Heart Failure in African Americans

Heart failure in African Americans

Heart failure in African-Americans occurs more often and is more deadly.  African Americans have a significantly higher risk and earlier onset of heart failure and heart-related death compared to all other populations in the United States.  In fact, African Americans are two and a half times more likely to die from heart failure than Whites, and it occurs at an earlier age.  Much of the added occurrence of heart failure can be attributed to poor blood pressure control and being on the right medications to better control your blood pressure (take a look at my article “Are you on the right blood pressure medicine?”).  But there are also other causes to know.

The “heart failure” term is not the best (in my opinion) to describe the situation with the heart because it gives an impression of impending and unavoidable “failure” of the heart.  In reality, people are admitted to hospitals across the nation with the diagnosis of “heart failure” and then are given medications that readily reverses the “failure.” The term “congestive” heart failure is also used and reflects the situation of too much fluid for the heart to process. The “congestion” in the heart effects its proper function like the congestion in your nose when you have a cold.  In congestive heart failure, “water pills” and other medications are given and the “extra” fluid is flushed (urinated) out.

Heart Failure in African AmericansThe problem with heart failure is complicated, but for our purposes can be considered a combination of

  1. too much fluid in the body
  2. too much heart muscle (from high blood pressure)
  3. abnormal squeezing (or relaxation) of the heart muscles

The occurrence of heart failure, although not as ominous as it sounds in the short term, is a sign of a serious heart condition that can bring premature death.  Like many other health conditions, heart failure occurs more frequently in African Americans.  The major drivers to this racial disparity is a higher incidence of obesity, high blood pressure, diabetes, physical inactivity, and smoking.  To see if you are at risk, let’s review each risk factor.

Obesity

A significant number of African Americans are obese by a number of standards.  A strict criteria starts obesity at a BMI (Body Mass Index) of 30. Your body mass index tries to predict an ideal weight based on your height.  Look at the chart below and find your height on the left and then tract across to your weight.  If you are in the red, many will say you are  “obese.”

Heart Failure in African Americans

You and I both know that African Americans culturally prefer being “meatier” and many African Americans in the red areas are completely happy with their weight and size.  Others have suggested a different (more racially appropriate) chart be used for African Americans and other racial groups, but there is not widespread acceptance.

High Blood Pressure

Heart Failure in African AmericansHigh blood pressure (also called hypertension) that is untreated is the biggest risk for having heart failure in African Americans.  Having your blood pressure controlled to less than 130 over less than 80 is a huge step in the right direction. And being on the correct medicines for the treatment of high blood pressure and watching how salt impacts your health is important as well.

Diabetes

Heart Failure in African AmericansType 2 Diabetes is the most common type in African Americans and occurs with an 80 percent greater chance.  Getting control of blood sugars with medications and diet adjustments is critical to avoiding poor control that could lead to heart failure. Shooting for a HbA1c near 7.0 or below is an indication of good control.  There are other important differences in the medical care of diabetes in African Americans and you can review them HERE.

Physical Activity

A lack of physical activity is bad for your health and that alone can be a risk factor for heart failure.  Studies have consistently shown that physical activity reduces risks of heart disease, stroke, and heart failure.  By walking, running, biking, dancing and more you can make great progress in decreasing the risk for heart failure.  Set a schedule, track your steps, and get started making the rest of your life more health drama-free.

Smoking

Heart Failure in African AmericansA recent study found that “cigarette smoking sharply increases the risk of heart failure in black men and women.”  The study that looked at thousands of African Americans (both smokers and non-smokers) and found that:

  • smokers had a larger heart size (which is associated with heart failure)
  • smokers had a lower heart muscle strength (which is associated with heart failure)
  • smokers had a greater risk for needing to be hospitalized for heart failure

All of this is in addition to the increased risk for diabetes due to smoking (See “Heavy Smokers at Higher Risk for Diabetes”) and the increased cancer and circulation problems.

Let’s get real . . .

Heart failure is real and touches almost ever African American family.  We all know family members with diabetes, high blood pressure, kidney disease, and smokers.  They are on the road to heart failure and because they are related to us . . . we are at risk too.

It’s time to get serious about preventing it.

Heart Failure in African Americans

More Sleep Apnea in African Americans

Sleep Apnea is more common in African Americans

More Sleep Apnea in African AmericansA recent study confirmed there is more sleep apnea in African Americans than in Whites. Sleep apnea (also call Obstructive Sleep Apnea / “OSA”) is a condition where people repeatedly stop breathing while they sleep.  The outcome is a very poor sleep cycle and interrupted sleep.  The lost sleep leads to daytime sleepiness, fatigue, poor concentration, poor energy, increased high blood pressure, heart disease, poor digestion and metabolism, and more.

Scientists found significantly increased sleep apnea patterns, more snoring, more obesity, and poor global functioning in African Americans.  The same study also showed decreased formally diagnosed sleep apnea in African Americans despite the disproportional increased occurrence.

African Americans have a poorer sleep quality overall associated with worse insomnia levels and the highest levels for excessive daytime sleepiness. That increased fatigue and sleepiness can cause difficulty at work, trouble watching movies without falling asleep, difficulty with drowsiness while driving, and so on.

With prolonged loss of sleep, high blood pressure results and with that the increased risk for stroke, heart attack, and sudden death from abnormal heart rhythms.

But CPAP fixes this.

Continuous Positive Airway Pressure CPAP therapy reduces daytime sleepiness, improves depression and quality of life, and reduces deaths.  Overall only about half of people with sleep apnea and a CPAP machine use it.  But in African Americans the use of this life-saving treatment is even worse.  Black Americans were over 5 times more likely to not use their CPAP machine than White Americans.

Because modern CPAP machines can monitor (and transmit data) about usage and sleep efficiency, researchers were able to determine that African Americans that used the CPAP machine still averaged one hour less of nightly sleep.

Sleep Apnea in African Americans

Like many health problems, African Americans show significant improvement in CPAP usage when they understand how it works . . . and why it works.  A large study found that only about a quarter (26%) of African Americans were using their CPAP machine at 2 weeks compared to almost half  (47%) of Whites.  They also found that adjusting for income, demographics, and other diseases had no impact on its use.

The finding that African Americans with more severe sleep apnea were 3 times more likely to use CPAP than those with mild or moderate sleep apnea possibly is due to subjectively perceived effectiveness.  In focus groups, African American patients said that even with the inconveniences of CPAP, they would use the device if they thought of it as helpful.  

The study also failed to show a correlation between socioeconomic status in African Americans and CPAP usage . . . there was no difference between wealthier and more educated African Americans and poorer less educated African Americas in terms of who took advantage of the benefits of the CPAP machine.  All were poor.

What makes African Americans avoid CPAP therapy?

The only thing that increased use of CPAP therapy in African Americans was having more severe sleep apnea.  The more severe the episodes of not breathing, the higher the use of the CPAP machine.  In mild and moderate sleep apnea, the patients may not trust their doctor enough to take their advice . . . this could explain the disparity.

I find that my patients prefer a Tap Pap CPAP mask that only goes into the nostrils and is held in place by your upper teeth.

Sleep Apnea in African Americans

This “mask” allows more sleeping on your side and is far more comfortable.  Wearing the CPAP at night and getting a restful nights’ sleep is essential for health.  People are shocked to hear that their heart is enlarged and may be barely functioning, or that their blood pressure is high, all due to poor sleep . . . and the simple use of CPAP therapy can potentially reverse it!

Don’t take a good night’s sleep for granted, it can literally shorten your life.  And ask your sleeping partner about snoring and gaps in breathing.  You could easily have sleep apnea.

Diet Differences in African Americans

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.

More Cultures Adding Diet Changes

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 while others prefer pasta.  Some avoid pork for religious reasons, while other avoid beef due to poor digestion or its increasing 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.

Adding Meat to Your Vegetables??

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 use smoked turkey to season cooked vegetables and beans.

African Americas Do Eat More Chicken

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 or 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”

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.

More Sugary Sweetened Drinks

By PepsiCo, designed by Edward F. Boyd – Downloaded from https://www.usatoday.com/money/books/reviews/2007-01-22-pepsi-book_x.htm?csp=34, Fair use, https://en.wikipedia.org/w/index.php?curid=11103395

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.  Marketing campaigns targeting African Americans like the one to the right from the 1940’s is just one of many that drove up the consumption of surgery beverages.

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 alternative 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.

Check out this great video on cooking oils and the dangers of reusing oils !!

Laser Tattoo Removal on Dark Skin

Dark skin present some problems

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. The modern lasers that are used work best when there is a significant contrast between the ink color and the skin color.  By definition, “colored skin” with an ink color on top represents less contrast.  In short, there is less “difference.”  The less difference presents a challenge for the laser.

Because African Americans have a “keloid” skin reaction much more easily than white Americans, a tattoo treatment laser result can (and frequently does) show this ‘build-up’ of skin.  A keloid is a build-up of scar tissue that frequently doesn’t go away. In the picture shown, the keloids are on his biceps.

Laser Tattoo Removal on Dark SkinIn deciding whether to have laser tattoo 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.

The laser technician should generally use a lower setting (or lower power level) initially to see how your particular skin turns out.  If significant scarring occurs, use adjust appropriately.  Many scars that initially occur after a laser treatment, will fade with time . . as all scars do.  Allow that healing to occur between sessions.

Once people finally decide to try to remove a tattoo, they are usually in a hurry and want to rush the process, but “slow and steady” always wins the race. And doing proper research is the key.  Take your time, choose and laser treatment facility that is used to skin of color, and wait a little extra time between treatments.

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.