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.
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 !!
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.
The 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.
In 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
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).
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.
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??
The 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”.
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.
Dr. Hall’s Podcast “Better Black Health” discusses multiple issues related to African American health . . . take a listen.
Lactose Intolerance Solutions
Others 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. Also check out the multivitamins I designed to compensate for the decreased vitamin D due to lactose intolerance and urban living — SEQUENCE Multivitamins for African Americans.
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.
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.
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!
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.
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
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 . . .
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) in African Americans as found in the “Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack” (ALLHAT) trial.
Best 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. Thus an African American male would be best served by amlodipine first line given the stroke prevention potential, 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 sometimes 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 white Americans with three distinct groups:
Their 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.
When considering all of these issues with ACE’s and ARB’s in African Americans, it should be noted that they are essential for preventing kidney disease in people with diabetes, and certain other kidney related problems. So if you don’t know why your on an ACE or ARB, call your physician and ask. The renal-sparing benefits of the ACE and ARB medications is still very valid when used to slow renal/kidney function decline (particularly in kidney disease due to high blood pressure), and they should still be used for kidney protection in African American patients with diabetes and similar conditions.
Please don’t just stop your medications based on this article, check with your provider to get your particular and specific advice. Use this article as a starting point for your discussion. Some providers are aware of these differences, and others may not be fully aware.
African Americans, Vitamins & Heart Health
African Americans also tend to be more deficient in potassium and magnesium and that can negatively impact your heart health. Vitamin D and vitamin C deficiencies have also been connected to poor heart issues. Consider Sequence Multivitamins for African Americans as a multivitamin that replaces what you need.
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.
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.
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.
As 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.
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.
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.