Recent studies have found a correlation between vitamin D deficiency and stroke risk as well as stroke severity. A study just published found that people with the highest vitamin D levels had fewer strokes and if they had a stroke, it was less severe. People with low vitamin D levels had more strokes with more severe symptoms.
As you know, we get most of our vitamin D from the sun, but urban living, colder/cloudy weather, and lactose intolerance (so we can’t drink “Vitamin D Milk”) have all resulted in wide-spread African American vitamin D deficiency.
African Americans Have Low Vitamin D Levels
Four of five African Americans have low levels of vitamin D, and we also have the highest rates of heart attack, stroke, and circulation problems. Risk factors for low vitamin D levels include older age, darker complexion, obesity, and limited sun exposure.
Studies have shown that hemorrhagic stroke patients (those strokes caused by a bleed rather than a blood clot) often suffer from low vitamin D levels. Another study suggested that putting stroke victims on vitamin D helped their recovery somewhat.
Biologically, vitamin D reduces total cholesterol and fat in blood as well as improves inflammation which helps your blood vessels stay healthy.
A Direct Effect Has Not Been Shown
To be clear, there has yet to be a study that showed taking a vitamin D supplement led to fewer strokes. These research studies are only able to find correlations and from these associations, they “suppose” that raising your vitamin D level will lead to better health. Some researchers believe that poor health leads to low vitamin D levels and that is the reason sicker people have low vitamin D.
Vitamin D levels have been positively associated with improved cardiovascular health, especially with reduction of stroke risk. Until the controversy is settled, everyone agrees that leaving a low vitamin D alone is not a reasonable option.
Vitamin D is best increased through natural means . . . sun exposure, a healthy diet, etc. Foods high in vitamin D include salmon, herring/sardines, cod liver oil, tuna, mushrooms, and fortified beverages (milk, orange juice, and cereal).
Good Vitamin D Levels Help in COVID Patients
Another study looked at COVID patients and vitamin D deficiency and found COVD illness directly related to vitamin D level. COVID-19 is greatly associated with increased stroke and heart attacks so having a normal vitamin D level was somewhat protective against severe COVID disease. Obviously the absolute best way to avoid COVID-19 is through getting an approved vaccination.
A new study is showing benefit from taking a multivitamin once a day in slowing the progression of dementia in older individuals. It has long been known that vitamin D deficiency is directly linked to Alzheimer’s Dementia and African Americans have the highest rate of vitamin D deficiency as well as Alzheimer’s Disease and some have called it a “silent epidemic.”
Research suggests that Alzheimer’s disease may be two to three times higher in older African Americans when compared to Whites. Studies also show that the disease progresses much more slowly in African Americans and people with it live significantly longer. These curious facts lead doctors to think that the cause for the mental decline may be different.
Alzheimer’s occurs in African Americans at a comparatively younger age and robs too many older adults of their independence, dignity, and resources. It has been linked to hypertension (high blood pressure), depression, diabetes, smoking, and some genetic factors. In fact, the risk for Alzheimer’s Disease is 44 percent higher if you have a close relative with dementia.
There are also studies that show a higher consumption of fruits and vegetables, taking cholesterol-lowering medicine, and high social engagement may help ward off dementia. A Mayo Clinic article addresses the connection between vitamin deficiency and dementia and given the widespread deficiencies we see in the Black community, there is certainly no harm in taking the right amount of vitamin D.
The article also outlines that the National Institutes of Health recommends adults age 70 and younger need 600 international units (IU) of vitamin D daily, and adults over age 70 need 800 IU daily. These recommendations are too low for African Americans who need much higher doses to achieve normal vitamin D levels.
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.
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.
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.
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.
The 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
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 !!
A 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.
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.
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.
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” name 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.
The problem with heart failure is complicated, but for our purposes can be considered a combination of
too much fluid in the body
too much heart muscle (from high blood pressure)
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.
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.”
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
High 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.
Type 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.
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. If you swim use this waterproof Fitbit to track your performance.
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.
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.
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.
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.
As 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.