growing use in the US.
Factors thought to be responsible for the growing popularity of waterpipe use include (a) the introduction of maassel, a
sweet and aromatic processed tobacco that has greatly simplified use of the waterpipe, (b) the apparent belief that it is safer
than cigarettes because smoke is passed through water, and (c)
dearth of information about health effects of WPS when compared to that of cigarette smoking. However waterpipe use
may be associated with greater toxicant exposure because longer use episodes as well as more and larger puffs lead to
inhalation of as much as 100 times more smoke than from a
cigarette [8, 9]. The World Health Organization [32] has called
for studying the health effects of waterpipe smoking.
Unfortunately studies among AAs adults on health hazards
of this smoking habit especially on cardiovascular disease
are scant.
Khat (Amphetamine-like) Use
Chewing the leaves of the plant Catha edulis (referred to
as khat, mirra, qat, chat, and quaadka, likely dates to
times of antiquity and may predate the use of coffee.
Cathinone, cathine, and norephedrine are the main components of khat. Cahthinone is structurally similar to amphetamine and functionally similar to amphetamine and
cocaine. We and others [10, 33] have recently published
observational reports of an association between khat use
and cardiovascular diseases and outcome. Khat use was
initially thought to be of limited concern to Western populations because of its complicated cultivation and distribution systems, however overnight delivery systems and
immigration of khat chewers contributed to its global distribution. Its use is highly prevalent among Arabs of
Yemeni and Somali origin. Recently, in the US, numerous
seizures of khat have been confiscated. According to the
National Drug Intelligence Center, East African and
Yemeni independent dealers are distributing khat in the
US [10].
Unfortunately data about khat use among AA is lacking
and is urgently needed.
Prevalence of Cardiovascular Disease
CVD are lauding causes of mortality in Arab countries, moreover the median age of presentation with first MI was 51 years
which was 12 years younger than that reported in the Western
world [4, 34]. A projected increase in coronary deaths in the
Arab countries of 171% between 1990 and 2020 was larger
than corresponding values for countries such as China (108%)
and Latin America (144%) [4].
Data about the prevalence of cardiovascular disease among
AAs is very limited; Jamil et al [24] studied the prevalence of

Curr Cardiovasc Risk Rep (2016) 10:25

heart disease using a self-report survey of whether they have

been diagnosed with having heart disease or not among 2084
women in Michigan (Chaldean-AA, other AA and African
American) in 2005. There were 543 Chaldean, 812 other
Arab-American, and 729 African American women. The
overall prevalence of heart disease was 5.1% (Chaldean
6.6%, other AA 7.1% & African American 1.8%). After adjustment for baseline variables between the various groups the
association between ethnicity and heart disease did not reach
significance.
Jamil et al also compared his findings with two earlier
studies reported by Hassoun and Aswad [24]. Hassoun reported a 3.7% prevalence of heart disease among a convenient
sample of 300 Chaldean and other Arab-Americans, with
2.6% prevalence among women. Hassoun found that the prevalence of heart disease among Chaldean was ~5% regardless
of sex. Aswad reported a 7.6% prevalence of heart disease
among a convenience sample of 1000 Arab Americans [24].

Page 5 of 6 25

Conclusion
There is a paucity of published studies about cardiovascular
risk factors and diseases among AA. The current studies suggest the urgent need for better ways to identify AA and the
development of large prospective studies on determinants of
cardiovascular health including potential factors such as
acculturation.
AA, Americans of Arab descent; US, United States;
NHANES III, Third National Health and Nutrition
Examination Survey; NHIS, National Health Interview
Survey; CVD, Cardiovascular disease; DM, Diabetes
mellitus; BMI, Body mass index; ATP III, Adult Treatment
Plan III; WHO, World Health Organization; ADA, American
Diabetes Association; HDL, High density lipoproteincholesterol
Compliance with Ethical Standard
Conflict of Interest Jassim Al Suwaidi declares that he has no conflict
of interest.

Mortality Rates and Life Expectancy among Arab Americans

Four studies evaluated mortality rates among AAs. Dallo et al
[35] studied cause-specific and age-specific mortality rates
among AA adults in Michigan between 1999 and 2000.
Although AA men (aged 25 years) relative to whites had
higher all-cause mortality and cause-specific mortality including heart disease, diabetes mellitus and stroke, AA women had
lower all-cause and cause-specific (including cardiac) mortality rates.
Among select samples of AA in California, Naserri et al
[36] reported higher DM and mortality rates among first generation AA (using Arab name algorithm to attribute to Arab
ancestry in the analysis) relative to US-born non-Hispanic
Whites in California. Similar findings were also observed by
the same investigators using data from Orange County and
Los Angeles County, California [37].
More recently, El-Sayed et al [12], explored life expectancy and age-adjusted mortality risk of AA (defined as selfreported Arab ancestry) using data collected about deaths in
Michigan between 1997 and 2007 (among children and
adults), and 2000 census data were collected for population
denominators. Despite better education and higher income,
AA had higher age-adjusted mortality risk than non-Arabic
and non-Hispanic Whites (AA males and females had lower
life expectancy than non-Arab and non-Hispanic Whites by 2
and 1.4 years, respectively), this higher mortality rates was
observed in both all-cause and cardiovascular mortality rates.
This increased risk may be attributed to higher risk of cardiovascular disease, cancer incidence, and smoking among AA
when compared to whites. Other potentially contributing factors suggested by the investigators included immigration, acculturation, and discriminations.

Human and Animal Rights and Informed Consent This article does
not contain any studies with human or animal subjects performed by the
author.

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