Is an Unacknowledged Eurocentric Paradigm Widening Ethnic Disparities in U.S. Health Care?
African-Americans consume
substantially less than the recommended daily intake of calcium and yet have
the densest bone mass of any American ethnic group, and are at the lowest risk
of osteoporosis, fragile bone disease and other calcium deficiency disorders.
Studies have shown that this occurs because blacks have higher rates of calcium
retention and greater calcium utilization efficiency than other ethnicities. So
what public health message is given to black parents? It is that their children suffer from calcium
deficiency and should therefore be fed more dairy products in order to prevent
osteoporosis. But what might the implications be of pushing high sodium, high
fat dairy products on a population that is not in need of supplemental calcium
but that is suffering from skyrocketing rates of juvenile obesity and
salt-sensitive hypertension? The medical
response is that those ailments are probably caused by a calcium-deficiency as
well.
The
greatest danger in perceiving all ethnicities to be biological carbon copies of
Northern Europeans is that such an unacknowledged paradigm blocks group testing
of its underlying assumptions. For
instance, the public health model employed by researchers in the United States is one based on the concept of "Northern European universality.” It operates from the unexamined premise that
whatever nutritional guidelines and health messages are most beneficial for mainstream
Americans, who are predominantly of Northern European ancestry, are ipso facto deemed best for all
ethnicities and population groups. Thus the Food and Drug Administration offers
a one-size-fits all set of nutritional
guidelines for food labeling.
The Eurocentric Paradigm
But
how do we tell when a paradigm does not conform to a universal biological
standard? It will only be when too many paradoxes
in the research findings pile atop one another.
In fact, African-Americans are suffering from growing health disparities
at a time when the larger society is making its greatest health strides. In 2010, The American Public Health
Association issued an ongoing progress analysis entitled “Black-White Health
Disparities in the United States and Chicago.”
It noted: “With more than 15 years of time and effort spent at the
national and local level to reduce disparities the impact remains negligible.”([1])
Blacks are not getting poorer. But they are getting sicker and the anomalies
are stacking up in a wobbling heap of file folders stamped with a “?”
However,
a clarification is in order. Even though
the subject of this article is “ethnicity,” it repudiates 19th
century pseudo-scientific racial classifications as bogus. Because over the past fifty thousand years,
the human species has migrated and adapted to new climactic, nutritional and
epidemiological environments, biogeneticists have shown that there are an
infinite number of ways to parse micro-populations. For example, convergent evolution has allowed
African-Americans to share dark pigmentation with East Indians of Dravidian
ancestry, the sickle-cell gene with southern Mediterranean populations, Saudi
Arabians and East Indians because of the presence of malaria.([2]) East and Southern Africans share lactase persistence
with Northern Europeans because of their dairy-farming food culture.([3])
African-Americans share salt-sensitivity with Yamamoto Indians of the Brazilian
rain forest because both groups originated in sodium-deficient tropical regions
far from the coast.[4]) In spite of these adaptations, the human
species has in common 99.9 percent of all
its biological traits.([5])
However,
in a multi-ethnic society like the United States, the small margin of genetic
variants that are environmentally
influenced must be identified and addressed in their own right. It becomes the responsibility of the
dominant ethnicity to ensure that it does not universalize its own medical
standards and pathologize any differing biological norms observed in minority
ethnicities. If the medical and public
health system does not rise to the challenge of establishing different sets of
standards for diverse populations when needed, it is inevitable that the
majority demographic will see health improvements over time. However, those minority ethnicities whose
nutritional or other medical norms are at greatest deviance from those of the
majority will see a deterioration in health no matter how well intentioned
government efforts might be at rectifying disparities.
One
illustration of this potential problem has already arisen in regards to ethnic
differentials in nutritional standards for daily sodium intake. Growing medical
evidence points to African-Americans being at greater risk of salt-sensitive
hypertension and also of dying from end stage renal failure at 3.5 times the
rate of whites.([6]) Studies
have consistently shown that an exceptional sodium retention capacity in the
kidneys of many black Americans compared to whites is caused by the longer
length of time it takes to excrete a sodium load and higher red blood cell
sodium levels.([7]) The
reasons may relate to the biological adaptations of their ancestors, who were
forced to survive sweltering tropical climates, which were geologically
deficient in sodium (being far inland from the salt-rich coastal areas).([8])
The Institute of Medicine has therefore come to recommend that healthy
African-Americans reduce their daily sodium intake to 1500 mg./daily, which is
a full 800 mg. less than the federally-recommended intake for the American
public.([9]) However recent studies by Scandinavian
researchers have called into question the 2300 mg. federal standard, even claiming
that it is too low.([10]) The popular media has widely reported this
medical report under such headlines as “Sodium Intake Guidelines are Too Low.” ([11]) While
this debate may indeed hold validity for people of Northern European ancestry,
not a single medical journal disputes the dangers of a high-sodium diet for
African-Americans.([12]) And yet, blacks have no way of knowing that
they are placing themselves at higher risk of end-stage-renal-failure unless
they ignore FDA nutritional labels as
well as the popular media and start poring through medical journals.
Whose
Calcium Deficiency?
However,
the clearest evidence of the Eurocentric paradigm’s blindspot regarding biological
differences in nutritional values has been the medical community’s preoccupation
with correcting calcium deficiency in blacks. ([13])
The focus on this issue began with an article that appeared in a 2005 issue of The Journal of the American College of
Nutrition entitled: “The Myth of Increased Lactose Intolerance in
African-Americans. Its authors asserted:
The 'African-American
diet' is more likely to be low in a variety of vitamins and minerals, including
calcium. African-Americans consume low amounts of dairy foods and do not meet
recommended intakes of a variety of vitamins and minerals, including calcium.
Low intake of calcium and other nutrients put African-Americans at an increased
risk for chronic diseases. . .
Research has shown that lactose maldigesters, including African-American
maldigesters, can consume at least one cup (8 oz) of milk without experiencing
symptoms, and that tolerance can be improved by consuming the milk with a meal,
choosing yogurt or hard cheeses, or using products that aid in the digestion of
lactose such as lactase supplements or lactose-reduced milks. ([14])
However lactase non-persistence, commonly referred
to in the United States as lactose intolerance is not a disorder. It is an ethnic trait, like skin color. It is most commonly seen in populations of
non-dairy farming ancestry. In fact, seventy-percent
of the human species ceases after weaning, to produce lactase, the enzyme required to
metabolize the dominant milk sugar, lactose.
While less than five percent of Americans being of Northern European
ancestry carry this trait, eighty to one hundred percent of American Indians do,
seventy- five percent of African-Americans, ninety-five percent of Asians,
fifty to eighty percent of Hispanics, as well as sixty to eighty percent of
Ashkenazic Jews.([15])
In
the U.S., because the mainstream population has inherited the gene mutation
that allows them to digest lactose, the medical community is generally unfamiliar with
lactase non-persistence. It is
clinically defined as a disorder, for which a range of medications, treatments,
and dietary supplements are offered to ameliorate the symptoms.([16]) However, a closer examination of the matter
shows that lactose intolerance is only a disorder (and one that can indeed
prove fatal) for those members of lactose tolerant ethnic populations, who are born
with a congenital defect in which the gene is missing or whose digestive organs
have been damaged and thus the enzyme cannot be produced. As for the lactose non-tolerant, the same
principles of genetic adaptation that protects Congolese people from skin
cancer, protects blacks and others of non-dairy farming ancestry from needing the
supplemental calcium that the bodies of lactose tolerant adults have come to
require for bone health.
Calcium
Efficiency
More
than two decades of research studies have confirmed that African-Americans are
not calcium deficient. The Third National Health and Nutrition Examination
Survey (NHANES) 1988-1991 documented the fact that blacks have lower calcium
intakes than whites but higher bone mass. ([17]) This finding was initially labeled a “paradox.” However, since then, medical researchers have
continued to study the phenomenon in order to piece together the mechanism by
which a non-dairy consuming ethnicity would have a stronger skeletal mass and
exhibit genetic protections against osteoporosis and other fragile bone
disorders. These subsequent studies have
revealed a highly efficient utilization mechanism for lower level intakes of
dietary calcium. Black adolescents were
shown to have higher rates of calcium absorption, increased net skeletal
retention and lower urine calcium than their white counterparts.([18]) Such processes occurring in childhood in addition to relative resistance to the bone
resorption of parathyroid hormone also offer bone protections, which persist
into old age.([19]-[20])
Nevertheless,
in 2006, an article appeared in the Journal of Nutrition asserting that
healthy blacks were Vitamin D deficient and that this condition, created by
their dark skin complexions, put them at risk of osteoporosis, cardiovascular disease, cancer, diabetes, and other serious
chronic conditions.([21]) A popular
website cautioned African-Americans that they needed ten times more sun
exposure to produce the same amount of Vitamin D as a person with pale skin.([22])
Fortunately, by 2013 a new study had appeared
in the New England Journal of Medicine
correcting the earlier report and asserting that blacks had been misdiagnosed
as Vitamin D deficient.([23])
Inversion
Theories
These
kinds of mistakes should be easily spotted.
But the “Eurocentric Paradigm” hides them behind easily-generated “inversion theories.” They borrow the same data sets and research
findings but switch symptoms. An example of an inversion theory would be acknowledging
that blacks do not suffer from osteoporosis, fragile bones or other calcium
deficiency disorders common to whites. But
the theory asserts that their calcium deficiency symptoms merely manifest
themselves in a different set of disorders, which just so happen to be whatever
disorders African-Americans are at greatest risk of suffering. In this case the diseases are obesity, high
blood pressure, diabetes II and prostate cancer.([24])
No actual research is needed to tie
these disorders to calcium, since the data already exists both that blacks
suffer a calcium deficiency and that they suffer from this other range of
disorders as well. This is a classic
case of falsely inferring causation from correlated but mismatched data.
Worsening
of Health Disparities
A
flawed Eurocentric Paradigm and the inversion theories it spawns cannot help but
worsen health disparities. This is
because they carry consequences. Vital
clues are lost. Time and funding are frittered away on quixotic journeys to
cure phantom diseases. In the meantime, the
real disorders take lives that might have been saved had public health
knowledge identified a particular ethnicity’s biological signatures rather than
founder in undifferentiated data.
For
example, African-American men have the highest rate of prostate cancer in the
world.([25]) A growing body of research has also pointed
to the fact that overconsumption of calcium increases the risk of prostate
cancer, including in black males. This
rate of prostate cancer does not however extend to West African males, who
share the same genetic ancestry. But
neither do the latter consume dairy products.
On the other hand, this has become a steadily increasing part of the
black American diet because of the public health focus on calcium deficiency
among blacks.
Over
the past two decades, the prevalence of obesity among African-American
adolescents has nearly doubled, rising from 13.4 percent to 24.4 percent.([26]) Earlier studies appeared to show that dairy
products might have a weight-loss effect, but on whom? The primary dietary shift for black juveniles
has been the addition of high fat-dairy to their diets during this same period
and at the instigation of health experts concerned at possible calcium
deficiencies.
Also, if
lactose intolerant African-Americans are born with genetic advantages,
which protect them from osteoporosis and bone disease, through a mechanism of
calcium homeostasis, and which also reduces the amount of calcium intake
required, is it necessary or even safe for them to over-consume calcium? What might happen if this homeostatic process
is unbalanced?
There
is an urgent need to establish micro-population/ethnic databases, so that the
most critical findings and medical advances that could be of special relevance
to target ethnic population do not vanish into the mainstream data ocean. Such an undertaking would also require some
effort at substituting population genetics for antequated racial
classifications. While ethnic
terminology can be a convenient shorthand, we must be careful. Most American ethnicities, including black
Americans are admixed populations, meaning that genetic biomarkers, rather than
self-identification will be required to distinguish populations in research
purporting to establish causes and correlations. For example, the range of African-American
ancestry goes all the way from individuals with 100% West African ancestry to
those who might, for example, have 1% West African Ancestry, 97% European
Ancestry, and 2% Native American ancestry.
Thus studies looking for correlations between disorders or traits common
to West Africans but not to Europeans would spoil their data findings without
first having clarified the genetic admixture of the test pool. If for instance a study showed that African-Americans who drank milk also had
lighter complexions, did the milk lighten their complexions, or did darker
blacks refrain from drinking milk because of lactose intolerance, a trait that
those having more European ancestry had not inherited?
Conclusion
The Eurocentric Paradigm does not need to be jettisoned.
It needs to be seen for what it really is – a model and standard of
excellence for what general human biology and all ethnic medicine must become
in the U.S. The care and sophistication
with which populations of Northern European ancestry are being examined becomes
a methodology for approaching genetic
variants identified in African-Americans, Latinos, Asian-Americans, Ashkenazic
Jews, Native-Americans and other ethnicities. This is an enormous challenge but
it is one worth embracing. For, it
recognizes the unique position America may hold for the biological future of
the human species, as the wanderings of 50,000 years of global migrations find
their way home.
([1])Orsi
JM, Margellos-anast H, Whitman S. Black-White health disparities in the United
States and Chicago: a 15-year progress analysis. Am J Public Health.
2010;100(2):349-56.
([2]
) El-Hazmi MA, Al-Hazmi AM, Warsy AS. Sickle cell disease in Middle East Arab
countries. Indian J Med Res.
2011;134(5):597-610.
([3])Catherine
J. E. Ingram, C.J.E., Elamin, M.F.,
Mulcare, C.A., Weale, M.E., Tarekegn, A.,Raga,
T.O., Bekele, B. Elamin, F.M., Thomas, M.G., Bradman, N. A novel polymorphism
associated with lactose tolerance in Africa: multiple causes for lactase
persistence? Human Genetics. February
2007, Volume 120, Issue 6, pp 779-788
([4])
Gleiberman,L. Sodium, Blood Pressure, and Ethnicity: What Have We Learned? American Journal of Human Biology. 2009;21:679-686
([5])
Shastry, B.S. SNP alleles in human
disease and evolution. Journal of Human
Genetics. November 2002, Volume 47, Issue 11, pp 0561-0566
([6]
) Lipworth, L., Mumma, M.T., Cavanaugh, K.L., Edwards, T.L., Ikizler, T.A.,
Tarone, R.E., McLaughlin, J.K., Blot, W.J.,
Incidence and Predictors of End Stage Renal Disease among Low-Income
Blacks and Whites. PLOS, Published:
October 24, 2012.
([7])
Gleiberman,L. Sodium, Blood Pressure, and Ethnicity: What Have We Learned?
American Journal of Human Biology. 2009;21:679-686
([8])
Gleiberman,L.
Sodium, Blood Pressure, and Ethnicity: What Have We Learned? American Journal of Human Biology. 2009;21:679-686
([9]
) Available
at:
http://www.iom.edu/Reports/2013/Sodium-Intake-in-Populations-Assessment-of-Evidence/Report-Brief051413.aspx.
Accessed June 30, 2014.
([10])
Graudal, N, Alderman, M.H. . Compared With Usual Sodium Intake, Low- and
Excessive Sodium Diets are Associated. American Journal of Hypertension. Mar
20, 2014.
([11])Available
at:
http://www.thehealthierlife.co.uk/natural-health-articles/nutrition/low-sodium-intake-myth/.
Accessed June 30, 2014.
([12]
) Appel,
L.J., Frohlich, E.D., Hall, J.E., Pearson, T.A., Sacco, R.L., Seals, D.R.,
Sacks, F.M.
The Importance of Population-Wide Sodium
Reduction as a Means to Prevent Cardiovascular Disease and Stroke; A Call to
Action From the American Heart Association. Circulation.2011
(123) 1138-1143
([13])Heaney,
R.P. Low Calcium Intake Among African Americans: Effects on Bones and Body
Weight.The Journal of Nutrition 136
(4) 1095-1098
([14])
Byers, K.G., Savaiano, D.A. The myth of
increased lactose intolerance in African-Americans. Journal of the American College of Nutrition. 2005 Dec;24(6
Suppl):569S-73S.
(Accessed
June 2014)
([17])
Alaimo K, McDowell MA, Briefel RR, Bischof AM, Caughman CR, Loria CM, Johnson
CL. Dietary intake of vitamins, minerals, and fiber of persons 2 months and
over in the United States: Third National Health and Nutrition Examination
Survey, Phase 1, 1988–91. Advance data from vital and health statistics; no.
258. Hyattsville, Maryland: National Center for Health Statistics. 1994.
([18])
Bryant RJ, Wastney ME, Martin BR, Wood O, McCabe GP, Morshidi M, Smith DL,
Peacock M, Weaver CM: Racial differences in bone turnover and calcium
metabolism in adolescent females. J Clin
Endocrinol Metab 88: 2003. 1043–1047.
([19])Heaney
R P. Ethnicity, bone status, and the calcium requirement. Nutritional Research. 2002;22:153–78.
([20])
Aloia JF, Mikhail M, Pagan CD, Arunachalan A, Yek JK, Flaster E. Biochemical
and hormonal variables in black and white women matched for age and weight. J Lab Clin Med. 1998;132:383–9.
([21])
Harris, S.S. Vitamin D and African Americans. Journal
of Nutrition, 2006 Volume 136 (4) 1126-1129.
([22])
http://articles.mercola.com/sites/articles/archive/2014/05/28/vitamin-d-deficiency-signs-symptoms.aspx (Accessed June 2014)
([23]),
Powe, C.E., Evans, M.K., Wenger, J., Zonderman, A.B., Berg, A.H. Nalls, M.
Tamex, H. Zhang, D., Bhan, I. Karumanchi, S.A., Vitamin D–Binding Protein and
Vitamin D Status of Black Americans and White Americans New England Journal of Medicine 2013; 369:1991-2000
([24])
Heaney, R.P. Low Calcium Intake Among African Americans: Effects on Bones and
Body Weight.The Journal of Nutrition 136 (4) 1095-1098
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