Educated African Americans and their Understanding of Hydration for Health

Special Article - Anti Aging

Gerontol Geriatr Res. 2017; 3(1): 1031.

Educated African Americans and their Understanding of Hydration for Health

Britt R¹, Picetti D¹, George M¹, Kumar R¹, Pangle AK¹, Gibson R¹, Thomas BR1,2, Wei JY¹ and Azhar G¹*

¹Department of Geriatrics, Donald W Reynolds Institute on Aging, USA

²Department of Pediatric Neonatology, Arkansas Children’s Hospital, USA

*Corresponding author: Azhar G, Department of Geriatrics, University of Arkansas for Medical Sciences Reynolds Institute on Aging, 4301 West Markham, Little Rock, AR 72205, Arkansas, USA

Received: August 08, 2017; Accepted: August 31, 2017; Published: September 08, 2017

Abstract

Dehydration and over-hydration both play major roles in US healthcare. Due to healthcare disparities among different ethnic groups, we hypothesized there may be knowledge gaps regarding proper hydration among African Americans. We administered an anonymous hydration health survey to community-dwelling African American adults (n=66). Participants were divided into two groups: <50 years old, or =50 years old. Women accounted for 64% of survey participants and 45% of surveyed individuals had a college degree or higher education. Those <50 appeared to have a better understanding of physiological processes associated with hydration (64% vs. 59%). However, while 74% of both groups understood the role of water in waste elimination, approximately 40% of the participants had limited understanding of the importance of water in other physiological functions. The majority of participants in both groups overestimated the fluid loss amount associated with development of clinical dehydration by ~10%. In general, hydration health knowledge was similar between young and older adults, however the older adults appeared to be better informed about heart failure and the use of diuretics. A most concerning knowledge gap was the lack of awareness of the life-threatening consequences of suboptimal hydration by all participants. In summary, we identified significant gaps in current hydration literacy levels in a cohort of African Americans residing in Arkansas. Healthcare professionals and policy makers should design better strategies for increasing health literacy in order to reduce hydration-related morbidity and mortality and improve the quality of life and health of African Americans.

Keywords: Dehydration; Aged; Health literacy; African American

Abbreviations

IRB: Institutional Review Board; IV: Intravenous; UAMS: University of Arkansas for Medical Sciences; US: United States

Introduction

The human body is composed of approximately 60% water, with some vital organs composed of even greater percentages [1,2]. Therefore a proper understanding of the human body includes knowledge that adequate hydration is a fundamental requirement for every organ to function well [1]. An imbalance in adequate fluid intake may create a state of either dehydration or over-hydration [1].

Dehydration is defined as a depletion of total body fluid that disturbs body homeostasis, whether due to excessive fluid loss or decreased fluid intake [1,3]. Excess fluid loss may be the result of illness, exposure to high temperature, exertion with inadequate fluid intake, or due to medications such as diuretics [1,4]. Reduced intake of fluids is a common issue found in the elderly, dementia patients, and nursing home patients [1,5,6]. The elderly population is also at increased dehydration risk due to decrease in the thirst sensation, decrease in renal perfusion, altered sensitivity to anti diuretic hormone, and neurocognitive deficit [6-8]. There are numerous consequences of dehydration among the elderly, including delirium, confusion, infections, falls, and fractures [1,3,9]. Clinically, presentation of dehydration can vary from dizziness and confusion to seizures and death, and physical signs may include sunken eyes, dry axillae, low blood pressure, and delayed capillary refill [10-13]. Additionally, dehydration results in ionic imbalances in the body, the most important of which is sodium. If not corrected within an appropriate amount of time, this can result in potentially fatal outcomes [12]. Dehydration has also been attributed as a major predictor of morbidity and mortality, and is itself the second most common comorbidity, being present in 14% of all hospitalizations [6,14,15].

Over-hydration is a fluid overload condition that may be due to either excessive fluid intake or an organic failure in the body, resulting in disturbance of the body’s homeostasis. Excessive fluid buildup may occur as a result of excess intravenous (IV) fluid administration, blood transfusions, or steroid use [16]. Organ failure such as heart failure, renal failure, or liver failure, or other health conditions such as protein deficiency, may also result in over-hydration [17]. Additionally, excess fluid buildup may itself lead to heart failure or pulmonary edema, increase in blood pressure, seizures, confusion, or sometimes even death [18,19]. Over-hydration may also be a trigger for electrolyte imbalance, particularly in critically ill patients or patients that have recently undergone surgery. Thus, over-hydration is an independent risk factor for morbidity and mortality, especially for individuals with heart failure, acute or chronic renal failure, or those on dialysis [7,20].

Although there is a wealth of information regarding hydration in the clinical setting, one important piece of information is that dehydration and over-hydration, and their consequences, are preventable conditions. Thus, better hydration health literacy may potentially improve clinical outcomes and reduce healthcare costs [21-23]. Due to existing variances in the social determinants of health among different ethnic groups [24-26], we hypothesized there may be knowledge gaps regarding hydration’s role in health among ethnic groups in the state. African Americans are the largest ethnic minority in the state making up 15.4% of the population. Additionally, there is a higher prevalence of hydration-related health conditions among African Americans compared to White, non-Hispanics, such as stroke, cardiovascular disease, and kidney disease [27-29].

Materials and Methods

Study design

This was a cross-sectional study, conducted using an anonymous survey and convenience sample methodology. The questionnaire used in the study was designed to evaluate the health literacy of the local community-dwelling African American population regarding the significance of hydration in health. The survey was comprised of 5 demographic questions and 8 structured hydration-related questions. The questions were designed to evaluate the comprehension of the target population regarding quantity of fluids, importance of fluids and problems associated with dehydration or over-hydration. The study was approved by the Institutional Review Board at University of Arkansas for Medical Sciences (UAMS IRB Protocol #202607).

Method of survey collection

The survey was completed by 66 community dwelling African American adults. Participants were approached in various locations, such as the Reynolds Institute on Aging at UAMS, beauty salons, grocery and videos stores, the UAMS campus, etc. A trained research technician administered the survey to participants. The participants completed the survey by themselves or the research technician read the questions and possible answers to them, and participants indicated the answers verbally. These surveys were conducted in person and were not phone or mail surveys. The survey instrument was immediately collected by the research technician and data was entered into the database for analysis.

Analysis

The SAS Software (Version 9.3, SAS Institute Inc.) was utilized to analyze the results of survey. Categorical variables are presented as counts and percentages that were calculated with PROC FREQ SAS procedure. Responses to questions were compared by group with either the chi-square test or Fisher’s exact test for contingency tables with cells having expected frequencies of 5 or less. The chi-square and Fisher’s exact tests were performed with the PROC FREQ SAS procedure with the options “chisq” and “fisher”. The a cut-off for significance was accepted as p <0.05.

Result

Demographics

Participants were divided into two groups: under 50 years of age (younger group, n=33), or 50 years of age and older (older group, n=33).In the younger group, nearly 50% were between 40 to 49 years of age. In the older group, over 40% were 60 to 69 years of age. Female participants accounted for more than half of each group, averaging 63.6% of the entire study cohort. Individuals with a college degree or higher level of education made up 42.4% of the older group and 48.4% of the younger group, whereas those with a high school diploma or less accounted for only 27.2% and 24.2% of the older and younger groups, respectively. More than 39% of the younger group had an annual household income of $45,000 or more, as did more than 36% of the older group (Table 1).

Table 2: Demographics.



TABLECREATED







Table 2: Demographics.

Importance of hydration

While investigating the survey participants’ knowledge regarding the importance of hydration, we found that the younger group appeared to have a slightly better grasp overall of the physiological processes associated with hydration. However, while both groups (younger: 75.8% and older: 72.7%) understood the importance of water for body waste elimination, more than 40% of the survey participants had limited understanding regarding the importance of adequate fluid intake for other physiological functions in the body (Figure 1A).

Figure 1: Survey participants were asked about A) the physiologic processes associated with water, and B) the % of water loss at which the signs and symptoms of dehydration first develop. 1A: Waste elimination was the only physiologic function adequately recognized by both groups (??, p=0.05). 1B: The majority of subjects showed a lack of knowledge regarding the minimal level of water loss at which the symptoms of dehydration could potentially manifest (**, p =0.05).

    

    
    

    

    Figure 1:  Survey participants were asked about A) the physiologic processes
associated with water, and B) the % of water loss at which the signs and
symptoms of dehydration first develop. 1A: Waste elimination was the only
physiologic function adequately recognized by both groups (??, p=0.05). 1B:
The majority of subjects showed a lack of knowledge regarding the minimal
level of water loss at which the symptoms of dehydration could potentially
manifest (**, p =0.05).

In addition to the physiologic necessities of hydration in the body, we assessed the knowledge of our target population regarding fluid loss from the body. There was a significant knowledge gap regarding the amount of fluid loss required for symptom of dehydration to become apparent and 70% or more of the respondents in both groups over or underestimated this value (p <0.001). Approximately 25% of the older aged individuals selected the appropriate answer of 3-4% fluid loss being associated with symptomatic dehydration (Figure 1B).

Recognition of signs and symptoms of dehydration

We found that the average knowledge deficit regarding signs and symptoms of dehydration was more than 40% in both age groups. The most widely recognized signs and symptoms of dehydration was dizziness, for which the older group appeared better informed (72.7% vs. 57.6%). The second and third common signs of dehydration selected by young and older participants were fainting episodes (57.6% vs. 45.4%) and low blood pressures (57.6% vs. 54.6%) (Figure 2A).

Figure 2: Participants were asked to consider the different signs and symptoms that might appear during periods of A) dehydration and B) overhydration. 2A: Dizziness was the only symptom adequately recognized by the older group (?, p =0.05). Lack of knowledge: *= 1group, **=2 groups, p =0.05. 2B: Ankle swelling was the only symptom adequately recognized by both groups (??, p =0.05). Lack of knowledge: *= 1group, **=2 groups, p =0.05.

    

    
    

    

    Figure 2:  Participants were asked to consider the different signs and
symptoms that might appear during periods of A) dehydration and B) overhydration.
2A: Dizziness was the only symptom adequately recognized by the
older group (?, p =0.05). Lack of knowledge: *= 1group, **=2 groups, p =0.05.
2B: Ankle swelling was the only symptom adequately recognized by both
groups (??, p =0.05). Lack of knowledge: *= 1group, **=2 groups, p =0.05.

Other relevant and often serious signs and symptoms of dehydration were under-appreciated by both young and older adults and these included confusion (both groups: 45.4%), increase in heart rate (42.4% vs. 18.2%), excessive sleepiness (both groups: 30.3%), death (24.2% vs. 21.2%) and seizures (18.2% vs. 9.1%), (Figure 2A).

Recognition of signs and symptoms of over-hydration

Swelling of ankles was the most widely recognized marker of over-hydration, as it was correctly selected by 81.8% of individuals, followed by high blood pressure by approximately 60% of both young and older adults (Figure 2B). In general, the older group appeared to be equally or better informed with regards to most of the signs and symptoms of over-hydration as compared to the younger group, including shortness of breath (57.6% vs. 48.5%), death (42.4% vs. 30.3%), confusion (both groups: 21.2%) and seizures (18.2% vs. 15.1%). The younger group appeared to have greater understanding than the older group about high blood pressure (60.6% vs. 54.6%). On average, 40% or more of the entire study cohort failed to recognize 5 of the 6 signs and symptoms of over-hydration that were addressed in the survey (Figure 2B).

Conditions associated with dehydration and overhydration

We also asked survey respondents about health conditions and iatrogenic causes of dehydration and over-hydration (Figure 3). The older group also seemed to have an equal or greater understanding about the many causes of dehydration such as excessive perspiration (both groups: 54.6%), overuse of diuretics (66.7% vs. 45.4%), diarrhea (63.6% vs. 57.6%), and vomiting (57.6% vs. 51.5%). Interestingly, fever was under appreciated and less than 25% of individuals in either age group selected it as a cause of dehydration, even though it is a very common condition (Figure 3A). The older adults were also better informed compared with younger adults about over-hydration associated with heart failure (69.7%, vs. 48.5%), kidney failure (72.7% vs. 63.6%), protein deficiency (27.3%, vs. 18.2%), and steroid treatment (27.3%, vs. 18.2%). However, the younger group correctly selected over-hydration as a problem related to liver failure (48.5% vs. 30.3%), and excess IV fluids (36.4% vs. 18.2%) whereas there was a knowledge deficit exhibited in these areas by the older adults (Figure 3B).

Figure 3: Survey participants were asked to select which condition might lead to A) dehydration or B) over-hydration. 3A: Fever was the only significantly under-recognized cause for both younger and older participants (**, p =0.05). 3B: Kidney failure and heart failure were the only adequately recognized causes of over-hydration among either group (?= 1group, ??=2 groups, p =0.05). Lack of knowledge: *= 1group, **=2 groups, p =0.05.

    

    
    

    

    Figure 3:  Survey participants were asked to select which condition might lead
to A) dehydration or B) over-hydration. 3A: Fever was the only significantly
under-recognized cause for both younger and older participants (**, p =0.05).
3B: Kidney failure and heart failure were the only adequately recognized
causes of over-hydration among either group (?= 1group, ??=2 groups, p
=0.05). Lack of knowledge: *= 1group, **=2 groups, p =0.05.

Discussion

Researchers over the centuries have identified the key role of water in the human body. In light of the high mortality and morbidity associated with imbalances in hydration in the elderly, this topic remains relevant for health and education [14]. Because of the enormous magnitude of healthcare disparity experienced by African Americans, we decided to conduct a survey to assess their hydration health literacy. Therefore, we attempted to identify the current level of hydration health knowledge, specifically in the African American community.

Our survey results demonstrated an overall dearth of knowledge regarding the common signs and symptoms as well as conditions associated with an imbalance of hydration among both young and older individuals. This knowledge gap was particularly evident with under-recognition of a common condition such as fever as a cause of dehydration. Fever is a very common symptom, occurring with high frequency in community-dwelling adults and hospitalized patients. It may occur secondary to a variety of conditions or unknown etiologies and a lack of awareness may predispose individuals to dehydration [30]. The three most common signs and symptoms of dehydration recognized by both the age groups included dizziness, fainting episodes and low blood pressure. However, the more uncommon but serious consequences of dehydration and over-hydration, such as seizures or death, were significantly underappreciated by the respondents. Additionally, the information deficit regarding how little fluid loss may be required before dehydration symptoms occurred was alarming. As little as 3% to 4% loss of body fluids can lead to the beginning signs of dehydration and some studies have reported that even a loss of only 1% to 2% may impair cognition, making even mild dehydration of the utmost concern for elderly individuals [31].

Dehydration has been independently identified as an “ambulatory care-sensitive condition” [32,33]. A report from 2015 highlighted that ~$1.4 billion were spent to treat elderly patients hospitalized for dehydration [21]. The elderly are at risk for dehydration due to a variety of age-related changes including less fluid intake due to urinary incontinence, ambulation issues, as well as decreases in dexterity and cognition [34,35]. Physiological degenerative changes in the hypothalamic thirst center and the peripheral baroreceptors occur during aging which not only reduces the sensation of thirst but also the ability to respond to hypovolemia [33,36]. These agerelated changes are compounded by the fact that the signs and symptoms of dehydration in the elderly are often vague and might only be compromised of fatigue and mental confusion which could be attributed to aging or other co-morbid conditions.

Dehydration is also of concern for younger individuals, as it may increase the risk of developing certain health conditions, or may exacerbate current conditions, leading to increased treatment costs and loss of productivity [37]. Additionally, loss of productivity due to illness-related work absences is an indirect burden to the current economic structure. According to a 2013 report published by the Arkansas Department of Health, the cost to treat seven chronic conditions (cancer, asthma, diabetes, hypertension, stroke and mental health problems) in Arkansas was $2.6 billion, and the loss of productivity was $11.3 billion [38].

Health literacy regarding over-hydration was approximately equal between the groups. While most of our survey participants appeared to understand that heart failure and renal failure may lead to excess fluid retention, <30% of participants were aware of other medical conditions that may increase fluid retention. Additionally, other than swollen ankles, this study population appeared to have significant knowledge deficits regarding the effects of over-hydration. Over-hydration is not only a consequence of heart or renal failure, but is also due to iatrogenic intravenous fluids administered in hospitalized patients. Moreover, a common complication of overhydration is precipitation of heart failure, which occurs at a lower threshold and greater frequency in the elderly [17]. An increase of more than 7% positive fluid balance can increase morbidity and mortality independently of other factors [18,39]. Reducing hydrationrelated complications and improving quality of life will ultimately reduce the burden on the healthcare system and economic structure of the country [21].

Hydration-related health conditions are prevalent in African Americans [17,27,28]. Stroke is one of the leading causes of morbidity and mortality among African Americans in the US [27]. In 2013, the African American/Caucasian mortality ratio for stroke was 3.7 in men between 45 to 54 years of age [28]. Additionally, a higher prevalence of cardiovascular conditions has been reported in African Americans [27]. This is of great concern to us, as Arkansas is one of 5 states in the US that form the cardiovascular disease belt, and one of 8 states that form the stroke belt [40]. Furthermore, both dehydration and over-hydration are strong contributors to renal diseases. US kidney disease statistics showed that 17% African Americans developed chronic kidney disease from 1999 – 2012, 3% higher than the Caucasian population [29]. The higher prevalence of these health conditions among the African American population is part of a larger trend noted by the Agency for Healthcare Research and Quality, who reported that African Americans had the highest number of potentially avoidable hospitalizations [41].

Hydration-related health conditions are prevalent in African Americans [17,27,28]. Stroke is one of the leading causes of morbidity and mortality among African Americans in the US [27]. In 2013, the African American/Caucasian mortality ratio for stroke was 3.7 in men between 45 to 54 years of age [28]. Additionally, a higher prevalence of cardiovascular conditions has been reported in African Americans [27]. This is of great concern to us, as Arkansas is one of 5 states in the US that form the cardiovascular disease belt, and one of 8 states that form the stroke belt [40]. Furthermore, both dehydration and over-hydration are strong contributors to renal diseases. US kidney disease statistics showed that 17% African Americans developed chronic kidney disease from 1999 – 2012, 3% higher than the Caucasian population [29]. The higher prevalence of these health conditions among the African American population is part of a larger trend noted by the Agency for Healthcare Research and Quality, who reported that African Americans had the highest number of potentially avoidable hospitalizations [41]. health literacy as compared to Caucasians [26]. While the population of African Americans in this study tended to be well educated, their hydration health literacy was found to be significantly insufficient, suggesting that the general population of African Americans may have even greater hydration health literacy deficiencies. Additionally, Kenney, et al. reported the prevalence of inadequate hydration among US children and disparities by gender and race/ethnicity, discovering that African American children are more likely to be under-hydrated [49]. However, studies have shown that increased health literacy can improve clinical outcomes and reduce the healthcare burden, thus reducing the economic health burden [21,42,45].

Although there is considerable literature on the futility of artificial feeding and hydration towards the end-of-life and the complications associated with artificial hydration in patients who are terminally ill, there is a dearth of data in the African American population [50-55]. A few studies have observed that African American healthcare providers and caregivers tend to request continued hydration and feeding for terminally ill patients more than Caucasians [50, 53-55]. Hydration needs of the palliative care and hospice patients is an important area that requires targeted research and education especially in people of different ethnicities, social and cultural backgrounds [53,54]. Healthcare providers need to realize the important contributions they can make towards improving the quality of care and health span of their patients through enhancing education and hydration health literacy [56].

Limitations of Study

This study cannot be generalized to all ethnicities or rural areas. Our study included only the African American community of Central Arkansas. We did not include in this analysis the fluid preferences of the participants. Our study was designed for understanding the hydration needs of relatively healthy or ambulatory patients and did not address hydration issues towards the end-of-life, which is a complex topic and will require a separate investigation. Additionally, these study participants tended to be well-educated, as <70% had attended college at some point, a nearly 18% increase over the national average for African Americans [57].

Summary and Future Directions

Dehydration and over-hydration are important health care issues. We have identified significant gaps in the current level of hydration literacy in the African American population residing in the South Central region of the US. Although our numbers are very small, we think that, regardless of any statistical significance, these gaps in health literacy are important and clinically relevant. Healthcare professionals and policy makers need to design better strategies for increasing hydration health literacy to potentially reduce morbidity and mortality in African Americans secondary to hydration-related medical conditions.

Acknowledgment

This study was supported in part by the Claude D. Pepper Older American Independence Center grant, National Institute on Aging (1P30AG28718) awarded to University of Arkansas for Medical Sciences. Dr. Raveet Kumar is a medical doctor currently residing in Little Rock, Arkansas.

References

  1. Popkin BM, D’anci KE, Rosenberg IH. Water, hydration, and health. Nutr Rev. 2010; 68: 439-458.
  2. Perlman H. The water in you. Water properties: The water in you (Water Science School). The USGS Water Science School. 2016.
  3. Hooper L, Bunn D, Jimoh FO, Fairweather-Tait SJ. Water-loss dehydration and aging. Mech Ageing Dev. 2014; 136: 50-58.
  4. Lancaster KJ, Smiciklas-Wright H, Heller DA, Ahern FM, Jensen G. Dehydration in black and white older adults using diuretics. Ann Epidemiol. 2003; 13: 525-529.
  5. Mentes JC, Wang J. Measuring risk for dehydration in nursing home residents: evaluation of the dehydration risk appraisal checklist. Res Gerontol Nurs. 2011; 4: 148-156.
  6. Rowat A, Graham C, Dennis M. Dehydration in hospital-admitted stroke patients. Stroke. 2012; 43: 857-859.
  7. El-Sharkawy AM, Sahota O, Maughan RJ, Lobo DN. The pathophysiology of fluid and electrolyte balance in the older adult surgical patient. Clin Nutr. 2014; 33: 6-13.
  8. Weinstein JR, Anderson S. The aging kidney: physiological changes. Adv Chronic Kidney Dis. 2010; 17: 302-307.
  9. Schols JM, De Groot CP, Van Der Cammen TJ, Rikkert MO. Preventing and treating dehydration in the elderly during periods of illness and warm weather. JNHA. 2009; 13: 150-157.
  10. Grubina R, Klocke DL. 47-year-old woman with dizziness, weakness, and confusion. In Mayo Clinic Proceedings. 2011; 86.
  11. Figueroa JJ, Basford JR, Low PA. Preventing and treating orthostatic hypotension: as easy as A, B, C. Clev Clin J Med. 2010; 77: 298-306.
  12. Nardone R, Brigo F, Trinka E. Acute symptomatic seizures caused by electrolyte disturbances. J Clin Neurol. 2016; 12: 21-33.
  13. Okuyama M, Nishida M. The physical signs of impending dehydration among elderly people in nursing homes: The association with axillary skin temperature, humidity, intraoral moisture content, and salivary components. Nihon Ronen Igakkai zasshi. Jpn J Geriatr. 2016; 53: 379-386.
  14. El-Sharkawy AM, Watson P, Neal KR, Ljungqvist O, Maughan RJ, Sahota O, et al. Hydration and outcome in older patients admitted to hospital (The HOOP prospective cohort study). Age Ageing. 2015; 44: 943-947.
  15. Serra-Majem L, Nissensohn M. Beverage Consumption Habits around the World: The Burden of Disease Attributable to Hydration. Nutrients. 2016; 8: 738.
  16. Stanbury RM, Graham EM. Systemic corticosteroid therapy—side effects and their management. Br J Ophthalmol. 1998; 82: 704-708.
  17. Claure-Del Granado R, Mehta RL. Fluid overload in the ICU: evaluation and management. BMC Nephrol. 2016; 17: 109.
  18. Malbrain ML, Marik PE, Witters I, Cordemans C, Kirkpatrick AW, Roberts DJ, et al. Fluid overload, de-resuscitation, and outcomes in critically ill or injured patients: a systematic review with suggestions for clinical practice. Anaesthesiol Intensive Ther. 2014; 46: 361-380.
  19. Boyd JH, Forbes J, Nakada TA, Walley KR, Russell JA. Fluid resuscitation in septic shock: a positive fluid balance and elevated central venous pressure are associated with increased mortality. Crit Care Med. 2011; 39: 259-265.
  20. Besen BA, Gobatto AL, Melro LM, Maciel AT, Park M. Fluid and electrolyte overload in critically ill patients: an overview. World J Crit Care Med. 2015; 4: 116-129.
  21. Frangeskou M, Lopez-Valcarcel B, Serra-Majem L. Dehydration in the elderly: A review focused on economic burden. J Nutr Health Aging. 2015; 19: 619-627.
  22. Bailey SC, Brega AG, Crutchfield TM, Elasy T, Herr H, Kaphingst K, et al. Update on health literacy and diabetes. Diabetes Educ. 2014; 40: 581-604.
  23. Kindig DA, Panzer AM, Nielsen-Bohlman L. Health literacy: a prescription to end confusion. National Academies Press. 2004.
  24. Picetti D, Foster S, Pangle AK, Schrader A, George M, Wei JY, et al. Hydration Health Literacy in the Elderly. Nutr Healthy Aging. 2017; 4.
  25. Chen J, Vargas-Bustamante A, Mortensen K, Ortega AN. Racial and ethnic disparities in health care access and utilization under the Affordable Care Act. Med Care. 2016; 54: 140-146.
  26. Rikard RV, Thompson MS, McKinney J, Beauchamp A. Examining health literacy disparities in the United States: a third look at the National Assessment of Adult Literacy (NAAL). BMC Public Health. 2016; 16: 975.
  27. Lee H, Kershaw KN, Hicken MT, Abdou CM, Williams ES, Rivera-O’Reilly N, et al. Cardiovascular disease among black Americans: comparisons between the US Virgin Islands and the 50 US states. Pub Health Rep. 2013; 128: 170-178.
  28. Howard VJ. Reasons underlying racial differences in stroke incidence and mortality. Stroke. 2013; 44: S126-S128.
  29. Kidney Disease Statistics for the United States. National Institute of Diabetes and Digestive and Kidney Diseases. US. Department of Health and Human Services. 2016.
  30. Bleeker-Rovers CP, van der Meer JW, Oyen WJ. Fever of unknown origin. In Seminars in nuclear medicine. 2009; 39: 81-87.
  31. Riebl SK, Davy BM. The hydration equation: Update on water balance and cognitive performance. ACSM’s Health Fitness J. 2013; 17: 21-28.
  32. Xiao H, Barber J, Campbell ES. Economic burden of dehydration among hospitalized elderly patients. Am J Health Syst Pharm. 2004; 61: 2534-2540.
  33. Mkanta WN, Chumbler NR, Yang K, Saigal R, Abdollahi M. Cost and predictors of hospitalizations for ambulatory care-sensitive conditions among Medicaid enrollees in comprehensive managed care plans. Health Serv Res Managerial Epidemiol. 2016; 3: 2333392816670301.
  34. Briasoulis A, Silver A, Yano Y, Bakris GL. Orthostatic hypotension associated with baroreceptor dysfunction: treatment approaches. J Clin Hypertens. 2014; 16: 141-148.
  35. Marshall KA, Burson R, Gall K, Saunders MM. Hospital admissions for malnutrition and dehydration in patients with dementia. Home Healthc Now. 2016; 34: 32-37.
  36. Stachenfeld NS, DiPietro LO, Nadel ER, Mack GW. Mechanism of attenuated thirst in aging: role of central volume receptors. Am J Physiol Regul Integr Comp Physiol. 1997; 272: R148-R157.
  37. El-Sharkawy AM, Sahota O, Lobo DN. Acute and chronic effects of hydration status on health. Nutr Rev. 2015; 73: 97-109.
  38. Arkansas’s Big Health Problems and How We Plan to Solve Them: State Health Assessment and Improvement Plan. 2013. 1st ed. Vol. 1. Little Rock, AR: Arkansas Dept. of Health, Office of Health, Communications and Marketing. 2013.
  39. Tsai YC, Chiu YW, Tsai JC, Kuo HT, Hung CC, Hwang SJ, et al. Association of fluid overload with cardiovascular morbidity and all-cause mortality in stages 4 and 5 CKD. Clin J Am Soc Nephrol. 2015; 10: 39-46.
  40. Benjamin EJ, Blaha MJ, Chiuve SE, Cushman M, Das SR, Deo R, et al. Heart disease and stroke statistics—2017 update: a report from the American Heart Association. Circulation. 2017; 135: e146-603.
  41. Potentially Avoidable Hospitalizations. Agency for Healthcare Research and Quality. US Department of Health and Human Services. 2016.
  42. Villablanca AC, Warford C, Wheeler K. Inflammation and cardiometabolic risk in African American Women is reduced by a pilot community-based educational intervention. J Women’s Health. 2016; 25: 188-199.
  43. Schonlau M, Martin L, Haas A, Derose KP, Rudd R. Patients’ literacy skills: more than just reading ability. J Health Commun. 2011; 16: 1046-1054.
  44. Social Determinants of Health. US Department of Health and Human Services. Office of Disease Prevention and Health Promotion. 2017.
  45. Baker DW, Gazmararian JA, Williams MV, Scott T, Parker RM, Green D, et al. Functional health literacy and the risk of hospital admission among Medicare managed care enrollees. Am J Pub Health. 2002; 92: 1278-1283.
  46. Teno JM, Gozalo P, Mitchell SL, Tyler D, Mor V. Survival after multiple hospitalizations for infections and dehydration in nursing home residents with advanced cognitive impairment. JAMA. 2013; 310: 319-320.
  47. Williams DR, Mohammed SA, Leavell J, Collins C. Race, socioeconomic status, and health: complexities, ongoing challenges, and research opportunities. Ann N Y Acad Sci. 2010; 1186: 69-101.
  48. Havranek EP, Mujahid MS, Barr DA, Blair IV, Cohen MS, Cruz-Flores S, et al. Social determinants of risk and outcomes for cardiovascular disease. Circulation. 2015; 132: 873-898.
  49. Kenney EL, Long MW, Cradock AL, Gortmaker SL. Prevalence of inadequate hydration among us children and disparities by gender and race/ethnicity: National Health and Nutrition Examination Survey, 2009–2012. Am J Pub Health. 2015; 105: e113-118.
  50. Mebane EW, Oman RF, Kroonen LT, Goldstein MK. The Influence of Physician Race, Age, and Gender on Physician Attitudes towards Advance Care Directives and Preferences for End-Of-Life Decision-Making. J Am Geriatr Soc. 1999; 47: 579-591.
  51. Yamaguchi Y, Mori H, Ishii M, Okamoto S, Yamaguchi K, Iijima S, et al. Interview and questionnaire based surveys on elderly patients’ wishes about artificial nutrition and hydration during end-of-life care. Geriatr Gerontol Int. 2016; 16: 1204-1210.
  52. Davies A, Waghorn M, Johnsen S. O-6 A cluster randomised trial of clinically assisted hydration at the end of life. BMJ Support Palliat Care. 2017; 7: A2.
  53. Crawley L, Payne R, Bolden J, Payne T, Washington P. Palliative and endof- life care in the African American community. JAMA. 2000; 284: 2518-2521.
  54. Mitchell BL, Mitchell LC. Review of the literature on cultural competence and end-of-life treatment decisions: The role of the hospitalist. J Natl Med Assoc. 2009; 101: 920-926.
  55. Johnson J, Hayden T, True J, Simkin D, Colbert L, Thompson B, et al. The Impact of Faith Beliefs on Perceptions of End-of-Life Care and Decision Making among African American Church Members. J Palliat Med. 2016; 19: 143-148.
  56. Kavouras SA, Arnaoutis G, Makrillos M, Garagouni C, Nikolaou E, Chira O, et al. Educational intervention on water intake improves hydration status and enhances exercise performance in athletic youth. Scand J Med Sci Sports. 2012; 22: 684-689.
  57. Ryan C, Bauman K. Educational attainment in the United States: 2015. United States Census Bureau. 2016.

Citation: Britt R, Picetti D, George M, Kumar R, Pangle AK, Gibson R, et al. Educated African Americans and their Understanding of Hydration for Health. Gerontol Geriatr Res. 2017; 3(1): 1031.