Diet Differences in African Americans

There are a number of important diet differences in African Americans that need to be considered prior to offering advice regarding improvements or adjustments.  To tell someone to “eat better” without first knowing their current diet is a waste of everyone’s time.

Some of the basic foundations of African Americans’ diet stem from slavery days, but there are also more recent adaptations that have slowly weaved into the fabric of the African American diet.   Some of the changes were economic and others more convenience and culture-related.  To sum up the African American diet by only referring to slave influences is to ignore one and a half centuries of added impacts that made the African American diet what it is today.   Food availability, storage, financial independence, health literacy, and a sense of history and heritage all contribute to the ever changing components of the widening African American diet.

With the ever changing make-up of African Americans, their diet is equally changing. More Africans, Caribbeans, and mixed races folds in a number of cultural nuances that need to be considered.  Even within the African American community, the diets vary greatly. Some sub-cultures eat more rice whiles other prefer pasta.  Some avoid pork for religious reasons, while other avoid beef due to poor digestion, other simple cost.

These considerations aside, the basics of the African American diet mirror an American diet.  The “average” meal will have meat, starch, and vegetables in varying proportions.

African Americans more frequently will have their vegetables cooked rather than fresh.  Because of the scarcity of meat as a main course in slavery days, seasoning these cooked vegetable dishes with fatty cuts of low preference meat (whether smoked or not) quickly became a mainstay in the African American diet.  Having the lean cuts reserved exclusively for the more affluent, African Americans became accustomed to other cuts of meat (ham hocks, neck bones, and ox tails, etc.).

Now that the scarcity of meat is much less of a logistical problem, the ‘habit’ or custom of adding meats to vegetables is now merely a standard way to cook them. String beans, collard/mustard/turnip greens almost always have a smoked (and/or salted) cut of meat in the pot.  Because of a growing aversion to pork products in some circles, a significant number of African Americans used smoked turkey to season cooked vegetables and beans.

The breakdown in terms of specific meats preferred by African Americans show a predominance of chicken and turkey, as well as relatively more fish and pork, but less beef than white and Hispanic American diets.

Diet Differences in African Americans

Overall, African Americans eat less grains, fewer eggs, less vegetables, and much less milk, but they consume significantly more meat and fruits.  By increasing the amount of vegetables, particularly fresh uncooked in the form of salads, more nutritional balance can be brought to the African American diet fairly easily. The increased consumption of fish and poultry (both chicken and turkey) already represents a beneficial existing tradition.

Diet Differences in African Americans

Although African Americans eat relatively fewer vegetables, there are also distinct differences within this category with an increased consumption of fresh green beans, fresh cabbage, and fresh greens when compared with other vegetables.

African Americans prepare more meals “from scratch” when compared to majority populations.  This diet difference in African American home cooking leads to comparatively more purchases of cooking items including spices, seasonings, oils, and preparation items including baking powder, flour, extracts, and sugars in multiple forms.

Diet Differences in African AmericansThe more “home cooking” done in African American kitchens leads to less consumption of pre-processed or ready-to-eat foods which is considerably beneficial.  Conventionally, when people think of processed and ready-to-eat foods, they generally equate them with poor nutritional quality and lower socio-economic status.  Poti, Mendez, and colleagues looked at the nutritional value of “processed foods” and found they have “higher saturated fat, sugar, and sodium content” when compared to lesser processed foods.  Because of the higher proportion of African Americans that are poor, many assumed that they too consume more ready-to-eat foods, but studies reveal that, in fact, African Americans buy less overall ready-to-eat and/or highly processed foods when compared to European Americans.

One glaring exception in the purchasing of pre-processed foods was African Americans’ tendency to purchase a much higher proportion of pre-processed sugary beverages when compared to white Americans, and a much lower volume of milk and dairy purchases. Other exceptions include a significantly higher consumption of bacon and sausages.  Finally, there was also an increased purchasing of processed sweeteners including sugar, syrups, jams and jellies in African American consumers.

While there is far more diet differences in African Americans to cover, the best way to advise a patient on their diet is to first know their specific diet . . . don’t generalize . . . interview.  Find out what, exactly, they eat, and then devise an alteration plan with suitable substitutions.  Very few people will be able to completely change their diet, and providers should not expect this because it is unrealistic.  But we should be able to give helpful advise based on a detailed interview.

 

Strokes in African Americans

Strokes in African AmericansMost strokes in African Americans occur due to high blood pressure and a much higher number of African Americans have uncontrolled blood pressure.  A quarter of all strokes occur in the presence of atrial fibrillation (a fib) and while representing 13 percent of the US population, African Americans experience almost twice that percentage of all strokes (26%).

And when a stroke occurs, African Americans have them earlier in life and present with more severe and disabling conditions.    The “Cardiovascular Quality and Outcomes” group concluded that “compared with other race/ethnicity groups, (African American) patients were less likely to receive IV tissue-type plasminogen activator <3 hours, early antithrombotics, antithrombotics at discharge, and lipid-lowering medication prescribed at discharge,” a study looking at over 200,000 patients showed.

Not surprisingly, with these prescriptive deficiencies in play, data analysis also showed a persistently increased re-hospitalization rate in African Americans at both 30 days and one year for all causes.  African Americans also have a 2.4 times higher rate of recurrent strokes than white Americans, and the highest death rate of any racial group.

Stroke patients overseen by neurologists were almost 4 times more likely to receive IV clot dissolving medicine than those seen by non-neurologists for all races and ethnicities (study from the Baylor College of Medicine ), but unfortunately African Americans were half as likely as whites to be seen by a neurologist when presenting with a stroke.

Aspirin to reduce Strokes in African Americans

Aspirin use is also decreased among African Americans as compared to whites and the indications for aspirin use are actually higher in African Americans.

Aspirin reduces the risk of stroke, heart disease, and colon cancer at low doses and the risk for gastrointestinal bleed is much lower than the risk of stroke, heart attack, etc.

African Americans over age 40 should be taking aspirin given the increased incidence of colon cancer, heart disease, and strokes.

Overall, the USPSTF recommends referring adults who have cardiovascular disease risk factors and are obese to intense behavioral counseling interventions to promote a healthful diet and physical activity. By decreasing the intake of salt and fried foods, lowering the blood pressure and getting proper exercise, strokes in African Americans can greatly decrease.

 

Establishing Trust When Patients Distrust Doctors

Distrust DoctorsDistrust Doctors ??

Multiple studies over an extended period of time confirm what most doctors and providers already knew, African Americans are more likely to distrust doctors and other healthcare providers than patients of other ethnic groups.

What many of us did not know was why.  As providers, we spent many years training to help others.  Medicine is a service profession. Why would anyone suspect our intentions, question our motives, or assign us collectively as untrustworthy?  The answer lies in the historical experience African Americans had with America’s doctors, hospitals, and researchers.

While the Tuskegee Syphilis Study is a ‘classic example’ of abuse based purely on race, unfortunately the American experience has many more examples of why African Americans mistrust the medical community.

From African American’s earliest days in this country, abuse based on race was commonplace.  Slaves were frequently used as subjects for dissection, surgical experimentation, and medical testing. J. Marion Sims, MD, the so-called father of modern gynecology perfected many of his surgical techniques on slave girls without anesthesia. Stories of doctors kidnapping and killing southern blacks for experimentation consistently appear in literature throughout American history.

Distrust DoctorsAs Vanesa Northington Gamble, MD, PhD put in her article “Under the Shadow of Tuskegee: African Americans and Health Care” tales of ‘medical student’ grave robbers, recount the exploitation of southern blacks as their deceased family members would be stolen and sent to northern medical schools for anatomy dissection.  Dr. Gable writes:

“These historical examples clearly demonstrate that African Americans’ distrust of the medical profession has a longer history than the public revelations of the Tuskegee Syphilis Study. There is a collective memory among African Americans about their exploitation by the medical establishment.”

Chanita Hughes Halbert published a study in JAMA in 2006 looking at racial differences in trust in healthcare providers. Her study of almost one thousand white American and African American patients found that “compared with whites, African Americans were most likely to report low trust in health care providers.”

“Trust has been described as an expectation that medical care providers (physicians, nurses, and others) will act in ways that demonstrate that the patient’s interests are a priority. Trust is a multidimensional construct that includes perceptions of the health care provider’s technical ability, interpersonal skills, and the extent to which the patient perceives that his or her welfare is placed above other considerations. Trust is an important determinant of adherence to treatment and screening recommendations and the length and quality of relationships with health care providers.”

Fortunately, the level of trust a patient has for any specific provider is not stagnant, it can be earned.  Increased exposure to providers in general, and to the same provider in specific, has been shown to improve trust.

In the “Medscape Internist Lifestyle Report 2017“, Carol Peckham looked at internist’s admitted explicit biases “toward specific types or groups of patients” and found wide differences between racial groups in bias for a number of influences.  The study further examined if the physician bias actually impacted care delivery, and almost one in five providers (18%) admitted that their bias did impact the quality of their care.

Generally these biases are positive toward white American patients and negative toward African American patients as a study by Oliver et al demonstrated at the University of Virginia. They found providers explicitly preferred white Americans to African Americans with “significantly higher feelings of warmth toward white people” and also found that white American patients were “more medically cooperative than African Americans”.  This study found no significant difference in the quality of care between the racial groups.

“physicians demonstrated implicit pro-white bias, reported an explicit preference for white people, had beliefs that blacks were less medically cooperative than whites, and believed that subconscious biases could influence their clinical decision making.”

Biases that effect medical care can be consciously counteracted, and admitting the existence of biases is the critical first step in canceling its effect on medical care. Having a doctor who professes to treating “everyone the same” will undoubtedly provide inferior care to patients that are different.

A study done at Johns Hopkins by Lisa Cooper and colleagues found that primary care physicians who hold unconscious racial biases tend to dominate conversations with African-American patients during routine visits, paying less attention to patients’ social and emotional needs, and making these patients feel less involved in decision making related to their health. These patients also reported reduced trust in their doctors, less respectful treatment, and a lower likelihood of recommending the physician to a friend.

Because there are a limited number of physicians to provide care to African Americans, many patients simply “put up” with biases and unequal treatment . . . with others avoiding healthcare altogether until they they arrive in Emergency Departments with very advanced disease.

Patient centered care can positively improve care, specifically for African Americans.

Distrust DoctorsAlthough this seems obvious, spending time with patients is an easy approach to establishing trust. Fiscella and colleagues measured patient trust against the time spent with a patient and found a one-to-one correlation: the more time spent led to more perceived trust on the part of the patient.

Many delays in diagnosis and treatment are simply an outgrowth of the lack of trust. You will not accept someones advice, if you don’t trust them.

Find a physician you trust.

See another article about the history of distrust HERE.

Are you on the right blood pressure medicine? 

right blood pressure medicine? When it comes to treatment for blood pressure, there are a number of important differences in African Americans.  Evidence from studies suggests that African Americans do very well with thiazide diuretics (a “water”pill) and they should be used often for the treatment of high blood pressure.  Thiazide-type diuretics (chlorthalidone) was better at reducing blood pressure and preventing cardiovascular events than an ACE (lisinopril), or an alpha-adrenergic blocker (doxazosin) in African Americans as found in the “Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack” (ALLHAT) trial.

right blood pressure medicineFor ideal blood pressure control, the thiazide-type diuretic dose should be equivalent to chlorthalidone 12.5 to 25 mg/day or hydrochlorothiazide 25 to 50 mg/day because lower doses have not been found to be as effective.  Overall, calcium channel blockers (amlodipine) have also shown great effect in African Americans as an initial choice, and are more effective in decreasing strokes than water pills. right blood pressure medicineThus an African American male would be best served by amlodipine first line given the stroke prophylaxis, and a African American female better served with a thiazide diuretic initially to get to goal more efficiently.

Angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blocker (ARB) medications are less effective in African Americans for blood pressure control and are associated with worse outcomes.  A large study of over 400,000 patients done at the New York University School of Medicine compared outcomes in African Americans and European Americans with three distinct groups:

right blood pressure medicineTheir study  showed that ACE inhibitors were associated with a significant increase in stroke, heart failure, and combined cardiovascular disease when compared with calcium channel blockers or thiazide diuretics in African Americans. The worse outcomes with angiotensin-converting enzyme (ACE) inhibitors were similar to that of B-blockers in this population.

Because ACE inhibitors are commonly listed as “first-line” medications for blood pressure control in national and international guidelines and recommendations, it should be noted that this principally is based on their response in White populations.  Based on these large African American-inclusive studies and a number of considerations (including cost, co-morbid conditions and disease propensities), the National Institute for Health and Clinical Excellence clinical practice guideline suggests calcium channel blocker therapy initially in African Americans, and substitute a thiazide-like diuretic in the event of edema or intolerance “or if there is evidence of heart failure, or a high risk of heart failure.”

Putting all of these risks aside (imagine that??), ACE inhibitor blood pressure response in African Americans is usually less when compared to calcium channel blockers, thiazide diuretics, or even B-blockers. Researchers suspect that the low blood pressure response is related to “high sodium intake in salt-sensitive” patients, but others have suggested that hypertension in African Americans may just be different.

These landmark studies also confirmed that African Americans have a greater incidence of ACE related cough, and a higher rate of stopping due to cough compared to all other racial groups. African Americans were also more prone to develop ACE-related allergic reactions.

When considering all of these issues with ACE’s and ARB’s in African Americans, it should be noted that they are essential for preventing kidney disease in people with diabetes, and certain other kidney related problems.  So if you don’t know why your on an ACE or ARB, call your physician and ask.  The renal-sparing benefits of the ACE and ARB medications is still very valid when used to slow renal function decline (particularly in hypertensive renal disease), and they should still be used for kidney protection in African American patients with diabetes and similar conditions.

So don’t just stop your medications based on this article, please check with your provider.

The Tuskegee Syphilis Study

Tuskegee Syphilis StudyThe Tuskegee Syphilis Study (originally called “Tuskegee Study of Untreated Syphilis in the Negro Male”) was originally formed to record the natural history of syphilis with the hope of justifying the funding of public treatment programs for African Americans. The study, which began in 1932, included 600 African American men, 399 with syphilis and 201 without. While the study was originally slated to last 6 months, it was extended for over 40 years. Central to the study was the patient’s lack of informed consent.  None of the patients were told they had syphilis, instead they were told they had “bad blood” that required ongoing monitoring.  In exchange for taking part in the study, the men received free medical exams, free meals, and burial insurance.  Many physicians, including African Americans, and national physician societies, fully supported the study.

Tuskegee Syphilis StudyDuring the study, researchers not only allowed the disease to progress, but actively blocked the men from receiving curable treatment, not just from the study physicians, but also from other community physicians.   The researchers implemented a coordinated effort . . . a verified conspiracy, with area physicians and hospitals to actively block treatment for the study participants if they presented elsewhere for care. Needless to say, this endeavor required the widespread dissemination of personal health information across an entire region and involving hundreds of people.  The names and a stigmatizing diagnosis were circulated widely, and in a way that the patient would not know. The fact that nearly 400 African American men were denied effective treatment for syphilis without their knowledge or consent so that researchers could document the natural history of the disease, stands as a singular event that largely validates the mistrust African Americans have against the medical establishment.

Tuskegee Syphilis StudyIt wasn’t until 1972, when a news article reported the details of the study, that a government review panel finally halted it. The Tuskegee Health Benefit Program was established as a settlement for the class action suit brought against the United States which agreed to pay all medical and burial expenses for the subjects involved, with added support for their families. During the course of the study, 40 wives contracted the disease and 19 children were born with congenital syphilis.  Many credit the Tuskegee Syphilis Study as the primary reason informed consent regulations exist today, but for many African Americans, the study is a validated reason to not trust doctors, public health, medical research, or the healthcare system.

In 1996, a formal apology was issued by the US government and the survivors were invited to the Oval Office by President Clinton.

Tuskegee Syphilis Study

Some might argue that with the passage of time the Tuskegee Syphilis Study is merely a distant historical event for most African Americans.  A study done at Johns Hopkins looked at awareness of the Tuskegee Syphilis Study and found an overwhelming number of African Americans (81%) were aware of the study and outcomes, while only 28 percent of European Americans had knowledge of the study. With widespread knowledge of this government-sanctioned and funded study within the African American community, mentioning the study as a way to stimulate discussion, and build trust, is a preferable approach to ignoring its existence.

The health and social issues with tattoos

The health and social issues with tattoos

Greg Hall, MD

Almost half of people between 18 and 35 have tattoos, and almost one in four regrets it, according to a 2016 Harris Poll. Based on an estimate of about 60 million people in that age group, that would mean that about 7.5 million people have tattoo regret.

As a primary care physician, I’ve noticed anecdotally that many of my younger patients have regrets about their tattoos. When I ask about them, many say that they got them when they were young, and at the time put little or no research into the decision.

With no source (reliable or otherwise) of tattoo information to suggest to my patients, I began to investigate the topic myself. My goal was to write a quick reference for teens that reviewed the health and social issues they might encounter after getting a tattoo.

What I found was myriad unexpected and sometimes shocking concerns that everyone should know. To my surprise, there were a host of reports of ink complications, infections, toxin effects, scarring, burns, chronic irritations and much more.

The ink goes more than skin deep

Iron Oxide Oxide RedAmong the concerns are the long-term effects tattoo inks can have on the immune system, pathology specimen interpretation and other unforeseen health complications.

Certain tattoo inks can be toxic, with some containing carcinogenic compounds, a 2012 Danish Environmental Protection Agency found. In fact, one in five tattoo inks contained carcinogenic chemicals, and a vast majority of the inks tested did not comply with international health safety standards for ink composition, an Australian government-sponsored study found. Even more concerning, carcinogens were identified in 83 percent of black inks – by far the most popular color for tattoos.

The European Society of Tattoo and Pigment Research was established in 2013 with a mission of educating the public about the “fundamental facts about tattooing” which many in the younger generations ignore. That group found barium, copper, mercury and other unsafe components in tattoo inks. Their research also found a disheartening mismatch between the listed ink container contents and its actual chemical composition found on testing.

More recently, the Food and Drug Administration has become more involved with tattoo inks, stating “Many pigments used in tattoo inks are industrial-grade colors suitable for printers’ ink or automobile paint.” Like the studies started overseas, the agency is now examining the chemical composition of inks and pigments and how they break down in the body, as well their short- and long-term safety.

Tattoos have led to errors in medical treatment, testing

Metal-based ink tattoos can react with magnetic resonance imaging studies. For instance, two case studies detail patients who suffered MRI-induced burns in their tattoos that were attributed to iron compounds in tattoo pigments. Radiologists say this magnet-based reaction is rare, but some have suggested simply avoiding iron-based tattoo inks.

Pathologists, meanwhile, are reporting tattoo ink in surgical biopsy specimens of lymph nodes. For instance, a 2015 report in the journal Obstetrics and Gynecology detailed the case of a young woman with cervical cancer which doctors believed had spread to her lymph nodes. After surgery to remove the nodes, they discovered that what appeared to be malignant cells in a scan was actually tattoo ink. A similar misdiagnosis occurred in another patient with melanoma.

And then there are the infections

Hep-CThe most common infections associated with tattooing involve staphylococcus aureus or pseudomonas bacteria arising from poor skin preparation or equipment sterilization. “Staph” skin infections can become serious and even life-threatening, as antibiotic-resistant strains become more prevalent.

Three percent of tattoos get infected, and almost four percent of people who get tattoos recount pain lasting more than a month, a 2015 study from Tulane University School of Medicine found. About 22 percent of participants with new tattoos reported persistent itching that lasted more than a month.

A spate of mycobacterial skin infections in 22 people across four states in 2011 and 2012 was tied to a few specific brands of ink. The Centers for Disease Control and Prevention, in conjunction with local departments of public health, were able to contain these infections through intense tracking and investigation.

More serious tattoo-induced skin disorders like sarcoidosis, lichen planis and lupus-like reactions are increasingly reported in current literature. These skin problems can be more long-lasting and leave permanent scarring.

A study reported in Hepatology found that “tattoo exposure is associated with HCV (hepatitis C virus) infection, even among those without traditional risk factors. All patients who have tattoos should be considered at higher risk for HCV infection and should be offered HCV counseling and testing.”

Hepatitis, which is 10 times more infectious than HIV, can be transmitted through needles used by tattoo artists. It is the reason the American Red Cross restricts blood donations from individuals with newer tattoos done outside of regulated tattoo facilities.

A study from Tulane University added credence to these blood donation restrictions by showing that 17 percent of all participants had at least one tattoo done somewhere other than a tattoo parlor, and 21 percent admitted to being intoxicated while receiving at least one of their tattoos.

A youthful decision with adult implications

The primary reason Harris Poll respondents reported tattoo regret was they “were too young when they had it done.” The second most common reason, which coincides with the first, is the tattoo “didn’t fit their present lifestyle.”

Whether a tattoo depicts a name, a person, a place or a thing, its meaning and perception are in constant flux. Eric Madfis and Tammi Arford, writing about the dilemma of symbols and tattoo regret, note that “Symbols are dynamic in that they are time-specific, ever-changing, and always in a state of gradual transition.”

Tattoos have a different meaning depending on the interpreter, their relative history and knowledge, and they are dynamic because they can take on different meanings through time and experience. The first person to get a barbed wire tattoo on an upper arm could be seen as clever, inventive, unique and trail-blazing. The one-hundredth person to get the same tattoo was none of these things, and with time, if either was seen in public, both would receive the same reaction.

The “emotional response in the beholder” of any given tattoo can be based on “social stratification” and is not consistently predictable, according to Andrew Timmings at the University of St Andrews in the United Kingdom. Their interviews of hiring managers showed that tattoos can actually hurt job prospects.

Another study, at the University of Tampa, confirmed that 86 percent of students believe that having a visible tattoo is a detriment to their business prospects.

Researchers at the Harris Poll found that older respondents are less tolerant of visible tattoos as the prestige of the job position rises. While a vast majority of people age 51 and above are comfortable with professional athletes having tattoos, the acceptance decreases significantly when doctors, primary school teachers and presidential candidates are included.

Understandably, people who have many friends and family with tattoos are generally less stigmatized regarding their tattoo, and tend to suffer less tattoo regret, a study in The Social Science Journal reported in 2014. But the study also found that when tattooed respondents were exposed to individuals without tattoos, like in the workplace or institutions of higher learning, more stigma victimization occurred, and those impacted were more likely to suffer regret and ponder removal.

People often regret getting married when young, just as they do with tattoos. From www.shutterstock.com

Getting a tattoo, which is akin to a life-changing (and body-changing) decision, when young is really no different from getting married young (32 percent regret rate) or choosing a college major (37 percent change rate). For many, making a major decision when young is rife with regret. The difference with tattoos is having to face that regret on a daily basis.

As the pure number who have tattoos grow, the market for getting these tattoos removed has also found its niche. Laser tattoo removal services have rapidly grown across the nation and have become a multi-million dollar business, with additional potential for growth as the younger, highly tattooed, generations age.

But some problem tattoos can’t be removed

Laser with screenCurrent lasers still have limitations in the colors they can erase with added difficulty stemming from more vibrant tattoo colors. Darker pigmented people tend to have less success with certain lasers and require more sessions to avoid skin damage.

Because the laser shatters the pigment particles under the skin for removal by the body, the issues with infections, scarring and the ink spreading become a concern again. Tattoos covering extensive areas of the body are simply too large to tackle in one session, and could take years to remove.

Laser complications include pain, blistering, scarring and, in some cases, a darkening of the tattoo ink can occur, according to dermatologists.

As technology and the demand for tattoo removal advances, some of the limitations of current lasers will shrink. Newer, easy-to-remove inks are being patented, which may represent a healthier approach due to biodegradable ingredients, and a more predictable laser response. Picosecond lasers are also dramatically decreasing the number of sessions needed in select populations.

Teens Tattoos Piercings Front Cover aEducation is the key

With such a large number considering tattoos at a young age, informing young people of the health and social risks could help them avoid tattoos they may come to regret. Adding permanent body art education to health classes could mitigate some of these mistakes and decrease later regret.

The ConversationGreg Hall, Assistant Clinical Professor, Case Western Reserve University

This article was originally published on The Conversation. Read the original article.

Do Great Music Artists Die Young?

With the startling death of Prince at the age of 57,

many began to reflect on the seemingly ‘premature’ death of ground-breaking artists like Michael Jackson,  Elvis Presley, or Hank Williams.   Even as a physician, I began to wonder a number of questions.  Do great music artists die young?  Are there certain conditions that are more likely to cause a star’s demise?  And finally, is there some lesson to be learned that might help our remaining beloved music artists?

music artists die young
Prince in 2008. Photo curtesy of Micahmedia at en.wikipedia

I began by tabulating the vital statistics on the 252 members of Rolling Stone Magazine’s “100 Greatest Artists” from the music industry. The list ranged from the #1 group The Beatles with two members that met a premature death (John Lennon at age 40 and George Harrison at age 58) to the #100 group The Talking Heads without a death amongst them.  In between, were stars like Jimi Hendricks who died at age 27 from a drug overdose, Bob Marley who passed at 36 from skin cancer, and Marvin Gaye who was shot and killed by his father at age 44.  In all, 82 of the 252 members of this elite group had died.

Homicides and Accidental Deaths

music artists die young
Sam Cooke in 1961

There were six homicides for various reasons ranging from a psychiatric obsession that lead to the shooting of John Lennon, to the planned ‘hits’ on rappers Tupac Shakur and Jam Master Jay.  There is still a good deal of controversy surrounding the shooting of Sam Cooke by a female hotel manager who was likely protecting a prostitute who had robbed him.  Al Jackson Jr., the renowned drummer with Booker T & the MGs, was shot 5 times in the back by a burglar in his home amongst mysterious circumstances that still baffle authorities.

An accident can happen to anyone, but the “100 Greatest ” have more than their share. There were numerous accidental overdoses including  Sid Vicious of the Sex Pistols at age 21, David Ruffin of the Temptations at age 50, Rudy Lewis at age 27 of The Drifters, and country great Gram Parsons who was found dead at age 26.

While your odds of dying in a plane crash are about 1 in 5 million, if you are one of the “100 Greatest” those odds jump to 1 in 84.  Buddy Holly, Otis Redding, and Ronnie Van Zant of the Lynyrd Skynyrd Band all died in airplane accidents while on tour.

Increased Liver Disease

music artists die young
The Doors
By Elektra Records-Joel Brodsky

While liver-related diseases make up only 1.4% of the general population’s cause of death, it comprised over three times that number among the “100 Greatest Artists” deaths.  The increased occurrence of these diseases is probably related to the elevated alcohol and drug use in this group. Liver bile duct cancers that are normally extremely rare in the general population ran suspiciously high in our small but esteemed group with Ray Manzarek of The Doors and Tommy Ramone of the Ramones both dying prematurely from a condition that normally effects less than one in a thousand .

Tobacco Use Effects

music artists die young
Eddie Kendricks of the Temptations

The vast majority of the “Great 100” were born in the 1940’s and reached maturity during the 1960’s when tobacco smoking peaked.  As a result, an increased number of artists died from lung cancer including George Harrison age 58 of the Beatles, Carl Wilson of the Beachboys at age 51, Richard White of Pink Floyd at age 65, Eddie Kendricks of the Temptations at age 52, and Obie Benson of the Four Tops at age 69.  Throat cancer, also linked with smoking, caused the deaths of country great Carl Perkins at 65 and Levon Helm of The Band at 71.

A good number of the “100 Greatest” had heart attacks or heart failure  and included Ian Stewart age 47 of the Rolling Stones, blues greats Muddy Waters age 70, Howlin Wolf age 65, Roy Orbison age 52,  and Jackie Wilson at age 49.

We recently saw Glenn Frey succumb to pneumonia, but so did Jackie Wilson at age 49, nine years after a having a massive heart attack.  James Brown complained of a persistent cough and declining health before he passed at age 73 with the cause listed as congestive heart failure as a result of pneumonia.

Among those dead, the average age was 49.

One of the two shocking outcomes deals with life expectancy. While the average American male has a life expectancy of about 75 years, the males in the “100 Greatest Artists” who have died had an average age of just over 49 years and makes up almost one third of the entire group. Factoring their birth year and a life expectancy of 75 years, only 44  should have died by now, instead of the 82.  Incidentally, of the 44 that should have died based on life expectancy, 19 are still alive.

Alcohol and drug abuse

Dr Greg Hall
Click LINK to read more about alcohol abuse.

The second shocking outcome was the sobering and disproportional occurrence of alcohol and drug-related deaths ranging from Kurt Cobain’s gunshot suicide while intoxicated to Duane Allman of the Allman Brothers accidental death on a motorcycle while impaired. Members of legendary bands like The Who (John Entwistle age 57 and Keith Moon age 32), The Doors (Jim Morrison age 27), The Byrds (Gene Clark age 46 and Micheal Clarke age 47), The Band (Rick Danko age 55 and Richard Manuel age 42), and others all succumbing to alcohol or drug-induced death.

There were many including The Grateful Dead’s Jerry Garcia and country star Hank Williams who declined more slowly over the years from substance abuse while their organs deteriorated, and the official cause of death was heart-related, but in reality the cause may have been more directly related to substance abuse.

Alcohol and drugs accounted for at least one in ten deaths of these great artists, while nationally substance abuse as a cause of death effects one in 33. The threefold difference points to the much greater access and use of drugs and alcohol among these ultra-talented artists.

 

Too Much Opioid Use & Abuse

Dr Greg HallCurrently, the US is in the midst of a opioid abuse epidemic with heroin and prescription drug overdoses setting records across the country. Elvis Presley, Jimi Hendrix, Janis Joplin, Sid Vicious, Gram Parsons, Whitney Houston (who didn’t make this 100 Greatest List), Michael Jackson, and now possibly Prince all dying from accidental opioid overdose. While it is still unclear what the cause of death will be in Prince’s case, early evidence points toward opioids.

Controlling  the effects of oxycodone, fentanyl, heroin or morphine and thereby reducing accidental death is difficult, and for these stars and countless others across the world, in the end . . . impossible.  Put another way, without the inappropriate use of opioids or their addiction, all of these stars could still be alive.

What music could those who died young have created if they were given the chance to live and flourish? And more importantly for us, who’s next?

Laser Tattoo Removal on Dark Skin

As you have probably heard, laser tattoo removal on dark skin is a real challenge.  The process takes longer, is frequently more expensive (because you have to go more often), and can be more plagued by less perfect outcomes.  Because African American “keloid” more easily than white Americans, the laser result can (and frequently does) show this ‘build-up’ of skin.

Laser Tattoo Removal on Dark SkinIn deciding whether to have laser treatments, you will have to decide if you would be “okay” with a scarred outcome rather than a tattoo.  The current lasers on the market are not ideal for darker skin colors and the outcomes are frequently not what people expected.

The key is to treat skin of color differently than white skin. Not better or worse, simply different.  In these cases, laser tattoo removal on dark skin has to be approached delicately and with great care.  Slow and steady is always the best approach and wait 6 weeks at least between sessions to allow your skin to heal.

Genetic Clues Are Ignored By Too Many Doctors

Genetic Clues Ignored

With the availability of home genetic testing kits from companies such as “23andMe” and “Ancestry DNA,” more people will be getting information about their genetic lineage and what races and ethnicities of the world are included in their DNA.

Geneticists, meanwhile, are also getting more tailored information about disease risk and prevalence as genetic testing in medical research centers continues.

Physicians accept that cystic fibrosis, for example, is much more common in people with Northern European ancestry and that sickle cell disease occurs dramatically more often in people with African origins. These commonly accepted racial and ethnic differences in disease prevalence are just the tip of the iceberg when looking at clinical differences that vary based on genetics.

But there’s a problem, a recent study from the National Institutes of Health found. Many physicians and other providers are uncomfortable discussing race with their patients, and also reticent to connect race or ethnicity to genetics and clinical decision-making, the study suggested.

Overall, physician focus groups “asserted that genetics has a limited role in explaining racial differences in health,” the authors added.

As a primary care physician who teaches urban health to medical students and as a state minority health commissioner who advocates for health equity, I see this as a problem that health care systems, and their providers, need to address.

The state of the science

Commercial DNA tests, such as those provided by 23andMe, not only give people their racial and ethnic lineage but also can provide a weighted risk for diabetes, stomach ulcers, cancer and many other diseases. In April, the FDA granted approval to 23andMe to sell reports to consumers that tell them whether they may be at heightened risk.

These companies already have the data that describe the risks for health problems based on the percentage of their ancestry composition. Those differences have been published and known in academic circles for many years. With the widespread availability of DNA tests, patients will now know their increased individual risks.

For example, Ashkenazi Jews, a specific Jewish ethnic population originating from Central and Eastern Europe, are known for having a disproportionate occurrence of a number of diseases, including Tay-Sachs disease, amyloidosis, breast cancer, colon cancer and many more.

The BRCA1/2 gene mutation greatly increases the propensity for breast and colon cancer and occurs in 1 in 40 people of Ashkenazi Jewish heritage, whereas 1 in 800 Americans in general carry that mutation. This 20-fold increased risk should prompt more aggressive screening for the gene, and more frequent and earlier mammography and colonoscopies in Ashkenazi Jews compared to the general population.

Relatively higher rates of these cancers occur in certain populations, such as Ashkenazi Jews, and demonstrates the need for more nuanced care based on data that is already available. But this information is too infrequently accessed by providers.

Genetics knowledge growing fast

African-Americans are another group with higher rates of certain genetically driven diseases. African-American men have an increased occurrence of prostate cancer, kidney failure, stroke and other health problems. Prostate cancer in African-American men, for example, grows faster and metastasizes four times as often than in European-Americans.

African-American men are at higher risk for prostate cancer.
pixelmedia/From www.shutterstock.com

But despite this increased risk for prostate cancer, doctors’ use of the PSA (prostate specific antigen), a test that works well with identifying prostate cancer in African-Americans, has steadily decreased due to recommendations aimed at majority patients who come from European-related heritage. In European-Americans, prostate cancer can be more indolent and occurs at a lower rate than African-Americans.

Also, certain types of blood pressure medications – ACE inhibitors, for example – lead to worse outcomes in African-Americans when used singularly as first-line therapy for high blood pressure, yet these medications work very well in Americans of European decent, a large study of hypertension therapy found.

A follow-up study that looked at subsequent clinical practices – which was done in response to changed recommendations based on race – showed nearly a third of African-American hypertensive patients continued to be prescribed medications that cause worse outcomes.

African-Americans also have a four-fold increased risk for renal disease leading to dialysis. Geneticists suspect that they have identified the gene that drives this difference yet most clinicians do not have the resources to test for this gene and identify the 30 percent of African-Americans that carry it.

And a gene that greatly increases the risk for Alzheimer’s disease, APOE-4, has also been identified and occurs disproportionately higher in European-Americans yet is almost nonexistent in African-Americans and is inconsistent in Hispanic-Americans. Great controversy exists surrounding the testing for this gene, given the devastating impact it could have on a patient or family. (Hispanic and African-Americans still have a very significant risk for Alzheimer’s disease, but it is not driven by this gene).

Genetically different responses to medications

Patient response to medications vary according to the presence or absence of genetic variants, which can impact the dose and the effect of many pharmaceuticals. Some of these differences can be anticipated based on race or ethnicity. For example, Warfarin is a commonly used medication in the treatment of a number of cardiovascular disorders including atrial fibrillation, deep vein thrombosis and heart valve replacement. It shows wide variations in dosing, with Americans of Asian descent requiring less medication and African-Americans requiring more to achieve equal effects. European-Americans have a variant gene that make having a major bleed on Warfarin much higher.

Some types of medications affect different groups of people in different ways.
Maoyunping/From www.shutterstock.com

A popular cholesterol-lowering medication, Rosuvastatin, better known as trade name Crestor, is twice as powerful in patients of Asian descent, and their manufacturing label indicates starting at a much lower dose in this population. In fact, the highest manufactured pill dose of Crestor is “contraindicated in Asian patients.”

Patient-centered care is the key

Because of the “patient-centered” movement in hospitals, clinics and insurance plans, providers are now feeling increased pressure to improve the quality of care provided to individual patients. Many outcomes and patient cost of care are now tracked by providers. And countless well-designed studies have validated verified differences in the clinical care of a number of pervasive diseases based on ancestry.

Providers need to educate themselves about the important differences that exist in their patient populations. Health disparities, while driven by a number of social factors, are also the result of some clinicians not applying known nuances in the care of special populations.

The ConversationAs home genetic testing grows, patients will be bringing their results to physicians for reaction and response. Physicians will need to be proactively prepared.

Greg Hall, Assistant Clinical Professor, Case Western Reserve University

This article was originally published on The Conversation. Read the original article.

Smoking is an Addiction

Smoking isn’t a habit, Smoking is an addiction.

As I encounter tobacco smokers in my practice, my family,  and in the community, one supreme issue comes through: smoking for these “hold-outs” despite smoke-free practices, taxes, and in-your-face campaigns is not a habit, smoking, for them, is an addiction, and we need to start fully appreciating this problem more effectively in order to have an even greater impact. 

National campaigns have made great strides in decreasing the smoking rate over the last 50 years . . . from almost half of all Americans in 1965 to a new low of 15% in our most recent report. Unfortunately, that 15% still represents 47 million people, who still need help to stop.

Smoking is an addictionThink about it . . . if someone said “let’s take a leaf from a plant, dry it, wrap it up, set fire to it, and then inhale its smoke repeatedly” many would think the idea is crazy.  People who have never smoked struggle to understand because many still believe smoking is a ‘habit’ like spitting in public or chewing gun.  Many believe we can effect change by repeatedly saying “just say no” or by make logical associations between smoking and premature death.   While these approaches will (and have) worked with some, the many others who have continued to smoke in the face of these campaigns need better, more effective information that truly addresses why they don’t stop.

Unfortunately, a disproportional number of smokers come from underprivileged minorities. Consider these smoking numbers from the CDC’s most recent data (2014):

·       More than 29 of every 100 American Indians/Alaska Natives (29.2%)

·       Nearly 28 of every 100 multiple race individuals (27.9%)

·       More than 18 of every 100 Whites (18.2%)

·       More than 17 of every 100 Blacks (17.5%)

·       About 11 of every 100 Hispanics (11.2%)

·       More than 9 of every 100 Asians (9.5%)

And these numbers are after many heroic and largely successful campaigns.

What remains are still 70% of smokers who actively want to stop, and 40% who have actually tried in the last year. If smoking was truly a ‘habit’, most if not all of these people would have stopped already. 

What percentage of people who actually want to stop spitting in public, or stop chewing gum, are successful? I bet the number is in the high 90’s. True ‘habits’ while aggravating to handle, aren’t that hard to break.

Smoking is an addictionUnfortunately, many of the 47 million people who still smoke also believe smoking is a habit.  They actually believe they are ‘choosing’ to smoke.  Many think they ‘want’ to smoke.  But the evidence to the contrary is overwhelming. With economic strains, unemployment, low pay, and decreasing wages, why would someone choose to pay $8 for a pack of cigarettes (here in Cleveland, Ohio) which totals 40 cents per cigarette!  Based on the time to smoke a cigarette . . . 6 minutes, they pay 40 cents for 6 minutes of satisfaction.  People with financial hardships are not willingly choosing to spend that kind of money for a ‘habit.’

Add the overwhelming horrible health data associated with smoking which essentially says that whatever time a smoker spends smoking is lost on the back end. To put it differently, every minute spent smoking takes a minute off of your life. These are hard truths that almost everyone knows, but remains ignored by many.  To then call smoking a ‘habit’ in the face of all of these truths, is missing an overly obvious point.

Many believed that raising the cost of cigarettes would simply ‘price-out’ its wide-spread use, and to a limited extend, it has, but unfortunately the hardened addicts will simply ‘find’ the money to buy ‘what they need’ at almost any cost.  Former Surgeon General C. Everett Koop, the first to assert that smoking was an addiction, initially faced strong opposition from the general public.  His mandate to place warning labels on the cigarette packs was revolutionary and one warning simply states: ” Smoking causes a strong addiction, do not start it”.

My overriding point to the smokers reading this article is to recognize the evidence staring you in the face.  Recognize that a “nicotine fit” is evidence  of withdrawal from an addictive substance.  Recognize that planning your day around smoking breaks, deciding your travel options based on smoking availability, and spending an outlandish amount of money on tobacco . . . are ALL signs of severe addiction.  

Smokers cannot take steps to address an addiction unless they first recognize its presence. The non-smokers (including many of my doctor colleagues) also need to stop having the smug “I’m not that stupid” and “why don’t you just stop” attitude about the smokers in their life and practice.  Addictions are not stupid, they are real, strong, difficult to overcome, and need to be addressed in a sensitive and effective way.

Addiction is merely a diagnosis to be addressed.  It is not a sign of personality weakness or inferiority. Like cancer, migraines, and the flu, addictions need to be treated with the proper approach. Let’s start recognizing and treating nicotine addiction with proven and multi-pronged approaches. And let’s take the taxes we collect from current tobacco users and help them stop.