From the Heart

In elementary school, Latrice Goosby Landry, A02, N04, N09, M12, thought pills were a normal part of any adult's dinner, like butter on cornbread.

"Everyone in my family had some sort of low-level chronic illness—mainly high blood pressure—that they were treating with medication," she recalls. "They accepted it as inevitable. So I did, too. I just figured that one day I'd probably have the same thing."

As she grew older and started thinking about medicine as a possible career, Landry noticed her family seemed to have more than its fair share of poor health. Her grandmother had died of a brain aneurysm at 43. Her mother, aunts and sister had all experienced at least one miscarriage. Births were always premature, often dangerously so. No one asked why, Landry noticed. That's just how it was.

In fact, her family's experience isn't unusual. Forty percent of black Americans suffer from hypertension, a condition that can lead to more severe health problems, especially if untreated. Consequently, African Americans suffer heart attacks, strokes, kidney failure, vision problems, poor birth outcomes and premature death in far higher numbers than any other race or ethnic group. According to the Centers for Disease Control and Prevention, an American has a 30 percent greater chance of dying from heart disease—already the nation's leading cause of death—if he is black.

While researchers have been aware of the race-related disparity in heart disease figures for decades, isolating the cause is a politically sensitive and scientifically complex task. Investigators must round up all the usual suspects—genetics, diet, economics, culture, plus social factors such as racism—and take a hard look at how they interact and influence one another. It is precise and painstaking work, but Landry welcomes the challenge. At 27, with a nearly complete Ph.D. in nutritional epidemiology from the Friedman School and the first year of Tufts Medical School under her belt, she is involved in new research that may reveal why African Americans are more prone to heart disease than Caucasions.

For the last four years, her thesis has required her to shuttle back and forth from the laboratory in Boston's bustling Chinatown to a converted strip-mall in Jackson, Mississippi, where she has joined the staff of the Jackson Heart Study, the largest ever single-site investigation of cardiovascular disease in African Americans.

Since 2000, the Jackson Heart Study has established a cohort of 5,302 black residents from three nearby counties where rates of heart disease are among the highest in the country. A staff of prominent doctors, nurses and students, including Landry, have spent several years gathering and analyzing genetic, nutritional and general lifestyle data from these participants, in an attempt to identify the many risk factors for this particular population.

Landry's specific research examines the interactions between genes and nutrients and a variety of fatty acids, from "good" mono-unsaturated fats like the kind found in olive oil to "bad" trans-fats once common in margarine and vegetable shortening and now banned from many restaurant menus.

"We've found that depending on what genetic inheritance you have, fatty acids have a different impact on your health," Landry explains. "So, you might be more likely to get cardiovascular disease if you have some genes rather than others. Some drugs might work on you, and some may not."

Once the study is further along, there is a possibility that her results may be used to build a nutrition intervention, a strategic plan aimed at a particular group to reduce that group's harmful eating habits. While such a plan might begin with Jackson, where heart disease is rampant, Landry hopes the study will eventually reveal how some African Americans might be able to prevent the onset of heart disease by following a particular diet.

From 'Food Police' to Nutrition Scholar

Landry, a bubbly, resourceful woman with a warm smile, has been welcomed by her fellow researchers in Jackson as one of their own. Though she was born and raised in suburban Maryland, she feels at home in the deep South, and it shows. Visits to her grandmother in Alabama steeped her in the culture, especially the strong ties to food, faith and family.

"I was always attracted to the idea of following rules," she says with a smile. "Even as a very young child, I took rules very seriously. For example, I made sure we went to church on a regular basis."

Around the same time, Landry also decided that her family should observe the nutritional guidelines laid out in the USDA's food pyramid. She used it to supervise family mealtimes, banishing cake and cookies. Her parents coined a half-joking nickname for her: the Food Police.

As a pre-med major at Tufts, Landry enrolled in a graduate class in primary care at the Friedman School. The class taught nutrition students the basic clinical knowledge needed to deal with famine and HIV in refugee camps and international crisis situations. Landry was fascinated by how many health problems could be prevented by proper nutrition. In 2002, she was accepted to the Food Policy and Applied Nutrition master's program at Friedman, with a specialization in nutritional intervention.

Landry had always assumed a genetic risk factor predisposed people in her family to develop high blood pressure. Her sister Cherita had been diagnosed with hypertension in her 20s, an unusually young age. Once they had the condition, they were advised by doctors to cut salt and fat. But Landry, who maintained a fairly strict diet, had not had any health issues, at least so far. Was it possible some combination of bad genes and the wrong food was the smoking gun? Could the right food prevent the onset of the disease altogether?

"I knew I had to become a doctor to understand the medicine, but I also wanted to continue with research in the nutritional field," says Landry, who sought academic counsel from University Professor Irwin Rosenberg, M.D., then the dean of the Friedman School. Though Tufts offered no formal program that coupled a Ph.D. at the Friedman School with an M.D., he encouraged her to see if it could be done. Landry convinced deans at both schools that that if anyone could meet such an ambitious goal, she could.

"That's one of the remarkable things about Tufts. If you have a good idea, they'll help you make it happen," says Landry.

Professor Katherine Tucker, Ph.D., Landry's thesis advisor and a senior scientist at the Jean Mayer USDA Human Nutrition Research Center on Aging, saw that Landry's talents extended beyond laboratory research and introduced her to the Jackson Heart Study.

A week before her med school board exams, she got an urgent call from her mother. Cherita, then 25 weeks pregnant, was being prepped for an emergency C-section after tests revealed her fetus had stopped growing. Landry knew her sister's hypertension was to blame. Only weeks before her blood pressure had spiked at a stroke-level high of 220 over 100—most probably the point at which the placenta began to decline.

At birth, her niece weighed just 13 ounces, less than three sticks of butter. After months of intensive care, the baby began to thrive, but Landry was shaken. Her family had been through tremendous strain. Medical research had to offer something better.

Getting to the Heart of the Problem

Nearly everything that is known about heart disease and what causes it -- high blood pressure, high blood cholesterol, smoking, obesity, diabetes and physical inactivity -- comes from a landmark experiment begun in Framingham, Mass., in 1948. The Framingham Heart Study, which surveyed three generations of Yankee stock, is considered one of the most successful clinical inquiries of all time.

Fewer than ten blacks took part, but researchers claimed that the study's results applied to everyone, regardless of race. While the known risk factors may apply across the board, curiously higher levels of heart disease for blacks, especially Southerners, suggest the portrait is more complex.

"The question that arose in any academic conference, in any cardiologist meeting, was always, do the results in Framingham apply to non-Caucasian Americans? Are there unique aspects for African Americans, particularly in the South?" says Herman A. Taylor, M.D., head of the Jackson Heart Study. He and his fellow researchers are the first to focus on the complex interplay of nutritional, genetic and socio-economic factors in a sizeable African-American population.

Structurally, the Jackson Heart Study is similar to the Framingham one. But the Jackson study also monitors social stresses that may be unique in their degree and effect on the black, Southern population. These could include perceived discrimination, cultural differences such as religious faith or regional factors like high unemployment rates.

According to Taylor, the Jackson data has revealed some interesting differences from the Framingham study. For example, a person who is likely to develop heart disease is also likely to have multiple risk factors—he might not only suffer from high blood pressure, but be overweight, a smoker or diabetic.

In African Americans, however, the prevalence for multiple risk factors is extraordinarily high, and the factors themselves are slightly different from those seen in the white population. While whites at risk for cardiovascular disease typically have high triglyceride levels, African Americans tend to have a combination of truncal obesity, hypertension and low HDL, the "good" cholesterol.

"That's surprising in some ways," says Taylor. "Historically, it's been thought that if there's anything good about the risk profile for African Americans, it's that they have high HDL levels, and that protects them from having even more cardiovascular disease than they might otherwise have had. And there's old data to suggest that's true—that high levels of HDL were common in African Americans and therefore they were protected against heart disease. In the Jackson Heart Study, we have found that's not the case."

A Matter of Trust

In 2007, Landry remembers calling several of the study participants for a follow up visit. One of the men declined to return. He claimed that taking part was too expensive.

But it's free, she told him.

"He said, 'No, you all referred me to a doctor, and now I've got to take medicine,'" says Landry. "That was his perception—that there was an associated cost with the study. But of course, it's our responsibility as medical people to refer someone if we find they have a condition that requires treatment."

Clinical trials that focus on African-American populations, particular in the South, have a burden of responsibility to bear ever since Alabama's infamous Tuskegee Syphilis Study, which, between 1932 and 1972, led almost 400 poor, black sharecroppers infected with the disease to believe they were being treated when in fact they were not.

Whether Tuskegee's legacy has permanently affected African-American trust of the medical community is a matter of debate. A 2008 study by Johns Hopkins suggested that blacks are willing to participate in trials, but are more fearful than whites that they'll be treated as guinea pigs. Donna Antoine-Lavigne, Ph.D., coordinator for the study's community outreach and partnership office, agrees there is some distrust, and emphasizes the importance of a tight bond between the public and the study's administration.

"It's not that black people don't want to be involved in clinical trials," she says, "but certain conditions have to be in place."

The Jackson Heart study has been careful to meet those conditions, drawing in community support and participation from the very beginning. Each of the study's committees includes two local residents, who help guide how the data will be used to benefit the study participants and the wider public. Volunteers suggest and carry out public programs such as weight loss initiatives and cooking demonstrations.

"Trust, truth and honesty," were the study's watchwords, according to Francis Henderson, the study's deputy director. Most participants wanted to be informed immediately if they had a medical condition.

"They wanted black doctors and researchers. It was important that the people on the staff look like them. Most importantly, though, they wanted to know they would be listened to."

With Grace and Gusto

The Kentucky-born mystery writer Sue Grafton said that as a Southern woman, she was taught two things: "Never call attention to yourself, and never make anybody uncomfortable."

It's excellent advice for an aspiring physician who wants to get the most out of the patient-doctor experience, and Landry follows it to the letter. Her voice is one of her greatest assets. Experience and travel abroad and in the U.S. has helped her cultivate an accent that she alters to suit the company and situation—anything from a brisk Boston clip to a leisurely Alabama stroll.

In an interview with one of the Jackson Heart Study participants, Landry senses the woman's slight reluctance to open up about her eating habits. With a bit of conversation about the weather and local restaurants, and a polite sprinkling of "yes, ma'ams" and "no, ma'ams," Landry easily establishes a common language of graciousness. In short order, her subject is smiling and talking about buffet dinners, barbecued chicken and her ongoing struggle for weight loss, which she knows is important if she wishes to stay healthy.

Her clinical experiences in Jackson and abroad have taught her, she explains, that you have to listen to people if you're going to discover how to treat them. Doctors need to understand that circumstances might be different for some patients, and maybe if they asked a few more questions, they'd get at something essential.

"An African American from the South might use different words than a Northerner to describe an illness," she says. "In some parts of the South, people still refer to diabetes as "the sugar." As in 'I've got a touch of the sugar.' You have to be sensitive to these things." Taylor and the others on staff at the Jackson Heart study value her delicate touch as much as her research.

"Latrice is such a sweet, gracious individual that you are sometimes taken aback by how brilliant she is," he says. "Her work is outstanding, and really poises her for a position of leadership in the field. If I had 10 more like her, I could retire."

But Landry says it's simple stubbornness.

"You remember Ashley's wife, Melanie in Gone with the Wind?" she says, laughing. "When I was young, I wanted to be just like her, because she was so sweet and unselfish and gracious with everyone. But I realized I had a lot more in common with Scarlett. When someone tells me I can't do something, I become twice as determined to do it."