As the largest city in the Commonwealth of Kentucky, Louisville faces significant health challenges to its citizens. Many of these challenges are magnified in the city due to its larger Black and African-American populations being disproportionately affected by the same health risk indicators routinely showing Kentucky ranked at or near the bottom as compared to other states. The Mission of the nonprofit, nonpartisan Foundation for a Healthy Kentucky is, “To address the unmet health needs of Kentuckians by developing and influencing policy, improving access to care, reducing health risks and disparities, and promoting health equity. And their Vision is, “A Kentucky where every individual and community reaches their highest levels of health.”
Foundation for a Healthy Kentucky President/CEO Ben Chandler served as a United States Representative for Kentucky from 2004-2013. He now acts as the public face of the Foundation and sets policy with the Board of Directors. Ben and the Foundation work with Louisville Metro Public Health and Wellness Director Dr. Sarah Moyer and Louisville health providers to increase public health investment in the city. The underlying issue in many healthcare concerns is the delay of care due to a lack of insurance coverage. While the Affordable Care Act made great strides in closing the gaps with Medicaid expansion, more work is needed to preserve that and expand coverage even further. Ben points out that early stage and ongoing preventive care are much less costly than treatment of acute and/or chronic health problems.
The other Foundation initiatives aligning with Louisville health risk management are in the areas of tobacco use reduction, obesity prevention, and children’s health. Kentucky competes with West Virginia for the highest tobacco use in the nation; and tobacco use is particularly high in Louisville’s West End. Tobacco use exacerbates most every other health risk and yet is the most preventable risk factor. Obesity also complicates other health issues. “Cheap food tastes good but is low in nutrition and high in calories,” says Ben. The answer seems simple, “Eat right and move around.” But some neighborhoods and communities lack access and the ability to afford fresh, whole foods. Children’s health is negatively impacted by Adverse Childhood Experiences (ACEs), such as abuse, neglect, trauma, and growing up in households with instability due to substance abuse, mental health issues, and parental separation or incarceration. In Louisville’s annual health report, ACEs emerged as “a tale of two cities” and, according to Ben, “the inequality leaps off the page.” Disproportionalities similar to these have surfaced in tracking Jefferson County’s COVID-19 cases and where coronavirus infection “rates are considerably higher,” especially among Black and African-American populations. Investment in identifying, examining, and correcting the root causes of these issues is necessary to prevent them.
We consulted with leading medical specialists and experts for more information in these areas and other top health risks in Louisville.
For the last 50-75 years, allergies and asthma have become increasingly prevalent worldwide, particularly in Western countries. Urbanization has produced more pollution and allergens leading to more asthma. Viral infections, more easily spread in dense populations, often affect the respiratory system. Inner-city housing lacking proper sanitation and pest control can lead to dust mites and cockroach and rodent infestation, all of which trigger allergic reactions and asthma attacks. Pollution and allergens settling in the Ohio Valley, especially in spring and fall, add to asthmatic complications in Louisville.
Dr. James Sublett is Co-Founder, Managing Partner, and Chief Medical Officer of Family Allergy & Asthma established 41 years ago in Louisville. FAA is now a regional practice with offices in Kentucky, Indiana, Ohio, and Tennessee. Dr. Sublett is also a Clinical Professor and Section Chief of Pediatric Allergy and Immunology at the University of Louisville School of Medicine and is the American College of Allergy, Asthma, and Immunology (ACAAI) Executive Director for Advocacy and Governmental Affairs. His main professional interests lie in “managing difficult-to-control asthma and the environmental triggers of allergy.” Unlike so many other health risks, Dr. Sublett says, “There is not a lot you can do to prevent allergies. Smoking cessation and reducing pollution can help ease the effects.” He cites a Cincinnati study of residents living near interstates and the impact of diesel particulates. Avoidance of allergens and keeping clean, low-humidity “healthy homes” free of dust and pests can also help to reduce asthma attacks. Reliever and rescue inhalers may still be necessary. Severe asthma is treated with “biologics and allergy shots to help boost immune response.”
When asked what we need to know now and what news or advancements he has to share concerning asthma, Dr. Sublett says it is important to realize that “You don’t have to suffer from it. Although it is a chronic condition, you can take long-term control of it. Seeing a Board-Certified Allergist can be life-changing.” It is estimated that 10 to 12% of the population in Louisville has asthma. The national average is 8%. For asthma support and information, visit the Kentucky Asthma Partnership at asthmacommunitynetwork.org and cdc.gov/asthma. For allergy testing information, visit familyallergy.com.
According to the CDC, Kentucky is “ground zero” for the highest cancer incidence and death rates in the United States. Some contributing factors are tobacco use, radon exposure, and rural and inner-city populations’ lack of access to care. Regarding treatment, the underrepresentation of older and non-white cancer patients in clinical trial enrollment is of particular concern to Medical Oncologist, Dr. Rebecca Redman. Dr. Redman has 10 years of experience in oncology with a background in internal medicine and is Deputy Director of Clinical Trials Research with the University of Louisville. Clinical trial participation potentially eases the burden of the patient and helps other cancer patients in the future.
The National Institute of Health’s National Cancer Institute at cancer.gov outlines several examples of statistical cancer disparities, including:
The prospects for our city and state concerning cancer are not necessarily all grim. According to Dr. Redman, cancer risk can also be reduced through healthy living: “a healthy diet and lifestyle, tobacco cessation, and age-appropriate screenings based on family history and risk factors.” The national cancer death rate has declined by 26% from 1991-2015 with advancements in immunotherapy versus the more conventional chemo and radiation therapies. More research is also aimed at “personalized medicine and individual disease with tumor and tissue analysis of genetic mutations in tumors to target or block the gene.” Prevention is key. But once a cancer is diagnosed, a patient’s best bet is “a team of doctors who personalize the new treatments in our toolbox.” Dr. Redman currently specializes in cancers of the head and neck at the James Graham Brown Cancer Center.
As the Commonwealth of Kentucky’s “Healthy at Work” phased reopening continues, following Governor Beshear’s coronavirus “Healthy at Home” orders, Louisvillians are navigating yet another new normal. Mask-wearing is recommended in indoor public and shared spaces and in crowded outdoor spaces; and citizens should maintain social distancing of at least six feet apart. The coronavirus is still with us. As of mid-June, Jefferson County still had over 3300 cases, nearly three times the number of cases in any other Kentucky county. Jefferson County’s COVID-19 death rate represents nearly 35% of all Kentucky COVID-19 deaths. While the county was successful at “flattening the curve” to prevent hospitals from being overrun, the possibility of a second spike remains.
Dr. Anna Hart is an Infectious Disease Specialist, Advisor to Infection Control, and Co-Chair of the Antimicrobial Stewardship Committee for Baptist Health Louisville, and was named a Louisville Magazine Top Doctor in 2019. Before the coronavirus pandemic, Dr. Hart worked part-time at the outpatient clinic, on in-patient consults, and in administrative meetings. Then rather suddenly she found herself working full-time, weeknights until 7 or 8pm, and on weekends. She still works full-time with COVID patients, at the outpatient clinic, and in meetings, continuing to monitor, respond to changes, and implement plans. But she is no longer on call and can spend more time with family.
Baptist Health’s Chief Medical Officer, emergency management team, and hospital administrators work directly with Louisville Metro Government officials on coronavirus planning and response. Dr. Hart recommends that Louisvillians continue to monitor the most up-to-date information on the spread of the coronavirus and maintain awareness of respiratory droplets as a vehicle, even from those who are asymptomatic. In addition to mask-wearing and social distancing, she emphasizes the continued importance of diligent hand washing, sanitizing, and disinfecting of high-touch surfaces. “The coronavirus is still unpredictable. No one knows how it will play out over the summer and in the fall as kids go back to school. Be on high alert. Don’t get complacent because it seems to have died down. Be very vigilant, seek accurate sources of information, and avoid misinformation.” Dr. Hart recommends using kycovid19.ky.gov as a primary resource.
Mental health and substance use disorders are particularly pertinent issues that are at risk for worsening during a global pandemic. Rates of distress, anxiety, and mood disorders have tripled in recent months according to Dr. Mary Helen Davis, a practicing psychiatrist at Integrative Psychiatry and consultant for Baptist Hospital of Louisville’s Cancer Program and director of their Psychosocial Oncology program and past president of the Kentucky Psychiatric Medical Association and Southern Psychiatric Association.
Recent events from the pandemic to the public health crisis of racism and racial disparities have created significant levels of interpersonal and psychic distress. If left unchecked this distress can become the gateway to more serious mental health and substance use disorders. Dr. Davis encourages being proactive in the recognition and management of stress and distress. Although it may be a common and normal reaction to the events we are currently dealing with, having a plan can help diminish the impact. Dr. Davis recommends creating and following a “daily structured schedule” that includes being physically active, defining meaningful activity, utilizing one’s spirituality through prayer or meditation, and staying socially engaged. Although we are currently practicing physical distancing, it is important to maintain social connections with friends and family even virtually in the short term. We also have to be sensitive to emotional wellbeing across the lifespan, recognizing the impact of the “psychological footprint of the epidemic” on children through seniors.
If your level of stress seems excessive in that it interferes with your ability to function, impacts your sleep, concentration, or energy level, then you may need to seek medical care including medication assistance for persistent symptoms. “Primary care doctors are often the foot soldiers of mental health,” says Dr. Davis. Many of them already offer screenings for anxiety and depression and can initiate treatment. It is also important to monitor lifestyle choices and avoid using alcohol or substances to cope with increased anxiety or sleep disturbances.
Just as individuals must cope with the pandemic, so do medical providers. The practice of psychiatry has entered the telehealth arena virtually overnight. This is likely to be the most significant change in mental health in 2020, has been well received by patients, and improved access to care for many vulnerable populations. Kentucky leads the nation in telehealth legislation that passed in 2018 and went into effect in July of 2019 before the pandemic. In addition to the adoption of telehealth, advancements in neuromodulation, neuromagnetic stimulation, medication-assisted treatment in opioid addiction, and cognitive behavioral therapy offer hope to those who have not responded to more traditional treatments.
Dr. Davis is a big proponent of population health and understanding the impact of social determinants of health. She reports that in times of crisis there tends to be an increase in domestic violence and child abuse. Ongoing awareness with education on resources for help is critical. Dr. Davis is encouraged by the expansion of insurance efforts by Governor Beshear, which should help in addressing some of the disparities in health care as well as protecting those who have lost insurance coverage due to unemployment.
Two out of three Americans are clinically overweight or obese, with a Body Mass Index (BMI) of 25 or above. Contributing factors are lack of education or misinformation, highly processed foods, and financial and racial disparities in income and health, according to Dr. Meredith Sweeney, a bariatric surgeon with Norton Healthcare. She is board-certified in general surgery and is a Fellow of the American Society of Metabolic and Bariatric Surgeons.
Dr. Sweeney cautions us that the old Food Guide Pyramid many of us were taught simply does not work to address weight issues. Its emphasis on consumption of fruit and grains overloads the diet with sugar and carbohydrates. “Processed ingredients also cause more problems than solutions,” says Dr. Sweeney. She recommends that we not shy away from healthy fats and proteins that the old pyramid suggested we should limit. “Whole foods” or foods with only one ingredient are anti-inflammatory. Those who live in urban areas known as “food deserts” often lack physical and financial access to affordable, quality fresh foods. Their easier options are typically cheaper fast food and/or processed foods.
Overweight and obesity are pre-inflamed states that exacerbate the inflammatory nature of infections such as coronavirus and virtually guarantee worse outcomes. To reverse the inflammatory state, Dr. Sweeney instructs current and prospective patients to remove processed foods, sugar, and starches from the diet. “Little changes can change your way of thinking. I encourage patients to take their health into their own hands with a whole foods diet. Live the years you have left to the fullest. Take control now. The benefits are well worth it.” To track progress, she suggests downloading “the ZERO Fasting app and Carb ManagerⓇ carb counting app that helps guide people to make good choices.”
Bariatric surgery can be a great tool not only for weight loss but also for reversing chronic diseases such as diabetes, high blood pressure, and sleep apnea.” Norton Weight Management Center has 3 full-time, Fellowship-trained bariatric surgeons on staff, which is unique to Louisville. Dr. Sweeney is proud to be a part of the entire team, including therapists, dieticians, and nurses.
Diabetes is a condition in which blood sugar levels are elevated due to insulin deficiencies. Insulin is the hormone which regulates food storage and energy, storing glucose in the blood or moving it into the cells as necessary. When the body does not produce enough insulin or cannot use it efficiently, blood glucose rises and results in a variety of symptoms and an increased risk of organ damage or failure and other chronic illnesses.
Diabetes is an increasingly significant health threat, especially in the last twenty years as rates have almost doubled. According to the American Diabetes Association, diabetes was prevalent in 10.5% of the population as of 2018. The CDC says one-third of American adults are prediabetic and only 20% of those are aware of their status. In Kentucky adults, the rate of diabetes is up to 13%. Jefferson County’s rate stood at 11% in 2018. In West Louisville, the prevalence is as high as 32%, a disparity rooted in issues such as access to care, food deserts, poverty, and unemployment. Metro Louisville government, in partnership with Louisville-area health systems, is committed to working on these and other issues to close that gap and lower the overall rate of diabetes in the city.
On an individual level, we can lower the risk or manage diabetes by losing 5-7% of total body weight, avoiding sugar and unhealthy fats, drinking more water, exercising 30 minutes per day five times per week, minimizing stress, prioritizing sleep, and keeping up with regular doctor visits. Baptist Health offers a Diabetes Management Program and Pre-Diabetes Fitness Program. Louisville is fortunate to have one of the leading medical research universities in the nation. “The University of Louisville Diabetes & Obesity Center supports leading-edge basic and clinical research to generate new knowledge for the prevention and management of diabetes and obesity. We believe a collaborative, multi-disciplinary approach to research has the power to yield dynamic results. Our team is making new discoveries every day - discoveries that bring us one step closer to a more effective strategy for the treatment, management and prevention of these growing epidemics.”
“Hypertension is an important risk factor for heart attack, stroke, and kidney disease,” says Dr. William Dillon of Baptist Medical Group. Kentucky lies in the “Heart Attack Belt” of the nation. There is a very high prevalence of cardiovascular disease in the state. As many as 20% of adults over the age of 20 have high blood pressure, while 40% of Kentuckians suffer from hypertension. Not to mention, 1 in 5 adults don’t even know they have hypertension because, due to fear or lack of insurance coverage, they do not make regular doctor’s visits. Another contributor to high blood pressure in Kentucky is the typical Southern diet, delicious though it may be with its high fat and salt content.
Dr. Dillon is an Interventional Cardiologist who has been in practice in Louisville for over 20 years. He attended DePauw University and Indiana University School of Medicine, served his residency at the University of Minnesota, and completed a fellowship with IU School of Medicine. Dr. Dillon’s clinical focus is cardiac catheterization and intervention, prevention and management of cardiovascular disease, pulmonary embolism intervention, structural heart interventions, and cardiac arrest care. “Surgeries are often a band-aid. They don’t reverse heart disease. Cardiovascular disease can often be slowed or prevented through risk factor modification.”
For the prevention of cardiovascular disease, Dr. Dillon recommends a four-pronged approach:
Together, following these lifestyle changes can lower the risk of heart attack or stroke by as much as 80%.
Once a heart attack has occurred, quick intervention is key. A heart attack is not necessarily a death sentence, but the sooner someone is treated usually the better they will do. “There have been great advancements in procedures - less invasive and better techniques are being developed and refined. While stents can save lives during a heart attack; the cornerstone of cardiac care is risk modification and medical therapy. Medical therapy has gotten better.”
Dr. Dillon adds, last but not least, “I would be remiss if I did not address the healthcare inequities of African-Americans and minorities versus Caucasians. The chronic stress of systemic racism contributes to hypertension. African-Americans have two times the risk for cardiac arrest.” For more information on prevention and treatment of heart disease and hypertension, visit cdc.gov/heartdisease/ and cdc.gov/bloodpressure/ and the American Heart Association at heart.org.
The Louisville Metro area is located in the “Stroke Belt” or “Stroke Alley” - an 11-state region in the southeastern United States where the risk of stroke is 34% greater than the general population. This disparity is largely attributable to diet and lifestyle choices and tobacco use. According to the American Stroke Association, “Stroke is a disease that affects the arteries leading to and within the brain.” It is the 5th leading cause of death and a leading cause of disability in the US. The Greater Cincinnati/Northern Kentucky Stroke Study, an ongoing survey by the University of Cincinnati, found that the overall incidence of stroke among the Black and African American populations in our region was about 2/3 higher than for Whites. “A stroke occurs when a blood vessel that carries oxygen and nutrients to the brain is either blocked by a clot or bursts (or ruptures). When that happens, part of the brain cannot get the blood (and oxygen) it needs, so it and brain cells die.”
Dr. Ben Thornton is a neurologist, neurohospitalist, and Medical Stroke Director with Baptist Health. He attended medical school and served his neurology residency at the University of Louisville. Dr. Thornton emphasizes the importance of “primary prevention” or healthy diet and lifestyle changes, which are “more effective and more powerful than any medication a doctor can prescribe.” Lifestyle changes should include smoking cessation and exercise at least 30 minutes per day 3 times per week. He advises finding an exercise you enjoy so that it will get done consistently.
Dr. Thornton specifically mentions two diets proven to be effective in reducing inflammation and preventing atherosclerosis: the Mediterranean diet and the DASH diet. The Mediterranean diet is based on the eating habits of 16 countries bordering the Mediterranean Sea. Because of the many differences between those countries, there is no one standard Mediterranean diet. However, according to the American Heart Association, there are common factors:
The DASH (Dietary Approaches to Stop Hypertension) diet is similar but allows more dairy products and meat.
Regarding treatment of stroke once it has occurred, time is of the essence. IV tPA, or intravenous tissue-type plasminogen activator, is most effectively administered within 90 minutes of stroke occurrence. A catheter to mechanically open the blocked artery is a newer treatment that is best applied within the first 6 hours. TIAs (or Transient Ischemic Attacks) “should be evaluated in hospital for the cause to determine the best diet, lifestyle, or medical treatment including more long-term heart monitoring.” says Dr. Thornton. “We really try to hammer home time-sensitivity, that when you experience symptoms, it is best to call 911 and get to a hospital as quickly as possible, no matter how mild those symptoms may seem.” For symptoms of a stroke, remember FAST: Face Drooping, Arm Weakness, Speech Slurred, Time to Call 911.
Ben Chandler’s work with Foundation for a Healthy Kentucky will continue in the second half of 2020 with “a vigorous program of coronavirus contract tracing” promoted by PSAs. He urges everyone in the city to volunteer to participate or to participate if called upon to do so. “Louisville is a city with wonderful quality and pace of life. Health is the rock that everything is built on in our lives.” Regarding overall health in our community, Ben says social determinants such as location, circumstances, education level, and access to healthy meals can be addressed with more public health investment and policy changes. Black and “African-American productivity in the community affects everyone,” at least economically. “We can improve the quality of life in Louisville if we focus on these things. The numbers are sobering; but there is room for improvement, to move the needle up with conscious decisions.”