Greg Hall, MD is a physician, author, speaker, inventor, professor, and public health professional. Dr. Hall specializes in urban health and the clinical care of African Americans. He strives to improve the quality of medical care through improved health education and awareness. As an expert in the healthcare of African Americans, Dr. Greg Hall strives for health equity in all patient care.
People continue to ask me about health issues and why Black Americans’ health is inferior to every other racial or ethnic group. My podcast Better Black Health covers many of these important topics. The environmental dynamics of being Black drives up our blood pressure, increases our risk for cancer, and makes us struggle with our weight and diabetes. The Better Black Health podcast is also on Spreaker and Spotify to allow easy access to this vital information.
Why do African Americans have a greater cancer risk with smoking . . . and why do so many smoke menthol cigarettes? There is a potential genetic reason behind this huge disparity. And stopping smoking was much harder when there was a household partner or family member who still smoked.
Why do Blacks distrust healthcare providers (doctors, NPs, etc.) at such a high rate? How does our history with medical providers drive this dysfunctional relationship?
The first episode looks at a curious case of high blood pressure and the potential causes including alcohol, sleep apnea, and heart disease. A follow up episode looks at the vitamin needs of African Americans.
African American cancer survivors should make a deliberate effort to stop smoking because cancer recurrence or return was much higher in cancer patients who continued to smoke. In this study done at Wayne State in Detroit, Black patients were more likely to continue to smoke after being diagnosed with cancer and were more likely to continue if their partner continued to smoke.
A longer smoking history and living with a smoker increased the odds of continued smoking after cancer diagnosis. Over all, lung cancer survivors were most likely to quit after diagnosis.
These findings are similar to other ethnic populations and highlight that continued smoking after a cancer diagnosis is both common and highly risky. Stopping smoking must remain a primary priority to patients diagnosed with cancer because by continuing smoking, their risk for the cancer returning and spreading is much higher.
Health care providers like doctors and nurse practitioners should emphasize the importance of both the patient and other house members (wife, husband, adult children, etc.) stopping smoking because their success rates are linked.
There is definitely a science to sleep and why sounds can both improve or interrupt a good night’s sleep. The internet is filled with people who report greatly improved sleep with sound producing devices, long-playing internet videos, and other media. The sound of ocean waves, constant rain, or even a partners’ breathing has been reported to promote a more restful sleep. Curiously, when sleep experts at the University of Pennsylvania Perelman School of Medicine recently pulled together research in the field, they found “the quality of evidence for continuous noise improving sleep was very low.” Their disclaimer added that more research is needed in higher numbers to either fully discredit or completely support the use of “noise” as a clinically beneficial sleep aid.
What are the potential benefits?
There are components of sleep that improve or detract from its quality. By minimizing the onset, and the interruptions in sleep, it is presumed that the duration of the restorative components (REM sleep and non-REM) will improve. Deep sleep, which is the most restorative and a component of non-REM sleep, shortens with age and its reduction has been liked to poor health including obesity, diabetes, hypertension, heart disease, and more. By improving overall sleep duration by reducing interruptions and decreasing the time it takes to go to sleep, it is hoped that a better quality of life ensues.
What type of noise is best to listen to on a sound machine? White noise, pink noise, or any other types.
There is a science behind the various noises and why they may help sleep. White noise is a balanced frequency of sounds that has a higher overall pitch. Because higher pitched sounds are more easily heard by the human ear, a balance of sounds with give an overall higher pitch. Pink noise is proportionately decreased as the pitches increase in an effort to better “balance” what is actually heard. Pink noise therefore has a lower, and some say, more soothing, tone. To takes this concept even further (and more soothing), Brown noise (Brownian noise) decreased the frequency even lower than pink noise. There is no scientifically reported evidence that one noise is better than the others . . . just personal preference.
How does the experience of listening to a sound machine differ from sleeping in silence?
The difference between silence and consistent invariable noise is not as great as some would think. The issues with sleeping in silence is the potential interruptions by sound. The “noises” I have described work to potentially drown out the sound variabilities in life. True silence has no interruptions and is consistent. These various noises work to make urban (or even rural) existence less variable in sound and thus more conducive to uninterrupted sleep.
As descendants from Africa, African Americans were genetically conditioned to best survive in a hot, sunny, mineral rich land. The continent of Africa is known for its fertile land and renowned as the “richest continent in the world” in terms of natural resources. The days are sunny and generally consistent in length throughout the year. Living in a mineral rich land, your body adjusts its absorption of vitamins and minerals according to it’s exposure in the environment. In Africans, their absorption is blunted because the environment is so fertile with sun, nutrients and minerals. When relocated to North America, with its variable daylight, urban dynamics, and processed food and water, African Americans are now displaced from the environment that their system was best designed to thrive.
Low Vitamin D and Increased Health Problems
With vitamin D generally coming from the sun, the shift from Africa to North America was dramatic . . . and so was the drop in vitamin D in Black Americans. Low vitamin D has been linked to more severe COVID illnesses, increased diabetes (type 2), increased prostate cancer, increased colon cancer, worsened asthma, and more. The graph below from a study done at the University of California at Berkeley shows significantly higher vitamin D levels in both men and women in Africa and Jamaica that are consistent with those of white Americans . . . whereas the levels in Chicago Blacks were much lower.
Blacks in America need vitamin D supplementation to offset the significantly decreased vitamin D we get from the diminished sun in North American cities. It is proposed that the added vitamin D will help to offset some of the worsened diseases we see in African Americans.
Africa has also been known to have high zinc reserves. In fact in some mining areas in African, the mineral content of “heavy metals” in the water was too high. From a biological perspective, the people living in these high mineral content areas needed to develop a way of decreasing their absorption of too much minerals, including zinc. In a study done looking at prostate cancer tissue in Black Americans versus whites, researchers found significant fewer zinc absorption (“transport”) channels in the prostates with the more aggressive cancer, and this decreased zinc transport occurred much more often in African Americans than whites. Overall, zinc has the highest concentration in the body in the prostate, and scientists report that the high zinc in the prostate acts to suppress tumor formation. The graph below shows the higher prostate cancer incidence in green as well as the higher mortality (red) by race/ethnicity.
African American men should take zinc daily.
Vitamin C has long been known to benefit a number of health conditions including boosting immunity (your ability to fight infections), slowing atherosclerosis (hardening of the arteries), decreasing gout attacks through lowering uric acid levels, as well as improving lead clearance from the body. Taking vitamin C on a daily basis either in the form of high vitamin C foods or supplements is highly recommended.
Vitamin K promotes blood clotting. While biologists have insisted that vitamin K doesn’t cause “too much clotting” there have been no studies in African Americans to confirm this. Given the lack of vitamin K deficiency in the US, there is no reason for an African American to take added vitamin K.
Sequence Multivitamins for African Americans
I developed Sequence Multivitamins with these and many other facts in mind. It is the first science-based multivitamin for African Americans and uses research, population data, and 25 years of treating Black patients as evidence. Sequence Multivitamins were developed for men, women, men over 50, and women over 50. Sequence Multivitamins for African Americans have increased vitamin D, vitamin C, magnesium, potassium, and zinc to compensate for the migration from Africa to North America and the dramatic adjustments that many of our bodies are still making! And it leaves out vitamin K to potentially avoid an increased risk for blood clots.
Which multivitamin should I take? As a physician, I get this question multiple times a day, every day. And the answer would frequently depend on who was asking. Are they younger or older? Male or female? How is their diet? What race are they? What family disease risks exist? All of these issues influence my answer, and the final answer is yes, there is one best multivitamin for African Americans to take: VitaCode’s Sequence Multivitamins.
Sequence Multivitamins were designed to meet the needs of African American men, women, and the unique needs of older adults.
Vitamin D Deficiency
Because my patient practice is 90 percent African American, the vast majority are severely vitamin D deficient. The normal range for vitamin D levels in the blood is 20 to 80 pg/ml. As an example, I am African American and my initial vitamin D level was 9 pg/ml. Most of my patients also have very low vitamin D levels . . . in fact I’m surprised when I see a normal level in a Black patient. In contrast, most of my patients of other races/ethnicities generally have normal vitamin D levels.
Given these stark differences in blood levels of this critical vitamin, the approach to its replacement is also different. The USDA currently recommends 600 international units daily for vitamin D for everyone age 1 to 70 years. Most multivitamins start with the USDA recommendation when designing their content. 600 IU is entirely too low a replacement dose for most African Americans. The amount of vitamin D to take to correct these significant deficiencies is over three times higher. African Americans should take 2000 IU daily.
Vitamin C Deficiency
Other vitamin deficiency patterns exist as well in African Americans. A study conducted at Duke University Medical Center found that “in African Americans, but not whites, lower levels of beta-carotene and vitamin C were significantly associated with early markers implicated in cardiometabolic conditions and cancer.”
Higher vitamin C levels were also protective against lead exposure due to the vitamin’s ability to inhibit the intestinal absorption of lead as well as its ability to promote urinary excretion of lead. Essentially vitamin C acts as a barrier to lead absorption. Environmentalists confirm that urban air, soil, and water tend to hold comparably higher lead levels due to a history of industrial presence in cities and their closeness to neighborhoods mostly populated with African Americans. Increasing the vitamin C content in a multivitamin for an urban population disproportionately exposed to lead is a sound approach to population health.
Vitamin E May Be Bad for You
Interestingly, there are also significant risks and poor health outcomes associated with certain vitamins. Vitamin E supplementation was studied in over 130,000 people and those that took 400 IU (the most common supplement dose) or higher, had an overall higher risk of dying from any cause. Vitamin E supplements were also shown to significantly increase the risk of prostate cancer in healthy men. Given that African Americans have the highest death rate of any racial/ethnic group (including prostate cancer) in the United States, taking a vitamin that potentially increases these already bad outcomes, makes no sense. Unlike most other multivitamins, Sequence Multivitamins has no vitamin E.
Vitamin K Promotes Blood Clotting
Vitamin K is critical for normal blood clotting but African Americans have an increased propensity to form adverse blood clots after surgery and associated with strokes, heart attacks, and other embolisms, therefore additional vitamin K in a multivitamin for this population should also be avoided. Unlike most other multivitamins, Sequence Multivitamins has no vitamin K.
Potassium has shown benefits in cardiac rhythm stability, blood pressure control, and electrolyte balance. There has been data that suggests African Americans have lower potassium levels overall which could be related to the increased incidence of diabetes, and helpful in preventing heart or stroke problems. Sequence Multivitamins has added potassium for this purpose.
Chromium has promising data that it positively impacts diabetes control across populations. With African Americans having significantly higher risk for diabetes, adding chromium to the Sequence Multivitamins formula was a plus.
Due to its distinctive ability to neutralize free radicals, lycopene is believed to give measurable protection against cancer, atherosclerosis, diabetes, and other inflammatory diseases. Evidence suggests that lycopene consumption is associated with decreased risk of various chronic diseases that disproportionately impact African Americans.
As you can see, a good deal of thought and research went into developing the formula for Sequence Multivitamins. Their formulas for men, women, men over 50, and women over 50 means there is a multivitamin best for almost anyone. Health disparities, premature death, and chronic illness has been a way of life for too many African Americans. VitaCode’s Sequence Multivitamins hopes to make a difference . . . making them the single best multivitamin for African Americans.
While wearing a mask in public, washing your hands, social distancing, and covering your cough/sneeze greatly decreases your risk for contracting COVID-19, there a some other less-proven approaches that also need discussion and consideration.
A good amount of theoretical approaches to minimize the spread and severity of COVID-19 have been published. Given this new coronavirus has limited confirmed supplement approaches to prevention and treatment, providers are using foundational knowledge regarding populations and viral infections, and hypothesizing (or guessing) what might be effective.
African Americans have been disproportionately impacted by COVID-19 with a much higher hospitalization rate and mortality. At the core of worse outcomes in African Americans is poorly controlled chronic diseases like diabetes, hypertension, and COPD. But there is also firm population data that points to trends in vitamin and mineral deficiencies that may also contribute to poor outcomes. Using what we know about these trends and the fundamentals of infections (both viral and bacterial), and also keeping a keen eye on safety, here is what I have been recommending my patients consider.
Zinc (10 to 15 mg) one to three times a day when COVID-19 exposure risk is high
Zinc is an essential trace element that is critical for a variety of biological processes and proper immune function. Studies have consistently shown zinc deficiencies in African Americans and believe the dramatically increased rate of HIV and hepatitis C in African Americans represents an impaired immune defense linked to lower levels of zinc. Zinc’s antiviral activity has been confirmed against a variety of viruses and the science of how zinc either prevents infection or slows viral spread is well established.
There is also emerging evidence that zinc’s antiviral and antibacterial activities may help slow coronavirus spread and ease the complications that result from an infection. The improved antiviral immunity conveyed by zinc could be particularly impactful during the COVID-19 pandemic. Some suggest that the increased severity of COVID-19 in African Americans may reflect a low zinc status and the Mayo Clinic confirms that zinc is clearly more beneficial in populations that have deficiencies.
Vitamin D (2000 IU) once daily
The most dramatic vitamin differences by race or ethnicity relate to vitamin D levels which nutritionists agree is deficient in four of five African Americans. The widespread vitamin D deficiency is somewhat related to the melanin in darker skin, widespread lactose intolerance (also genetically driven) as well as urban living leading to decreased sun exposure.
The lack of vitamin D has been associated with an array of bad outcomes including increased stroke, heart disease, pre-term birth, and a host of cancers including lung, colon, ovarian, breast, and prostate. Low vitamin D has also been associated with a higher risk for lupus (SLE), multiple sclerosis, diabetes and hypertension. African Americans have the absolute highest risk for diabetes, hypertension, stroke and the cancers listed. The lack of vitamin D has also been linked to worse outcomes in COVID-19 infections, but its association may simply be a marker for the chronic diseases listed above. Most African American patients, particularly the elderly and those with limited sun exposure and the potential for exposure to COVID-19 should consider taking vitamin D at 2000 IU daily.
Famotidine (20 mg) once daily
In a study at Columbia University, patients hospitalized with COVID-19 that had famotidine, the acid blocker also known as “Pepcid” within the prior few days had better outcomes. They concluded that “famotidine use was associated with a reduced risk of clinical deterioration leading to intubation or death”. This mechanism of action is not random. Researchers note that famotidine is known to inhibit viral replication in some instances. There are also first-hand accounts of rapid improvement after COVID-19 infection. Given its safety (and over-the-counter availability), its use in a COVID-19 exposed vulnerable population can be justified.
While this information is far from confirmed, its science has a good foundation. Given African American’s well-established vitamin D and zinc deficiencies in the face of a “curiously high” infection rate, these largely safe measures, may make a difference. As always, check with your provider before starting any of these supplements or vitamins as your individual case may warrant a different approach.
There are racial disparities in sleep with African Americans having a shorter sleep duration, a harder time falling asleep, and a tendency to wake up more easily after falling asleep. There is also a decreased ability to phase shift African Americans sleep cycles when exposed to jet-lag and shift work situations, and the total duration of the cycle was smaller, a study by Eastman and colleagues at Rush University Medical Center found. Sleep differences in African Americans cause a good deal of suffering.
These researchers surmised that the differences in sleep architecture grew from thousands of years of genetic modifications resulting from, for African Americans, exposure to year-around consistent 12-hour light-dark cycles, versus whites coming for northern regions with significant variability in the day length, dawn, and dusk times.
For example, in Ohio the day length changes from as short as eight hours in the winter to as long as sixteen hours in the summer. Ohioans are constantly adjusting to time shifts. With thousands of years of exposure to time changes, Ohioans would develop an increased ability to tolerate the changes. Closer to the equator (like western Africa), the time doesn’t shift nearly as much. The days are 12 hours long all year and there is no need to have an ability to tolerate time shifts.
Therefore “the shifting circadian periods in non-equatorial regions left a genetically modified increased tolerance for variable light-dark productivity hours.” Put simply, people who genetically come from regions near the equator are less able to adjust to time shifts, daylight savings times, jet lag, or anything else that causes a shift in sunrise and sunset.
Everyone has a “circadian period” which is an innate sleep wake cycle. We also have an ability to shift that cycle somewhat. People whose genes come from northern areas of the earth (Europe, Canada, etc.) have an ability to tolerate shifts in time whereas those of us from Caribbean, African, South American regions have much more difficulty adjusting.
In another study, researchers exposed African Americans and White Americans to a 9 hour delayed light/dark sleep/wake and meal schedule, similar to traveling from Chicago to Japan. Essentially what would take 10 days for full adjustment in White Americans, would take 15 days for African Americans to adjust.
Swing shifts are bad for your health!
The need to adjust to time zone changes is only occasional in most people, and there are methods to make this adjustment smoother, but shift work seen in factory workers, police and fireman, healthcare staff, and other positions place an additional health burden on these workers. Shift working was found to add an additional 40 percent risk of heart disease as compared to non-shift work.
There is also increased weight gain as a result of decreased glucose tolerance from meals consumed in the night. When eating at night, your body tends to store more of the calories rather than burn them. Therefore night workers (who have to eat sometimes) tend to be more overweight. Researchers have also found that shifts workers have worse cholesterol results.
All of this contributes to increased health problems and premature death.
Shift work is more prevalent in the African American community and is also associated with worse health outcomes including:
By incorporating a planned exercise schedule and diet, emphasizing the dangers of smoking (particularly in shift workers), and providing better insight into the social impact of these schedules, can help many shift workers. And the few individuals that continually fail to adjust to shift work may feel better knowing there is a simple explanation for their troubles.
Vitamin D is acquired through diet and skin exposure to ultraviolet B light. The skin’s production of vitamin D is determined by length of exposure, latitude, season, and degree of skin pigmentation. African Americans produce less vitamin D than do White Americans in response to equal levels of sun exposure, and have dramatically lower vitamin D concentrations with some studies indicating up to 96 percent of the African American population as low. Yet both races tend to have similar capacities to absorb vitamin D and to produce vitamin D when exposed to light. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4030388/)
“Lower levels of vitamin D–binding protein in blacks appear to result in levels of bioavailable 25-hydroxyvitamin D that are equivalent to those in whites. These data . . . suggest that low total 25-hydroxyvitamin D levels do not uniformly indicate vitamin D deficiency “
The result of these studies suggest that having both a low vitamin D level and a low vitamin D-binding protein in African Americans actually causes a ‘re-set’ of true deficiency. With both being low, it is vitamin D’s bioavailability that drives calcium levels, parathyroid hormone levels, and true bone risk.
Ken Batai and colleagues at the University of Arizona, after studying over two thousand people, found a direct benefit to Vitamin D supplements to preventing prostate cancer in African American men and a pro-carcinogenic effect (inducing effect) of calcium supplementation on the prostate. These findings were strongest in African Americans.
“Calcium and vitamin D are important nutrients, and they may have preventive effects against many health conditions. Although toxicity from high vitamin D supplementation may be low, high calcium intake is associated with increased prostate cancer risk as well as risk of cardiovascular disease and kidney stones. High calcium consumption might be harmful and for prostate cancer prevention, high dose calcium supplementation and fortification should be avoided, especially among AA (African American) men.”
High calcium intake in African American men may actually increase the risk for prostate cancer, but taking vitamin D can reduce the risk.
There is a multivitamin designed just for African Americans. Sequence Multivitamins has high vitamin D, vitamin C, magnesium and much more of what African Americans need, while leaving out those substances that may be harmful.
There has been some startling discoveries lately in the differences in how diabetes is diagnosed and treated in African Americans. Because of genetic nuances that we normally may ignore as insignificant, hundreds of thousands of African Americans remain under-diagnosed and under-treated for diabetes.
Diabetes already occurs at an unusually high rate in African Americans and we are 80 percent more likely to be diagnosed than White Americans. Of those with diabetes, there is a higher tendency for organ damage (heart disease, kidney failure, or blindness, for example) than Whites. The prevalence of visual problems, kidney problems, leg amputations, and overall hospitalizations are dramatically higher in African Americans with diabetes.
The CDC reports that African American men die at over twice the rate of any other race or gender group from diabetes. It was also found that these differences were not solely due to the African American diet, genetic differences played a part as well.
Diabetes is diagnosed at an earlier age (median age 49 vs. 55.4 in White Americans) and this earlier age is significant because the development of diabetes complications is directly related to both blood sugar control as well as the total time a person has the disease. By getting diabetes earlier, there is more time to get complications. Make sense??
Most research dealing with the increased diabetes in African Americans points to increased insulin resistance when compared to White Americans. This means your body has insulin but is “resistant” to its normal function.
A recent study of over five thousand African Americans curiously showed that heavy smoking (more than a pack of cigarettes a day) significantly increased their risk for diabetes by worsening the insulin resistance. Former smokers and people who never smoked had a much lower risk for diabetes compared to the heavy smokers.
HbA1c (Hemoglobin-A-One-See), the blood test used to diagnose and track diabetes, is generally a point higher in African Americans (8.9 in White Americans and 9.8 in African Americans), and when controlling for socioeconomic status, quality of care, self-management behaviors, and access, African Americans still have higher HbA1c levels.
Another study by Saaddine and colleagues looked at younger patients age 5 to 24 years and found that African American youths consistently had higher HbA1c levels even without diabetes.
HbA1c is Different in African Americans
In all, HbA1c value differences in African Americans essentially equates to a 0.4% difference (higher) for glucose matched White American patients. So a HbA1c of 7.0, the normal threshold to diagnose diabetes, is really 7.4 in African Americans. Diabetes should have been diagnosed when the HbA1c was 6.6. Put simply, the accepted relationship between HbA1c and the coinciding blood glucose used by doctors and laboratories is different for African Americans.
If these facts aren’t confusing enough, another study found the HbA1c levels are “less dependable” when they are “near normal” in African Americans. High and low HbA1c levels tend to be much more accurate when estimating the average blood sugars.
Because of the limitations of HbA1c measurements in some situations and the racial differences discussed above, some of the patients with a HbA1c level between 5.5% and 7% will clearly have diabetes, and others will not.
Another curiosity with HbA1c has to do with patients with a sickle cell trait:
Given that one in ten African Americans have sickle cell trait, it is important to consider their trait when interpreting the results of a HbA1c. In the end, people with sickle cell trait can be tricky to diagnose diabetes. Many doctors neglect to ask if someone has sickle cell trait because, outside of genetic counseling before having children, there has conventionally been little impact on other disorders. Is your doctor aware of this genetically-based difference?