Clearing the Cholesterol Confusion

This article is written in response to the opinions expressed in social media that any amount of cholesterol in blood is safe and good for the body. Such playing to the gallery with half-truths is dangerous and misleading.

Let us talk facts:

1.Yes, cholesterol is needed by the body for its various functions, but that amount need not be large. For example, when we are born our LDL cholesterol is as low as 40 to 50 mg%, but enough for our rapid brain and cellular development.

2. Yes, most of our body’s cholesterol is made in the liver. But liver can make more of it if we have faulty genes, or if our diet is high in trans-fats and saturated fats, and if we are sedentary or stressful.

3. Thus some people will have extra cholesterol beyond what is needed by the body

4. Is excess cholesterol harmful?

5. The simple answer is: anything in excess is harmful, just as

    Blood pressure is required for blood to flow in our arteries, but excess BP

(hypertension) is harmful.

    Sugar in blood is required for energy but excess sugar (diabetes) is harmful.

6. So, is high amount of cholesterol in blood related to heart disease?

7. A type of cholesterol in blood is called LDL cholesterol: in people in whom it is genetically high-above 190 mg%, it is the direct cause of fatty deposits in arteries called atherosclerosis- the basis of coronary heart disease

8. In most other people high cholesterol is a RISK FACTOR, increasing the chances of disease by interacting with other RISK FACTORS like hypertension, diabetes, smoking, physical inactivity, stress, lack of sleep, unhealthy diet etc.

9. These risk factors cause injury and inflammation of the inner linings of arteries making it sticky so that cholesterol can easily enter the linings and cause fatty deposits.

10. Higher the levels of LDL and other types of cholesterol, greater its ingress into the inflamed lining of arteries.

11. Studies done on more than 2 million people with over 20 million person-years of follow-up and over 1,50,000 cardiovascular events demonstrate a remarkably consistent association between the amount of LDL-C in the blood along with the duration for which the body is exposed to it, on one hand and the risk of atherosclerotic disease like coronary heart disease, on the other.

12. Conversely, reducing or correcting it (whether by lifestyle changes alone or along with cholesterol lowering drugs like statins) reduces the chances of disease, whatever the initial cholesterol levels.

13. These measures not only reduce cholesterol levels in the blood but also cause the fatty deposits in arteries to stabilize and even regress, which can REVERSE CORONARY DISEASE proven scientifically with intracoronary imaging. Hence, lifestyle measures and cholesterol lowering drugs like statins are a must in people who already have established coronary artery disease. These measures are also advisable in people who have not had disease but are estimated to be at higher risk.

Q: But how is it that some people with high cholesterol do not suffer from heart disease and some with average or low cholesterol suffer?

1.     Firstly, we should know that cholesterol is carried in blood by particles called lipoprotein particles. ‘Atherogenicity’ or likelihood of disease depends more on the number, size and characteristics of these cholesterol carrying particles rather than the amount of cholesterol in blood. But since in most people the amount of cholesterol and the number of particles correlate, and since the amount of cholesterol is more easily measurable, we estimate the risk by the amount of cholesterol in blood.

2.     Now, in some people if a large amount of cholesterol is carried by small number of large sized particles, even if their blood cholesterol levels are high they may escape heart disease because of small number of large size of particles or due to antiatherogenic factors like apoA1.

3.     Conversely, if in a person with low average cholesterol levels, if the cholesterol is carried by large number of small sized particles, he may still be more prone to disease due to large number of small sized particles.

4.     So, some people with low-average cholesterol levels may still get the disease and a few people with high cholesterol levels may not get the disease as explained above. But these are exceptions.

5.     Other reasons why people with average cholesterol levels may get heart disease is that other risk factors like hypertension, diabetes, diet, physical activity, sleep etc may play a major role causing inflammation of the artery and facilitating entry of cholesterol (whatever its level)

6.     In some other people high levels of other lipid particles in blood like Lp(a), remnant particles  etc may play a bigger role than LDL cholesterol.

So high cholesterol (especially high LDL cholesterol) is a risk factor increasing the chances of heart disease. How much is high and what is its desirable level varies from person to person. A conversation with your cardiologist can help you decide what is the desirable level for you and how to lower it to that level.

Cholesterol is needed by the body, but small amounts are sufficient.

Heart patients whose LDL cholesterol is brought down to such low levels with lifestyle changes or drugs or both, reduce their risk of heart disease remarkably. Although a small percentage can have side effects (which can be addressed to by their doctors) most tolerate the drugs well for life.

After all, millions of interventional cardiologists the world over wouldn’t all be wrong in trying to lower the cholesterol levels in their patients (with lifestyle changes and cholesterol lowering drugs if required) to help them prevent not only heart attacks and deaths but also procedures such as balloon angioplasty and bypass surgery.

 

At last……. an exercise study on normal weight diabetics!

Yes, most exercise studies on diabetics are on the overweight or obese diabetics with the recommendation to do 3–5 days per week of aerobic activity at moderate to vigorous intensity, achieving a minimal exercise duration of 150 min per week, and two to three sessions per week of strength training.

However, worldwide about 20% of diabetics are of normal weight (Body mass index <25 Kg/m²) and more so in India.

Not only that but compared with overweight/obese subgroups, people with a normal weight at diagnosis of type 2 diabetes are shown to have a higher risk of mortality. Thirdly, normal-weight type 2 diabetes is associated with sarcopenia or loss of muscle mass which mediates the elevated mortality risk in people with normal-weight diabetes compared with overweight people with type 2 diabetes.

So what exercise advice to give in such diabetics of normal to low weight?

In a study published in July 23 issue of the journal Diabetologia (STRONG-D study), 186 normal weight type 2 diabetics who did strength training exercises only, decreased their HbA1C levels significantly more than those doing aerobic exercise alone or a combination of aerobic and strength training.

Also, their muscle mass improved much more than the groups doing aerobic or combined exercises, which correlated with the decrease in HbA1C.

The moral of the story is that if you are a lean diabetic, concentrate on strength training with an aim to improve your muscle mass.

 

Medication for preventing coronary heart disease

Medications: The third step in preventing coronary heart disease

The first two steps we can take to prevent heart disease are some tests and a few lifestyle changes, which was discussed elsewhere. For many people, taking certain medications under a doctor's supervision to prevent heart disease is necessary and very beneficial. It can be called the third step to prevent heart attack.

The two main groups of drugs used to prevent heart disease are 1. Cholesterol lowering drugs like statins and 2. “blood thinners” like aspirin.

For people who are known to have coronary heart disease, for example people having angina or who have had heart attack, angioplasty  or bypass surgery, or brain stroke or disease in the arteries of the legs, both the above kinds of medicines are important and advisable for lifelong use under medical supervision. This is so that the chances of progression of disease or recurrence of untoward events like heart attack are minimized.

Those who have no symptoms of the disease but have a high coronary artery calcium score (done due to any reason) or if the heart arteries appear diseased in CT coronary angiography (again, done for any reason), it is better to take these two drugs as per the doctor's advice.

Statins not only lower LDL cholesterol in the blood but also stabilize or ‘shrink’ the fatty deposit in the arteries, preventing their erosion or rupture which can lead to a heart attack.

Other drugs which may be advised in addition to or instead of statins are ezetimibe, bempedoic acid, PCSK9 inhibitors, fibrates and ecosapent ethyl, which reduce cholesterol and triglycerides.

Drugs like low dose aspirin prevent clumping of platelets and clotting which can occlude arteries leading to a heart attack. Other “blood thinners” which may be advised in addition to or instead of aspirin are clopidogrel, ticagrelor and prasugrel.

What about people who have not had any sign of heart disease and are apparently healthy? Should they be taking these preventive drugs?

Well, statins may also be necessary for those who have no symptoms of heart disease, but who are at high risk of developing heart disease in the future.

So how do you know in seemingly healthy people who are more likely to develop heart disease in the future?

The likelihood of future heart disease in apparently healthy people depends on their risk factors and certain physical conditions. Doctors take these two factors into consideration or use certain formulas (risk scores) to predict how likely people are to have a heart attack in the next 10 years. All risk scores (Google ‘CVD risk stratification in Indians’) are estimated on the basis of how many and how severe the risk factors are in us. As mentioned earlier the known factors are hypertension, diabetes, cholesterol, smoking, obesity, lifestyle, improper diet, family history of heart disease etc.

If the chance is more than 20% according to the risk scores, or if if LDL cholesterol is over 190 mg% or if there is long standing diabetes, then taking a statin (of course, in addition to healthy lifestyle choices) may have more benefits than risks.

If the likelihood of having heart disease on the basis of risk scores is less than 5%, then only lifestyle changes may suffice to prevent the disease.

If the chance is between 5% and 20%, the decision to take the drug requires further tests, such as coronary artery calcium score, doppler test of femoral and carotid arteries, BP difference between all 4 limbs and blood tests like apoB, hs CRP, LPA, troponin, etc. Other physical conditions like lung or joint disease, kidney disease, HIV, high blood pressure, diabetes during pregnancy in women or a history of premature birth or lack of breast feeding may put one at higher risk so that it may be beneficial in these people also to take a statin under medical guidance.

The decision to start a statin should be based on discussion with the doctor and after understanding its benefits versus harm for the individual.

Other ‘preventive’ drugs are all medications to keep blood pressure and sugar under control. Of particular preventive benefits are certain medications such as SGLT2 inhibitors and GLP1 agonists for diabetes, RAAS blockers for hypertension, beta blockers for hypertension with angina, or after a heart attack or heart failure.

Should seemingly healthy people take aspirin for life to prevent heart attacks?

It was a popular belief that everyone should take baby aspirin to prevent heart attacks because heart attacks are caused by blood clots in addition to fatty deposits and aspirin prevents these clots from forming. But after a few years of research on many people, it was found that along with the benefits of aspirin, there is also adverse effect of bleeding. In people who have a history of bleeding or are over 70 years of age, the risk of bleeding outweighs the benefits of preventing heart attacks, so the net harm is greater. So, taking aspirin over the counter or without medical advice is inappropriate for such people. Yes, it can be taken to prevent heart attacks (not to prevent death) in people younger than 70 with risk factors for heart disease or with long-standing diabetes, but after consulting a cardiologist.

Thus, almost 90% of heart attacks can be avoided by 3 steps: 1. certain tests, 2. certain lifestyle changes and 3. taking certain medications as advised by the doctor. Despite all these efforts, if a heart attack (the remaining 10%) still occurs, the damage caused by the heart attack can be avoided by immediately recognizing the symptoms and getting prompt treatment.

 

 

 

 

Key Points on low dose aspirin

Yesterday some of my more well informed and alert patients and friends drew my attention to a newspaper report of the US preventive task force’s latest recommendation about low dose aspirin. This short write up is pertaining to the same so that there is clarity in minds of people.

1.       Clotting and bleeding are opposite phenomena. Agents which prevent clotting can cause bleeding. Aspirin is one such agent.

2.       There are two groups of people for whom preventive therapy with low dose (LD) aspirin is applicable.(Low dose which is less than 100mg has been shown to have same benefits as full dose of 325 mg, but with the benefit of less bleeding.)

3.       One group is composed of those who already have evidence of arterial disease such as a heart attack, angina, angioplasty, bypass surgery, ischemic brain stroke or arterial disease of the limbs.

4.       For these people, life-long LD aspirin (or another antiplatelet drug like clopidogrel) is HIGHLY advisable because the benefit in terms of preventing another clotting event like a heart attack far outweighs the risk of bleeding in the gut or the brain-the most important risk with aspirin. This is called secondary prevention.

5.       The other group of people is composed of those who are apparently healthy and wish to prevent heart attacks or strokes in future, which is called primary prevention.

6.       Some years back, the popular notion was that LD aspirin should be given to all above 40 years to prevent a heart attack. This was not based on scientific evidence, but from observation and impression gathered from population.

7.       In the last few years came hard evidence in form of placebo controlled, randomized trials with aspirin which showed that for primary prevention, the risk of bleeding may outweigh the benefit with LD aspirin.

8.       Hence in 2019 American College of Cardiology & American Heart Association recommended that LD aspirin for PRIMARY PREVENTION is not advisable for people above age 70 or ANYONE at high bleeding risk.

9.       But they said LD aspirin MAY BE advisable for primary prevention in people between ages of 40 and 70 who are at high cardiovascular disease risk (such as people with family history of premature heart disease, people with hypertension, diabetes, high cholesterol, smokers, obese etc) and low bleeding risk, to prevent heart attacks and colorectal cancer. It may also be recommended for people who already are on LD aspirin without side effects.

10.   The current US task force’s recommendation is almost the same as the 2019 recommendation by ACC-AHA except that the upper age limit is brought down to 60 and prevention of colorectal cancer is no longer a reason for preventive therapy with LD aspirin. 

11.   These are general recommendations for the population. At the individual level, shared decision making with your cardiologist is recommended after weighing your probability of benefit against your risk of bleeding with LD aspirin.

12.   Lastly, one group of patients that is not covered by the above scientific bodies is people without any symptoms but with fatty deposits in their heart, brain or leg arteries as shown by tests like coronary artery calcium score, coronary CT angiography, doppler showing plaques in carotid arteries or BP in legs lower than that in arms.

13.   Such people (for example with coronary artery calcium score more than 100 and) at high risk may be well advised LD aspirin for prevention. Again, shared decision making with your cardiologist is advisable after discussing the risk-benefit issues.

 

Doc, are pills prescribed for BP and cholesterol, habit forming? Is it true 

that once started they cannot be stopped?

Well, the answer is that they are not habit forming (in the sense some drugs acting on the mind are), although if they benefit you in the long term helping you to prevent heart attacks and brain strokes, they are a good “habit” to form!

If BP and cholesterol levels are not at desirable levels as per your risk profile, and if your cardiologist feels you that in addition to the lifestyle changes you have instituted, pills are also required to control their levels to reduce the risk of heart attack or brain strokes, then it may be advisable to take them as long as your cardiologist feels you should take them, which in many cases could be lifelong. But that will drastically cut your risk of heart attack or brain strokes in future, if taken as advised.

About stopping them once started? Well it depends on your risk of having heart attacks in future (which depends on your lifestyle and risk factors like family history, presence of hypertension, diabetes, cholesterol etc.), and your response to changes in lifestyle and drugs.

For example, if your BP comes down with lifestyle measures such as weight reduction, salt and alcohol restriction, doing regular exercise, sleeping well and increasing fruits and vegetables in diet, your pills can be tapered gradually over weeks and months keeping a watch over your BP, lest it should go up again.

If it remains normal on repeated checking despite tapering and stopping pills, one can do away with the BP pills. If after tapering and stopping pills, BP rises again, then the pills will have to be reinstituted.

In case of cholesterol pills, commonest of which are called statins, research has found tremendous benefits with their use in people at high risk, for example people who are known to have coronary artery disease or people with multiple risk factors alluded above.

But again, in people with low or intermediate risk, if cholesterol levels plummet with intensive lifestyle changes, these pills can be stopped, and lipid levels checked again at regular intervals to see if they remain low. If they rise again, one may have to reinstitute the drugs at the advice of one’s cardiologist after a risk-benefit discussion.

One caveat to all the above is that there are certain drugs which are dangerous to stop suddenly. For example, a class of drugs called betablockers or a drug like clonidine, if stopped suddenly can cause rebound hypertension (to levels higher than those before drug was started) and rarely even cause heart attacks. Hence if they are to be stopped, it should only be done gradually under the guidance of your cardiologist.

As far as cholesterol lowering drugs (like statins) are concerned, stopping them suddenly in a person having underlying coronary disease may increase his/her risk of worsening his/her condition. Hence again, if one wants to stop or alter them, it should be done under a cardiologist’s guidance.

Thus, BP drugs and Cholesterol drugs are a good “habit” to form if they are required to control your BP and cholesterol levels which will benefit you in the long term to prevent heart attacks and brain strokes. If you are at low or intermediate risk and if BP and cholesterol are well controlled with healthy lifestyle and habits, then stopping or altering drugs is possible but not without medical guidance.

 

 

 

 

 

 Purpose in life, sleep and walking speed

A page from my book “Romancing the Heart” (available on Amazon)

·         There is a curious relationship between having a purpose in life, your walking speed and your sleep.

·         Not only are they inter-related, but they all also independently impact health.

·         This is especially important for those above 55 or 60 years of age, when both walking speed and sleep start being affected, commonly.

·         Studies have found that if you have a higher purpose in life, a pet project or an exciting reason to get up in the morning, you are more likely to have better sleep. Also, in that case, your walking speed does not diminish as you age and you may stay more physically fit.

·         Now the interesting thing is that although a higher purpose in life improves walking speed and sleep, both these latter are also affect each other: if you walk better, you sleep better and if you sleep better you can walk better.

·         To top it all, the three, each by independent mechanisms, impact health, for example walking speed by cardiorespiratory fitness, purpose in life by psycho-neuro-immune pathways and cell repair with better sleep.

·         Finally, the silver lining is that both can change for the better. Walking speed can be improved with practice and purpose in life can be cultivated. These measures can improve sleep and overall health.

·         Volunteering, learning new things, cultivating relationships and hobbies and interests can be important ways for increasing one’s sense of meaning in life. This protects against many negative health and psychological outcomes, especially of older age.

·         Hence, don’t wait. Increase your walking speed, but first better find out something exciting to do which fills a need and fulfils yourself! It will help you sleep better, walk faster.

 

New motherhood and reducing long term risk of cardiovascular disease

When new motherhood should get help from three different kinds of doctors:

The most common risk factors to cause cardiovascular disease (CVD) are the simple seven-smoking, physical inactivity, overweight, diet, blood glucose, cholesterol, and blood pressure.

In pregnant females, added to these risk factors are problems related to pregnancy such as preeclampsia, gestational hypertension, preterm birth, and intrauterine growth restriction, which increase CVD risk several fold and represent an opportunity to identify at-risk women and prevent or reduce future CVD like chronic hypertension and coronary heart disease.

Hence, the months after childbirth in women who have had complicated pregnancies are the period of great opportunity when a close collaboration between obstetricians and cardiologists can prevent or retard future development of CVD in such women.

When does the pediatrician come in?

Breastfeeding is recommended for infant nutrition across the world. According to the American Academy of Pediatrics, babies who are breastfed for at least 6 months are less likely to be overweight, and the duration of breastfeeding is inversely related to the risk of obesity. The incidence of type 2 and type 1 diabetes mellitus are less by 40% and 30% respectively, in breastfed infants. A likely mechanism in the development of type 1 diabetes mellitus is the infant’s exposure to cow milk β-lacto globulin, which stimulates an immune-mediated process cross-reacting with pancreatic β -cells. Additional benefits include boosting the baby’s immune system and lowering the risk for asthma and sudden infant death syndrome.

But those are the benefits for the child. What about the mother?

A large prospective study in nearly 300 000 women in China showed that a history of breastfeeding was associated with a 10% lower risk of CVD later in life. Moreover, each additional 6 months of breastfeeding was associated with a further 3% to 4% lower CVD risk.

The mechanism could be that breastfeeding increases metabolic expenditure by an estimated 480 kcal/d and may enable a more rapid reversal of metabolic changes in pregnancy, including improved insulin sensitivity and lipid metabolism and greater mobilization of fat stores.

Serum triglycerides, low-density lipoprotein cholesterol, and very low-density lipoprotein cholesterol all increase in the last trimester of pregnancy.

Lactation contributes to rapid reversal of these changes through excretion of triglycerides and cholesterol in milk. In addition, longer breastfeeding duration has been associated with a lower maternal risk of metabolic syndrome, hypertension, and diabetes mellitus later in life.

Besides, a 2019 longitudinal study of more than 100 000 Australian women found that ever breastfeeding was associated with lower maternal risk of CVD hospitalization and mortality compared to never breastfeeding.

Breastfeeding may be especially important for women who develop pregnancy complications such as preeclampsia, because we know that these conditions increase lifetime risk of CVD.

Thus, new motherhood (with pregnancy complications as mentioned) is the sacred place where Pediatricians Obstetricians and Cardiologists should meet. It will help the mother, the baby and the society.

Can you take it easy on diet and exercise if you are on ‘protective’ medications?

Medications for high blood pressure and cholesterol (statins) reduce the risk of heart attack and strokes. So, if you are taking them, can you become a little lax about healthy habits like regular physical activity and a prudent diet? In other words, are drugs a substitute for healthy behaviors?

Recently The Finnish Public Sector Study which included more than 41,000 participants aged 40 and older in Finland, and followed up for 14 years for their lifestyle behaviors, was reported in the Journal of the American Heart Association.

They found that among those who took medications for hypertension or elevated cholesterol, there was a tendency toward less favorable lifestyle practices. For example, there were greater instances of people  becoming physically inactive or reducing physical activity level, gaining weight and developing obesity during follow-up

.

The perception seemed that the medications were perhaps a ‘substitute’ for healthy lifestyle practices as opposed to a ‘complement’ to lifestyle.

However, the fact is that there are many benefits to be achieved from being regularly physically active and following a heart-healthy diet, such as reducing the risk for conditions like diabetes, cancer, osteoporotic fracture and several others.

Hence, even if you are on protective medications, don’t be lax about physical activity and proper diet.

BP measurement at railway stations- How useful?

BP measurement at railway stations- How useful?

The first step in correct BP measurement is to let the subject whose BP is to be measured rest for a few minutes on a comfortable chair in a quiet place.

Intuitively, a railway station with all its hustle and bustle can hardly be considered a place to take blood pressure of passengers.

However, the advantage at a railway station is in the quantity (large number) as well as quality (cross section of a diverse population) of subjects.

But certain precautions must be observed to lend credibility and legitimacy to the whole exercise, which we did that day to our satisfaction.

1.       Let the subject rest for a few minutes before checking his or her BP

2.       If the reading is less than 120/80, the person is reassured and asked to recheck at 6 monthly intervals.

3.       If the first reading is above 120/80 mm Hg, it is checked again after few minutes. If again high, the person is sent to an enclosure with some privacy where the BP is checked with an AOBP. This automated office BP instrument takes BP thrice at intervals and gives an average of 3 readings automatically. World over, this has been advocated as the most accurate way of BP measurement. Fortunately, we had 2 such instruments (being used for the first time probably on a railway station).

4.       If the BP is persistently high after using all above methods, we direct the subject to his or her primary physician to confirm readings with multiple measurements over a few days’ period and further medical advice.

5.       NO DRUG is PRESCRIBED, but ALL subjects, irrespective of their BP are advised about life style changes as the first and permanent step.

So, our experience at Andheri railway station on 12^th November 2019 of checking BP of about 153 people with the above precautions, on behalf of Rotary District 3141 and Rotary club of Bombay Airport was quite rewarding.

High blood pressure or hypertension problem world over has been described to have what is known as the “rule of halves”.

According to this rule based on a common observation, ‘half the people with high blood pressure are not known (“rule 1”), half of those known are not treated (“rule 2”) and half of those treated are not controlled (“rule 3”)’ 

Thus, more than 75% of high blood pressure people either do not know they have hypertension or are not optimally treated, exposing them to the risks of heart attacks, brain strokes and kidney failure.

If one considers that hypertension is prevalent in almost 30 to 50 % of our population, the above percentages imply a large burden of unknown, uncontrolled hypertension in the country.

Obviously, the first step is to diagnose as many people as possible correctly so that they can be given correct advice and saved.

The availability of large cross section of population at railway stations presents a unique opportunity to tackle this problem and save millions of people from the complications of hypertension by early detection and advice

Indeed, many subjects were happy at the availability of such a facility at a railway station in contrast to spending lot of time waiting for their turn at a family doctor’s clinic to get BP checked.

Hope our railway authorities take note and help us achieve this goal by giving permissions to set up booths and kiosks for measuring BP with modern, internationally validated and user- friendly BP instruments which well-trained para medics can use.

We at Rotary clubs are ready.

Sitting cross legged? Not a good idea.

My physiotherapist wife always tells me that sitting cross legged (on a chair or sofa) is not good as it weakens the gluteal muscles.

As a cardiologist, I have one more reason to advise against sitting cross legged on a chair i.e., thigh of one leg over the thigh of the other leg or ankle of one leg over the knee of the other leg (see pics).

This is because, sitting cross legged in these ways can raise your systolic (the upper number) blood pressure by 8 to 10 points (mm of Hg).

Carefully done studies in which participants were randomly assigned, using a crossover design, consisted of having seated blood pressures measured with their legs in three different postures:

Feet flat on the floor and legs uncrossed

Legs crossed, method 1: popliteal fossa of the dominant leg over the suprapatellar bursa of the non-dominant leg

Legs crossed, method 2: lateral malleolus of the dominant leg over the suprapatellar bursa of the non-dominant leg

The person measuring BP was ‘blinded’ by a screen from knowing the posture of subjects whose BP was being measured.

Results showed that systolic blood pressure in patients with hypertension increased by 8 mm Hg by method 1 leg crossing and 10 mm Hg by method 2.

Another study demonstrated that although crossing the legs at the knees influenced blood pressure, crossing them at the ankles had no effect.

Hence it is not a good idea to sit cross legged in general, especially if you have hypertension or are getting your BP measured.

Vegetarians Beware

Everything vegetarian may not be good :

Adapted from Ambika Satija etal. Healthful and Unhealthful Plant-Based Diets and the Risk of Coronary Heart Disease in U.S. Adults. Journal of the American College of Cardiology Volume 70, Issue 4, July 2017

Shown above on the right is a telling graph depicting food servings per day and the risk of heart disease found in a study of 2 lakh people over 2 decades to relate 3 kinds of diet with heart disease.

Ambika Satija, Shilpa N. Bhupathiraju and others report in the July 2017 issue of the Journal of the American College of Cardiology that high adherence to a healthful plant-based diet index (hPDI)  (whole grains, fruits/vegetables, nuts/legumes, oils, tea/coffee) was independently inversely associated with CHD, whereas less-healthy plant foods (juices/sweetened beverages, refined grains, potatoes/fries, sweets) and animal foods received reverse scores.

In fact, less-healthy plant foods were worse than animal foods in being positively associated with coronary heart disease.

So, everything vegetarian is not good, especially if it contains the following sugar rich carbs:

·       Apple cider (nonalcoholic) or juice, orange juice, grapefruit juice, other fruit juices

·       Refined grains: Refined grain breakfast cereal, white bread, English muffins or bagels or rolls, muffins or biscuits, white rice, pancakes or waffles, crackers, pasta

·       Potatoes: French fries, baked or mashed potatoes, potato or corn chips 

·       Sugar sweetened beverages: Colas with caffeine and sugar, colas without caffeine but with sugar, other carbonated beverages with sugar, noncarbonated fruit drinks with sugar

·       Sweets and desserts: Chocolates, candy bars, candy without chocolate, cookies (home-baked and ready-made), brownies, doughnuts, cake (home-baked and ready-made), sweet roll (home-baked and ready-made), pie (home-baked and ready-made), jams or jellies or preserves or syrup or honey

Vegan or Mediterranean diet or vegetarian food made up of whole grains, fruits/vegetables, nuts/legumes, oils, tea/coffee) was associated with less inflammation and decreased incidence of coronary heart disease.

Other healthier veg food stuffs were:

Whole grains: Whole grain breakfast cereal, other cooked breakfast cereal, cooked oatmeal, brown rice, other grains, bran, wheat germ, popcorn        

Fruits: Raisins or grapes, prunes, bananas, cantaloupe, watermelon, fresh apples or pears, oranges, grapefruit, strawberries, blueberries, peaches or apricots or plums

 Vegetables: Tomatoes, tomato juice, tomato sauce, broccoli, cabbage, cauliflower, brussels sprouts, carrots, mixed vegetables, yellow or winter squash, eggplant or zucchini, yams or sweet potatoes, spinach cooked, spinach raw, kale or mustard or chard greens, iceberg or head lettuce, romaine or leaf lettuce, celery, mushrooms, beets, alfalfa sprouts, garlic, corn        

Nuts and Legumes: String beans, tofu or soybeans, beans or lentils, peas or lima beans

   

Hence choose your food wisely, even if it is vegetarian!

Are saturated fats bad?

Are saturated fats bad?

A patient gives me an important clue.

He was a 102 Kg American with symptoms of angina due to coronary artery disease. 

He said that when his meal had meat, pork, cheese or butter, slightest exertion after the meal caused chest discomfort, whereas when he ate a Mediterranean like diet (fruits, salads, fish, nuts whole grains etc) he could walk a mile without chest discomfort.

We know that diet has long term impact on health, but what is less known is that it also has acute, short term effects, like my patient had.

Saturated fats (like in cheese, meat etc) are known to acutely increase the thrombogenicity (tendency to clot) of blood and inability of coronary arteries to relax (endothelial dysfunction).

This was a direct evidence of the harmful effects of diet high in saturated fats in a patient with coronary disease.

Hence large consumption of bad quality fats (meats, cheese, butter, chicken or fried food etc) is not a good idea especially if you are above 30 or already have coronary artery disease or risk factors like abdominal obesity, physical inactivity, hypertension, diabetes, abnormal lipids (cholesterol), smoking, family history of coronary heart disease, etc. whereas consumption of moderate amounts of good quality fats (olive oil, that from fish and nuts) would be alright.

Trans fats and sugars are the worst and should be minimum in diet.

Oh Kolkata !

The increasing spate of violence against doctors in the country and elsewhere, epitomized by the horrifying incidents in Kolkata compels me to write the following.

Most attacks on doctors occur in the accident and emergency (A & E) services of a hospital or a clinic for following obvious reasons:

In the hospital wards, for patients suffering from subacute or chronic diseases or awaiting an elective procedure, there is enough time for the doctors to explain and for the patient and the relatives to understand, accept and ask questions. Decisions can be made jointly, and responsibility shared after discussion. An example in heart diseases is what is known as a “heart team” approach for decision making in a case with stable but complex coronary artery disease.

On the other hand, the ‘scene’ that happens in the A &E units is due to a combination of factors that the 3 ‘actors’ in the ‘drama’ suffer from, like lack of time, agitated mental states and seriousness/acuteness of illness or injury. 

Firstly, actor number one: The patient- mostly is one who has serious and acute illness or injury which has high mortality despite best treatment. This is what the relatives HAVE to understand and accept. For example, a patient in cardiogenic shock after a heart attack. Even the best of treatments like urgent opening of a blocked coronary artery by angioplasty and stent implantation leaves a mortality rate of 50 % (and not doing anything a mortality rate of almost 100%). Would you beat up a doctor who in the middle of night endeavors to save someone but is not successful for reasons beyond him?

Then the actor number 2: The agitated, ignorant, aggressive relative. Gone are the days when relatives were compliant and more accepting of the results of treatment. Now we have a combination of lack of understanding along with aggression and muscle- a particularly lethal combination.  Of course, some of it comes from the lack of time and expertise in communication skills of the doctor on duty-the 3rd actor in the drama.

Generally, the doctor on duty is from the lower or middle rung-not a senior person, is already harrowed with the continuous flow of serious patients and his or her inadequacies of facilities, time and communication skills. The requirement of urgent action leaves little time to explain the relatives the seriousness of the illness and possible outcomes with or without treatment. Even if a doctor is accused of being inefficient, having poor knowledge or judgment, he or she can never be accused of poor intent. His or her first and last effort is to treat in ways best known to him or her-which hardly deserves the ‘treatment’ he or she is meted out. Although Although God judges by intent, the world judges by results, unfortunately.

Since the A and E units are hardly the place to discuss these issues, the best way to prevent violence is probably by doing the following:

1.       Have training and workshops for A & E doctors in communication skills and behaviour changes-it is how you say that makes all the difference; also, by skits and role playing. Justifiably or not, people expect the same courtesy from doctors as they get now-a-days from other service people. May be the IMA and MCI can take a lead on this.

2.       Make violence against doctors a non bailable offence-and put up sign boards prominently to that effect outside all A and E departments and as news item in the media.

3.       Have at least 2 bouncers in every A & E department, (to be paid by a surcharge on every patient).

4.       Explore the feasibility, effectiveness and safety of use of crowd dispellers like tear gas guns etc.

5.       Put up sign boards such as “Your patient may have illness or injury that has a high chance of death despite treatment and certain chance of death without it. Please decide whether you want treatment or not”.

6.       Have a short consent form in relation to the above for the relatives to sign (in presence of a bouncer or security staff).

7.       Have meetings and seminars with the police force to initiate rapid response systems.

8.       Have public seminars and write ups on this topic-especially to political groups.

Finally, last night one of the TV channels was showing how patients are suffering due to the medicos' strike in Kolkata which only implies how much needed they are and how much difference they can make.

Would you hit a person you badly need?

 No wonder Socrates was compelled to say: “Why do you hate me, I have not helped you!”