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

Heavy Smokers at Higher Risk for Diabetes

African American smokers have higher risk for diabetes

A large study consisting of over five thousand African Americans found that those African Americans who smoke more than a pack of cigarettes in a day were at increased risk for diabetes.  This ground-breaking news was published in the Journal of the American Heart Association. African American smokers have higher risk for diabetesThe study group included current heavy smokers, former smokers, and "never" smokers, all of whom were African Americans, and followed them over the course of  several visits. At the end of the study, they looked to see who had developed diabetes. Both former and non-smokers had similar occurrences . . . which is good news for people who have stopped smoking. African Americans who smoked more than a pack a day of cigarettes had a much higher occurrence of developing diabetes (up to 40 percent higher!!). The increased smoking was associated with "impaired pancreatic beta cell function." The pancreas is where insulin is made and proper insulin secretion is how sugars are absorbed into the body. The researchers go on to say:
"Although smoking cessation should be encouraged for everyone, certain high‐risk groups such as blacks who are disproportionately affected by diabetes mellitus should be targeted for cessation strategies."

Are you at risk for diabetes?

Being over-weight and having a strong family history of diabetes puts many African Americans at increased risk for developing this disease. Now we can add heavy smoking to the list! While African Americans have lower teenage smoking rates, they have high adult rates, longer smoking duration, and lower cessation rates when compared to Whites.  Almost half (42%) of newly diagnosed patients with diabetes were African American who smoked whereas only 29% (less than a third) that were White smoked. African American smokers have higher risk for diabetesIn general, smoking is associated with a lower body weight so many African Americans resist stopping smoking because of a fear of weight gain.  Many also fail to realize the smoking addiction aspect.  But in reality the increased smoking actually increases the risk for diabetes.  Smoking is known to produce "pot bellies" which in medical circles is known as "visceral adiposity" and that type of obesity (like in the photo) greatly increases the risk for diabetes. If diabetes "runs in your family" and you or someone you love is smoking, tell them about this new information and how stopping now can actually DECREASE their risk for diabetes!! Need more information about Diabetes in African Americans? Click HERE African American smokers have higher risk for diabetes

Is Cholesterol Lowering Medicine Bad for You?

Many of my patients have high cholesterol and are on cholesterol lowering medicines called statins like Lipitor (atorvastatin), Zocor (simvastatin), and Crestor (rosuvastatin).  Occasionally they will come in saying some well-meaning friend told them that “cholesterol medicine is bad for them.”  They ask me: “Is cholesterol lowering medicine bad for you?”

My answer is almost always: Absolutely NOT. But where does this notion this come from? Where does it say that statins (what we call this group of medicines) are bad for you?

Some of the interest in statins is purely from its widespread use. Over 30 million people are on statins and some recommendations predicts that over 70 million would benefit.   African Americans have significantly higher heart disease, diabetes, and circulation problems so the odds of an African American being recommended to start a statin are high.

What do statins do?

Essentially, statins lower your cholesterol (total cholesterol and bad cholesterol) and by lowering the cholesterol, the “clogging” of the arteries with cholesterol is lessened.

Is Cholesterol Lowering Medicine Bad for You?
Cholesterol in artery

The higher the cholesterol, the more clogging of arteries.  If you clog the arteries in your brain, you get a stroke.  Clog the arteries in your heart, you have a heart attack. Clog the arteries in your legs, you get poor circulation to your feet which could cause infections that could lead to amputation.  By lowering the amount of cholesterol, you lower the chance of clogging . . . anywhere.

Is Cholesterol Lowering Medicine ( statins ) Bad for You?
By BruceBlaus – Own work, CC BY 3.0, https://commons.wikimedia.org/w/index.php?curid=28761812

Scientists have also found that lowering a high cholesterol also reverses clogging that may have already happened. Mainly, the HDL “GOOD” cholesterol serves this artery-cleaning purpose and by lowering the overall burden of clogged arteries, it can “catch up” with clearing the narrow passages that could lead to total blockage.

What should my Lipid levels be?

When doctors measure your cholesterol (Lipid Panel), they look for a total cholesterol less than 200 and a LDL or “bad” cholesterol of less than 120.  In people with existing diagnoses of diabetes, circulation problems, heart attack, stroke, or a family history of early heart attacks or strokes, we shoot for an even lower LDL that is less than 100 . . . or even lower!

Is Cholesterol Lowering Medicine ( statins ) Bad for You?
Cholesterol in artery

Large studies of numerous patients have shown substantial benefit of cholesterol lowering medicines with significantly decreased heart attacks, strokes, and other circulation related medical problems.

Statins help people with kidney problems too?

Another study showed significant benefit of “statins” to people with kidney problems, and it helped many avoid dialysis.  Kidney problems are very common in the Black community so anything that improves kidney outcomes can be a big help.

African Americans have “better” cholesterol levels.

Curiously, in general African Americans tend to have “better” cholesterol numbers than White Americans.

With disproportionally higher heart disease in African Americans, researchers have wondered how these better lipid profiles coincide with the documented worse outcomes.  The variability seen based on race is yet another curiosity given doctors’ accepted association of bad cholesterol levels equaling worse health, and good levels leading to improved health.

“It is clear that there is further complexity in this relationship among African Americans, who have, on average, a more favorable lipid profile compared to European Americans, yet they do not experience an associated decrease in diseases that are expected to be responsive to reduction in this key risk factor”

Years earlier, scientists attributed elevated Lipoprotein Lipase (LPL) levels, the enzyme responsible for breaking down fat, and lower levels of other components, as principally responsible for the improved cholesterol picture in African Americans.  Others have confirmed that the better lipid profiles in African Americans is not due to diet and lifestyle considerations noting worse fat content in foods and less exercise in African American populations compared to White Americans.

Attempts to drill down to why good lipids do not lead to better outcomes in African Americans have continued to baffle doctors, but the assumption is the impact of uncontrolled high blood pressure, obesity, and higher diabetes rates overwhelm the beneficial impact of the improved cholesterol levels. It is also possible that African Americans patients should start cholesterol lowering medications at different (lower) thresholds.

Less Prescribed & Less Taken

Is Cholesterol Lowering Medicine Bad for You?Unfortunately, African Americans have a poor track record of taking cholesterol lowering medicines when prescribed after a stroke, heart attack, or most other reasons for starting the medication.  And doctors are less likely to prescribe statins in African Americans across the board.  The result is a deadly combination of a doctor that is less likely to give a medication to a patient . . . and a patient that is less likely to take it.  This inconsistency speaks to the trust issues African Americans have with doctors.

Overall statin use and lowering cholesterol saves lives.  Dr. Carol Watson, a Black cardiologist said it best in her article “Let the evidence speak”

“These trials thus confirm that significant benefits can occur from statin use in African Americans. Despite this, however, statins remain underutilized in the African American population, thus those that might stand to benefit most, are least likely to receive these life saving medications.”

So the question: Is cholesterol lowering medicine bad for you?

The answer for African Americans is crystal clear: lower cholesterol leads to fewer heart attacks, fewer strokes, better kidney function, better circulation, fewer amputations, and longer lives.  Don’t get it twisted . . .

 

 

 

 

 

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 !!

Atrial Fibrillation in African Americans

Atrial Fibrillation in African Americans

Atrial fibrillation in African Americans, also called “A Fib”, effects one in nine before the age of 80 and is the most prevalent arrhythmia in the US and is associated with significant bad outcomes that include stroke, heart failure, and increased death.  Surprisingly, studies also confirm a decreased atrial fibrillation incidence in African Americans (41% lower risk of being diagnosed than European Americans) but a greatly increased occurrence of stroke and sudden death in African Americans with atrial fibrillation. So compared to whites, African Americans are less likely to get atrial fibrillation, more commonly called “A Fib”, but if they get it, are more likely to have complications. This is just one of many “important differences” that exist in the care of African Americans.

“Racial Paradox?”

Some have suggested that the decreased incidence of atrial fibrillation in African Americans is actually under-diagnosis, but others have called it a “racial paradox” where despite atrial fibrillation being a result of increased high blood pressure, diabetes, over-weight, heart failure, and heart attacks, all of which are higher in African Americans, the incidence of atrial fibrillation is surprisingly lower.

Atrial Fibrillation In African AmericansAfrican Americans were also less likely to be aware they have A Fib, and much less likely to be treated with blood thinners like warfarin (Coumadin, Jantoven) that prevent the heart attacks and strokes that having A Fib causes.   Even more surprising was this decreased use of warfarin in African Americans was regardless of whether the person had insurance or made more money.   It is truly stunning that a medication to prevent strokes is used LESS in a group of people who are prone to have MORE strokes and this was found in a study by Meschia and colleagues who looked at over 30,000 patients:

“We also found that among those who were aware that they had AF (atrial fibrillation) and who had confirmation of the diagnosis of AF, (African Americans) were about one quarter as likely to be treated with warfarin as whites. In striking contrast, risk of stroke as stratified by the CHADS2 score was not a predictor of warfarin use. The fact that risk of future stroke did not significantly alter the likelihood of warfarin use would seem to reflect an evidence-practice gap.”

A Higher Risk for Death

The risk for death in the presence of atrial fibrillation (A Fib) in the first four months after diagnosis was very high with heart disease, heart failure and stroke accounting for the most of the deaths, the study also found.  The risk for hospitalization in African Americans from atrial fibrillation doubled as did the risk for recurrent stroke, and related dementia from repeated “little strokes” (multi-infarct dementia).

What is the Best Medication for A Fib?

So the medical evidence would suggest that African Americans should receive MORE treatment with blood thinning medications like warfarin and other newer medications like dabigatran (Pradaxa), rivaroxaban (Xarelto), or apixaban (Eliquis) . . . and in fact they receive LESS.

Some of the complaints about warfarin is the need to have relatively frequent blood tests to confirm the “thin-ness” of your blood.  These tests called “PT / INR” shoots for an INR between 2.0 and 3.0.  Less than 2.0 means your blood is “too thick” and more than 3.0 means it is “too thin.”  The newer medications to replace warfarin do not need blood tests.

Keep in mind that African Americans have an increased risk for complications from bleeding on some of these newer medications like dabigatran (Pradaxa), rivaroxaban (Xarelto), or apixaban (Eliquis), so although it can be more inconvenient with frequent blood draws, warfarin may be best for now until more information is available. There is also significant evidence that there are warfarin dosing differences between European Americans and African Americans that need to be anticipated and considered.

What You Need to Know . . .

While this topic may seem a little confusing, here are the main points:

  1. If you have atrial fibrillation (A Fib), you are at a much greater risk for stroke or another major event.
  2. Being on a blood thinner, like warfarin, can significantly decrease your risk for stroke (or another event).
  3. Being on a blood thinner increases your risk for bleeding . . . but not as much as it decreases your risk for stroke. So while you risk a bleed, your risk for stroke is much higher.
  4. The newer “blood thinners” do not require as many lab tests as warfarin, but they also may not be as safe in African Americans (this is controversial and not clear).

Here is a video on anticoagulation and warfarin:

 

Kidney Disease in African Americans

Kidney Disease in African AmericansKidney disease in African Americans

Kidney disease in African Americans is one the most dramatically different occurrences of a disease, and results in significant suffering and death.  Generally kidney disease is the result of diabetes and high blood pressure, and given the increased number of both of these in African Americans, there is a six to twelve-fold increased occurrence compared to whites.  Additionally, there is a 17-fold greater rate of high blood pressure as a cause of kidney failure in African Americans.  If you have high blood pressure or diabetes, or both, your risk for kidney failure resulting in needing dialysis is MUCH higher if you are African American.
Having diabetes and high blood pressure that is controlled on medications almost erases this increased risk. This is why it is critical that if you have high blood pressure, you should take medication to bring it down. If you have diabetes, you should make sure your blood sugars are controlled because if you don’t, your risk for needing dialysis is very high.
Kidney disease in African Americans

Risk for Requiring Dialysis is High

While African Americans are 13 percent of the general population, we make up 35 percent of all patients on chronic dialysis.  Diabetes as the leading cause of kidney failure and high blood pressure is the second most common cause.
Not having medical insurance or access to medical facilities and the increased number of people with high blood pressure contribute greatly to kidney disease in African Americans.  Having high blood pressure but being on the wrong medications can contribute as well.

Well designed studies have failed to fully account for the excess proportion of kidney disease in Blacks.  Anatomically, despite equivalent age, blood pressure, and other factors, African Americans tend to have reduced kidney blood flow. Despite similar dietary salt intake, the kidney’s processing of bodily fluids are somewhat different in African Americans compared to whites.  Reducing salt in your diet can greatly improve health.

A Possible Genetic Cause?

The Tsetse Fly transmits the African Sleeping Sickness. By International Atomic Energy Agency

Some of the increased risk for kidney disease in African Americans is attributed to a genetic variant (APOL1) found in more than 30% of African Americans and largely absent in white Americans.  It is thought that this gene offered protection from African Sleeping Sickness (a frequently deadly disease known in medical circles as African trypanosomiasis) that was carried by the Tsetse fly. Basically, having this gene gave protection from the African Sleeping Sickness and was beneficial in African regions where the tsetse fly lived.
Scientists believe that the increased risk for kidney disease seen in African Americans is equal to the increased occurrence of the same gene that offered protection from the deadly African Sleeping Sickness.

Obesity Can Lead to Kidney Problems Too

In addition to these genetic differences, researchers also suspect that increased obesity in African Americans is driving up kidney disease.  They found that as your BMI (Body Mass Index is calculated based on your weight and height) gets higher, the risk for kidney problems increases.

With all of the kidney disease in the African American community, there is one last bit of curious news.  African Americans have a better survival rate on dialysis than white Americans.  This paradox of improved survival in African Americans after initiation of dialysis has puzzled researchers.  Researchers at the Wake Forest School of Medicine suggest that the improved survival may also be due to the very gene that causes the problem . . . the APOL1 gene.  In this case the APOL1 gene gives protection against hardening of the arteries while on dialysis.

Kidney Disease in African AmericansHere’s What You Need To Do . . .

Kidney disease in African Americans can be a confusing topic to understand and there is a lot to consider.  The most important points are:

  1. If you have high blood pressure, take your medicine and watch your salt intake so that your pressure stays normal. That will allow your kidneys to stay normal.
  2. If you have diabetes, take your medicine and watch your diet so that your blood sugars stay normal.
  3. Watch your weight because the bigger you are, the higher your chance for kidney disease.


Lactose Intolerance in African Americans

Lactose Intolerance in African Americans

Three out of four African Americans are lactose intolerant.  Lactose intolerance means that if you drink milk, eat yogurt, have cheese, or any other dairy-based product in large amounts, your digestive system will have difficulty digesting it.  Most people report feeling bloated and later have loose gassy stool (sorry . . . but these are the facts).

Lactose Intolerance in African Americans

If you are not near a toilet (of your choice), this can be an embarrassing problem.  The stomach’s reaction to not being able to digest lactose (a sugar in dairy products) is to simply flush it through its system.   For a majority, lactose intolerance in African Americans simply leads to the avoidance of milk and milk-related products.

The significantly decreased intake of milk and dairy products in the African American diet presents a potential increased health risk as “moderate evidence shows that the intake of milk and milk products is associated with a reduced risk of cardiovascular disease, type 2 diabetes, and lower blood pressure in adults”.  Constance Brown-Riggs in her article “Nutrition and Health Disparities: The role of Dairy in Improving Minority Health Outcomes” has recommendations for African Americans to consume three to four servings of low-fat dairy daily.

If only one serving of dairy causes stomach upset and loose stool . . . what will three servings cause?  That question is what many African Americans ask themselves, and the answer has been very clear.  African Americans drink significantly less milk and eat substantially less cheese and yogurt when compared to the rest of the American population.

The decreased dairy consumption leads to decreased intake of essential nutrients that are found in milk and cheeses. Studies show that African Americans’ intake of the required nutrients calcium, vitamin D, and potassium were all lower than white and Hispanic Americans.  And it has been well known in medical circles that African Americans have significantly lower vitamin D levels in their blood.

A Genetic Link for Lactose Intolerance??

Lactose Intolerance in African AmericansThe choice for African Americans to avoid milk and related products is not voluntary.  Lactose intolerance in African Americans may be due to a genetic design.  Research has shown that the proportion of people that are lactose intolerant can be tied to their region of genetic origin.  Put simply, regions where dairy herds could be raised safely and efficiently produced people that could digest lactose. Harsher climates in African and Asia restricted the availability of milk, and produced people with much more lactose intolerance, a study at Cornell University found.  Researchers found a wide range of lactose intolerances with as low as 2 percent of the population of Denmark descendants as unable to have dairy products compared to nearly 100 percent of the people with Zambian African origin.

Their survey “found that lactose intolerance decreases with increasing latitude and increases with rising temperature”.

Lactose Intolerance in African Americans
Red = Lactose Intolerant, Green = Lactose Tolerant, Brown = 50/50

Newer information has revealed that maybe there are not as many purely lactose intolerant African Americans as previously thought.  Nutritionists have advised that adding milk to a larger meal helps with successful digestion.  Some find that having smaller amounts of dairy over time improves digestion and decreases symptoms.

Lactose Intolerance Solutions

Lactose Intolerance in African AmericansOthers advise to simply take a lactose enzyme supplement (Lactaid, for example), and the problem is solved because milk, yogurt, or cheese is then easily broken down normally and naturally . . . while the dairy products again provide improved nutrient supplementation.

Other ways of replacing the missing nutrients resulting from low dairy consumption has become fairly easy due to multiple milk equivalents including soy, almond, coconut, and other ‘milks’ that can be used as part of a healthy breakfast.  All have been ‘fortified’ with calcium and vitamin D if needed.  Oatmeal and/or whole grain cereals with milk equivalents can make a fast and nutritionally efficient meal.

A ‘new’ problem is that African Americans consistently eat fewer breakfasts, and therefore the “opportunity” to have milk, yogurt, cheese, or milk equivalents has substantially decreased. Look at my article on “Diet Differences in African Americans” for more details.

Making a point of having the required serving of calcium and vitamin D in the form of a dairy (or dairy-like) product is the next nutritional priority of Black Americans seeking a longer and healthier life.

 

Strokes in African Americans

 Strokes in African Americans

Most 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%).

Strokes are Worse in Blacks

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 decreased among African Americans as compared to whites while the indications for aspirin use are actually higher in African Americans. More African Americans should be taking aspirin because it reduces the risk of stroke, heart disease, and colon cancer. And this was proven at the low dose of 81 mg.  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 to help with the increased incidence of colon cancer, heart disease, and strokes.

Overall, prevention experts (USPSTF ) recommend referring adults who have stroke risk factors and are obese to intense behavioral counseling to promote a healthy diet and more physical activity. That means going to your doctor and having a detailed conversation about what you do . . . and what you eat.  For example, by decreasing your intake of salt and fried foods, lowering the blood pressure and getting proper exercise, strokes in African Americans can greatly decrease.

Take a look at this video that explains why you need to start your medicine, keep taking it, and come in to make sure it is doing what it’s supposed to be doing. Take care.

 

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 racial or 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.

A History of Abuse

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.”

Racial Differences in Trust

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.

Physician Bias

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.”

Unconscious Bias

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 Improves Quality

Patient centered care can positively improve care, specifically for African Americans.  Although 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. Making suggestions about diet changes requires a trusting relationship that involves a non-judgmental regard for the current diet.

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.

Are you on the right blood pressure medicine? 

High Blood Pressure in African Americans

When it comes to the treatment of high blood pressure in African Americans, there are a number of important differences. For reasons that are not entirely clear, many African Americans patients respond differently from white patients based on the hypertension medication used.

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 (hypertension).  Thiazide-type diuretics (chlorthalidone) was better at reducing blood pressure and preventing cardiovascular events like a heart attack or stroke 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 medicineBest Stroke Prevention in African Americans

For 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.

ACE Inhibitors are not preferred

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 hypertension 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.

More Side Effects in African Americans

African Americans have a greater risk of ACE-related cough, and a higher rate of stopping due to cough compared to other racial groups. African Americans were also more prone to develop ACE-related full allergic reactions.

High Blood Pressure in African AmericansWhen 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.

High Blood Pressure in African AmericansSo don’t just stop your medications based on this article, please check with your provider. Use this article as a starting point for your discussion. Some providers are aware of these differences, and others may not be fully aware.

The key is to have a doctor you trust that knows about these differences.

High Blood Pressure in African Americans