Jackson Heart Study to close the racial divide
Study fills gaps left after Framingham
It’s a big undertaking: design a study that follows populations of people over time in order to answer some of the basic questions about how African-Americans develop and experience heart disease.
Along the way, researchers say they want to attract more young black scholars to careers in public health, in order to get better minority representation among those in the profession, and in the process, discover the underlying mechanisms that contribute to make cardiovascular disease the world’s No. 1 killer among all people.
An elaborate program being planned
It’s going to take some time — both in planning and carrying it out. But organizers of the Jackson (MS) Heart Study say such an ambitious project is needed to help African-Americans get a better control over the disease.
"One of the truly notable successes in the second half of the 20th century is the steady decline of heart disease death," says Herman Taylor, MD, director of the Jackson Heart Study (JHS) and a cardiologist at the University of Mississippi Medical Center, also in Jackson.
"You see it in the American population as a whole, and it’s even true for the African-American population, but the improvements have not been equally shared," he adds.
Taylor says many factors are responsible for the lower success in fighting heart disease in black patients, but two recurrent problems are:
1. The knowledge of the manifestation of the disease is inadequate for these patients, especially when compared to what doctors know about the disease in white people.
2. Most studies are based on the white population.
"The fact that there is a widening gap between the two populations suggests things need to be changed," Taylor says. "The Jackson Heart Study is one way to do it."
Beginning next fall, the University of Mississippi Medical Center will start its baseline examinations on study participants from the local Jackson community. Data will be collected and processed by partner facility Jackson State University — with the help of undergraduate researchers training at the study’s third partner school, Tougaloo (MS) College. Taylor and his associates have a grant from the National Institutes of Health for $32 million to make it all happen.
Taylor says he is expecting JHS to be "The Framingham Study of the South." That monumental study began in 1948, when doctors were in "a woeful state of ignorance in terms of cardiovascular disease." They began to follow the health of the people in the Massachusetts town, and the research continued for decades, shaping the way doctors now think about heart disease.
It may be hard to realize at first, but Taylor points out that before the Framingham study, doctors didn’t use terms such as "risk factor." Physicians knew that major problems with high blood pressure could lead to myocardial infarction and heart failure but did not know anything about what he calls "the garden variety of hypertension" leading to the same troubles. The details of cholesterol had not been spelled out. "We just didn’t know," he says. "All these things we now take for granted were open to question."
But despite the 40 years of groundwork from the Framingham study, not all the lessons learned from the predominantly white, middle class cohort from New England are applicable to everyone. "There are some compelling theories, and we have ideas from the realm of conjecture and hypothesis, but we want to take them to something we can hang our hats on."
Taylor says smaller studies on the Jackson population have shown the differences in how cardiovascular disease affects African-Americans in ways that are different from what one may expect after following the Framingham study. For example, when 2,500 residents were followed as part of a trial on atherosclerosis, researchers found striking patterns on echocardiograms.
The implications for left-ventricular hypertrophy are quite different than what Framingham would suggest. (That study, Atherosclerosis Risk in Communities Project, or ARIC, has just been submitted for publication, and the participant sample will be part of JHS.)
Taylor says he wants JHS to teach caregivers about assessing classical risk factors such as obesity, hypertension, and left-ventricular hypertrophy. Many of these lessons will focus around the examinations of the parti-cipants. Because the researchers are not going into hospitals and pulling out patients to study, the investigators should be able to get a better sense of when heart disease first starts to develop.
"Ultimately, it shows you when to intervene," he says. "We have the advantage that the Fram-ingham Heart Study will show us how to do it."
But there will be more data to collect than what come from the typical medical examination. Taylor says questionnaires will be important tools in the study as well. The hope is to find out what’s contributing to obesity by learning about the patients’ diets.
In addition, there will be inquiries into the sources of stress and even religion’s role in health. Some of the questionnaires have been used elsewhere, others have been designed for the study, and still more will be used that have not been widely applied elsewhere.
"Some of the investigation of the psychological aspects of cardiovascular disease could truly be groundbreaking," adds Taylor.
What will make this study different, he says, is the researchers will try to correlate the examination data with the information they get from the responses to the questionnaires. The goal is to find the ties between clinical status with psychosocial elements of each patient. So the experiences of stress, social isolation, and religion and spirituality can be surveyed and tied to the outcomes of different patients.
"This will allow us to gain insight into something we see now in only fuzzy ways," he says.
Taylor says such correlations will help doctors to see how mental factors aggravate or ameliorate disease.
"Religion may be an incredibly important buffer," he says. "We want to find the bridge between the psychosocial and the biologic. . . . When you step back and look at it, it’s science making sense. The spiritual life can impact health in a profound way."
Painting such a detailed picture of these patients, the development of disease, and how much of it is a result of the life patients lead will give practitioners more information to help them decide what action to take. "It’s the informed intervention that will make the difference," says Taylor.
JHS may sound like Framingham in many respects, but organizers say it will go off in directions that are unique to this study and claim an equally important facet is getting undergraduate students interested in public health and involved in JHS.
"There is a woeful underrepresentation of African-Americans in these fields," Taylor says. The task is to get young scholars involved early in their education. Students can work with the study and gain practical experience.
"The ripple effect from this will be pretty large," says Bam Mehrotra, PhD, JHS director at the undergraduate training center at Tougaloo College.
Mehrotra says 10 incoming first-year students will be singled out and invited to take a four-class course in the new public health track. The course consists of an introduction to public health and epidemiology, biostatistics, research methods, and a nine-week mentorship program, where students work in an internship capacity.
He adds that Tougaloo will be reaching out to students long before they are ready for college: JHS is organizing summer programs for high school students as well.
The goal is to have a program after each year of high school to sharpen students’ math and science skills. This summer, Tougaloo’s director says they are planning an intermediate program to teach students how principles in chemistry apply to biology, such as pH and concentration of solutions.
The college targeted area public high schools in the Jackson metropolitan area, and because of a good response, had to expand the program from its expected 32 students to 37.
Representing all groups
Getting students involved not only trains the next generation of public health professionals but also spreads the word of JHS among family members to encourage them to participate.
"It’s important to have African-Americans [doing the] research on African-Americans," Taylor adds. "They bring a unique set of sensitivities and experiences that aren’t shared by all."
Getting everyone involved also spreads the feeling that African-Americans are part of the drive to make things better for themselves and in turn for everyone. "The future is much brighter when studies are represented by all groups of people," he adds.
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