Flaxseed- good for BP:

Adding flaxseed to the diets of patients resulted in large drops in blood pressure (BP) of around 10 mm Hg systolic and 7 mm Hg diastolic after six months, according to the results of a double-blind, placebo-controlled study presented at the recent American Heart Association 2012 Scientific Sessions.

Out of 110 patients, 58 were given milled flaxseed (30 g/day) in the form of bagels, muffins, and buns and the other 52 were given placebo products made from wheat with a similar flavor, for one year.

At 6 monthes, there was important decrease in SBP and DBP using flaxseed compared with placebo.

Flaxseed may reduce circulating cholesterol and trans-fatty acid levels. Also it has different components, including alpha-linolenic acid, enterolignans, and fiber, and all have been shown to decrease BP. Additionally it has antiatherogenic, anti-inflammatory, and antiarrhythmic effects.

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“Complete” Health Checkups : Are they complete? Are they useful ?

“Complete” Health Checkups :  Are they complete? Are they useful ?

There is a proliferation and plethora of health check up schemes offered by hospitals and clinics.

Conceptually, the expectation is they are very useful for making early detection of diseases and preventing their progression. Glaring examples are high blood pressure and diabetes which have no symptoms and can be only detected when measured as a routine.

However, an analysis of pooled results of nine trials involving 11,940 deaths has revealed the opposite. This recent Cochrane review (ref below and which was in the news recently) by Danish researchers lead by Lasse Krogsbøll has claimed that, “"We think it's unlikely that health checks reduce mortality to a degree where it would be beneficial," because in the analysis it was found that it did not lead to any substantial reduction in the deaths for instance from cancer and heart disease.

The reason for such findings could be that the health checkups are being utilized by the "worried well" segment of population- people who are usually fit and take an interest in their own health while unfortunately those who are at high risk of serious illness shy away from these regular checkups. Or it might be that genuine health problems are spotted at other times - when patients present with symptoms, to the physician. Following which the physicians generally do aggressively manage them and hence the results of regular health checkup do not seem to affect the statistics on deaths. Or it's possible that those getting the checkups were already well cared for by their regular doctor

A downside of general health checks is the problem of false positive and false negative test results.

The former (a test result which is falsely abnormal) may lead to unnecessary further testing or over treatment which may be harmful and anxiety development among the people.

The latter (a test result which is falsely ‘normal’, but actually the person has disease which is missed) may give a false sense of assurance and complacency. An example is a “normal” cardiac stress test and patient developing heart attack a few days or weeks later.

The again, if tests are normal but lifestyle is unhealthy, it could be dangerous. For example, a heavy smoker may get all his test results normal and hence may continue smoking. Sometimes all tests are done except the one relevant for that person. Hence the Cochrane reviewers mention that “public healthcare initiatives that are systematically offering general health checks should be resisted.”. “ The results don't imply that prevention is worthless”, Krogsboll said, “just that offering checkups to the general population of adults doesn't seem to add benefits.”

On the reverse, besides the examples of hypertension and diabetes alluded to above, there are ample examples of early detection of cancer and other diseases which lead to early treatment and prevention of progression of disease. Also, by providing an opportunity to both patients and physicians to contemplate and discuss potential risks, the check ups could also provide a vehicle through which patient worries can be more thoroughly addressed and methods to adopt preventive measures including lifestyle changes promoted.

So what is the way forward ?

As in many things in life, I think the middle way is the best. It helps to be selective.

1. Do a general health check if your doctor suggests or your organization requires it or if there is a suspicion that there may be a problem or if there is strong family history of a disease.
2. Add some more tests which are more relevant to a person if not included in the plan
3. Certain tests like routine & regular measurement of BP, blood sugar and lipid profile should be universally adopted, should start from age of 30 and done periodically in view of the high prevalence of coronary disease in our country especially in the young. Screening for breast cancer and cervical cancer in women and occult blood in stools are other examples. Hence the results of the Cochrane review does not imply that doctors should stop clinically motivated testing and preventive activities.
4. Remember the limitations of the tests. They are neither complete (no battery of tests can detect ALL the possible future abnormalities) nor 100% accurate. Don’t rely too heavily on test results or rush for further testing. The test results should be discussed with an independent consultant not related to the check up plans so as to take into consideration false positives and negative possibilities and the likelihood of disease in the person and to decide on the necessity of further testing or treatment
5. The most important role of life style should not be over shadowed by “health check ups”. One should remember that the test results could be normal, yet a person may develop disease due to faulty lifestyle or due to not doing important tests relevant to that person (not included in the check up plan). So a so called “complete medical check up” is no substitute to a healthy lifestyle consisting of regular aerobic exercise, prudent diet and avoidance of smoking.
6. How frequently should undergo “health checks” ( for example yearly ? every 2 years? every 5 years?)

      This depends on the risk profile of the person and the results of first test.  Not everyone requires an annual medical check up. For example certain professions like pilots on whom many lives depend, require annual checks even though first check up is entirely normal.

So do you want to go for a general health check up ? Go ahead, but tread slowly, with eyes, ears and mind open.

Young hearts in India-Not so Young !

Young hearts in India –not so young !

 A few days ago, I was invited to release at a press conference, results of a study carried out over the last 4 years by the research team of Saffolalife, a not- for- profit organization and "Via Media"  along with Indian market research bureau. They collected data from about 1,200,000 people who responded to their site. When a person logs in to this site, he/she has to enter his/her own data about weight, height, recent cholesterol, BP and sugar values etc. From these values, as per the Framingham Risk Score and a logarithm, the person’s heart age is calculated. If this age of his/her heart is greater than his/her actual age, the person is said to be at risk for getting coronary heart disease in future.

 Using this information and analyzing it, they came to the conclusion that about 70% of men, in age groups 30 to 60 were having their heart ages greater than their actual ages, ie they were at higher than average risk of getting coronary heart disease. In case of females about 60% were at risk. The major factors increasing their risk were low levels of the “good” HDL cholesterol and increased Body Mass Index (BMI) –in other words- obesity. What was most alarming was that the younger lot was equally at risk as the older people, in fact in the age group 40-44, the risk is 80%. Most of the causation lies with our lifestyle of eating and lack of physical activity. All this got a good and prominent press coverage the next day in most of the city’s prominent newspapers.

 Although the study suffers from the disadvantage of a selected sample (only those who log in to the site) and that of self reporting, its strength lies in the large numbers involved. This strength will increase all the more with passage of years as the numbers increase. Another area of strength is the simplicity of its methodology. In addition, it conforms to our experience in clinical practice in that we do see many patients in the 30 to 50 age group coming with severe coronary artery disease.

 The very fact that someone has thought to do such a study on a pan India scale is commendable.

 Of course, some refinements can be brought about, such as addition of waist hip ratios for one. It is now known that obesity by itself is not that important a risk as abdominal obesity which can properly be quantified by the waist circumference and its relation to the hip circumference. (Normal waist to hip ratio is 0.9). There are many people who appear misleadingly lean but have a high or abnormal waist to hip ratio. The exact method to measure hip and waist circumference will have to be described. The other factors to add would be family history of premature heart disease ( heart disease below 55 in a male first relative or below 65 in a female first relative), hs CRP measurement, fasting triglycerides (TG) and non HDL cholesterol if TG are above 200 etc.

 The study highlights why preventive efforts are so important. In a country where the incidence of coronary heart disease is high and increasing, (2 to 4 times the western developed nations), where the young are disproportionately more affected than the western counterparts, where the disease is already severe when first diagnosed and above all, where most of the times, the medical expenses of treatment is not covered by third party reimbursements, prevention is so very important. Add to this the enigma of sudden coronary deaths where there is NO TIME available for treatment. And there is ample proof of the benefit of preventive measures . .Deaths due to heart disease in the west have reduced by more than 50% in last few decades and a major cause of this reduction is risk factor management (with life style changes and medications) besides the high tech treatment methods.

 Thus, prevention is the key to this epidemic of heart disease and it is estimated that more than 80% of heart disease is preventable.

 Studies such as this one are the first step in that direction.

 Dr Akshay Mehta

Touch of life

Touch of Life!

It was in the early years of my practice as a Cardiologist. I was called to see a 47 year old Sikh at his residence. He was recuperating from a heart attack and was lying listless and weak on the floor of his small house. His wife seemed to be more alert, anxious, full of down-to-earth common-sense, and, as I was to discover later, having a sound knowledge of life, although uneducated in the usual sense of the term. After examining him and advising them, about medications, diet and activities and giving them a general idea about his heart condition, etc, I left.

From time to time the wife used to come to my clinic to apprise me of her husband’s progress. Gradually she started bringing him too, to the clinic. At each consultation, one constant refrain from her was, he was totally devoid of energy and enthusiasm. The look on her face betrayed anxiety. Sensing what the trouble could be, I discreetly asked her about their sexual life which is wont to go berserk after a major illness, and specially a heart attack.

As soon as I mentioned this, her face lit up and said there was no physical relationship at all for last 6 months. So much so that he hardly ever touched her. However, the sensible woman said, it was not full sexual relationship she desired, but rather, a touch, a caress, or a simple hug was all that she longed for. For her sake and for his own sake. She knew that was all that was required for their happiness and well being. She was also certain; his heart condition would allow that.

I called the patient aside and explained this to him. But no amount of explanation and discussion penetrated the stone wall he had around him. He remained depressed, apathetic and listless; repeated suggestions to see a psychiatrist or a counselor were turned down by him.

Eventually, months passed by and I had no news of them. Then one evening, the man came to my clinic, alone. As he entered my room, he sat and started weeping. I asked him what was the matter and where was his wife?

“Doctor Saab, last week SHE had a heart attack and died”.

Had she heard of scientific studies done on the importance of touch or of research about babies or animals not thriving well, if not cuddled or held in arms? Or did she know the oft quoted “as if” principle? Which is that usually our actions follow our thoughts, but many times our thoughts follow our actions, so that if you act “as if” you love a person, by a warm touch, or a smile (even if forced), magic happens! (Love) thoughts follow the action and fill you mind ! And that once there is love, fear and depression go out of the window ! How right she was when she had said that a simple touch or caress was all that was required and so important for their well being.

No, she was no psychologist, nor had she learned all this from books or people. Her short life was her book. And she passed on the lesson.

Thank you, dear lady, for a valuable lesson, a lesson of life.
Dr. Akshay Mehta.

When you go for a Blood Pressure check up

When you go for a Blood Pressure check up:


• Don't drink coffee or smoke cigarettes 30 minutes before having your blood pressure measured

• Prior to the BP check, go to the bathroom to pass urine if you feel your bladder is full. A full bladder can raise your blood pressure reading.

• Before the test, sit for five minutes with your back supported and your feet flat on the ground. Rest your arm on a table at the level of your heart.

• Wear short sleeves so your arm is exposed.

• If you are already on BP medications, do not stop them before coming for the BP check up. In fact take the prescription to the doctor, or the strips or bottles with their names printed on them.

• Get two readings, taken at least two minutes apart, and average the results.

• Ask the doctor or nurse to tell you the blood pressure reading in numbers and have it recorded on paper.

• Ask the doctor what is your goal blood pressure.

• Is the systolic pressure too high (over 140)?

• Ask the doctor about diet to help lose weight (if required) and lower blood pressure.

• Also understand if it is safe to start doing regular exercise and what type?

• Ask the name of blood pressure medication if prescribed (both the brand name and the generic name).

• Ask what are the possible side effects of the medication and what to do if they occur.

• Ask what time of the day you should take the blood pressure medicine.

• If you are taking any other concurrent medications-even if temporarily- please inform the doctor.

• Ask whether you should check your BP at home or with a family physician and how often.

• Ask whether any other tests are required to be done and when you should come for a follow up.

Of "cundumm", "baba"" and "annashetty"

Of "cundumm", "baba"" and "annashetty"


Those were the residency days of seventies and eighties. Our learning days in the wards of KEM hospital. They were the days of recycling materials, very few disposables.


When we saw a ward boy throw away an equipment or a material and we asked him why cant he re-use the same after washing and sterilizing, he used to say "baba e kahyun e cundumm chhe" meaning the staff nurse (baba) said it is condemned and to be thrown away. Besides the words cundumm" and "baba which the ward boys used, another word that amused us was used for anesthetists : "annashetty".

But recently I was reminded of the "cundumm" days when I was hearing Wayne Dyer's tape who mentioned 'you cannot correct anything (or anyone) by condemning it'! When you condemn a person- even mentally- it is as if you have thrown him on the floor, in the dust bin, from where he has no energy left to rise. He is written off- can't be corrected.

So be careful when you condemn someone- even mentally. In your eyes and in your mind, he will never get a chance to correct himself for you will see what you believe, you make your world by your thoughts. Although rare, even a die hard criminal can correct himself, because "when you change the way you look at things, the things you look at change."

And so, what is condemned can't be corrected and what can be or should be corrected shouldn't be condemned.

Because what is "cundumm" cannot be recycled ! The ward boy knew it well.

Love- akshay

Coronary CT angiography

Should all Indians above 40 years of age undergo screening with coronary CT angiography to detect coronary disease ?

Recently, a 56 year old man, a non smoker, who had no prior symptoms, had sudden severe chest pain and collapsed in his house with cardiac arrest. He was a regular tennis player, without hypertension, diabetes or obesity. The only adverse history was that both his parents had coronary heart disease and some cousins too at young age.

Could we have done a test earlier which could have help us predict his heart disease and helped us prevent it? Something like treadmill stress test? Or CT coronary angiography ?

CT coronary angiography is a test in which a liquid (called ‘contrast’ or ‘dye’) is injected into a vein, the subject is asked to hold his/her breath for few seconds, and the heart is scanned under a CT scanner. What comes out as a result are pictures of one’s coronary arteries. One can then see whether his/her coronary arteries have blockages or not.

What is the accuracy of the test- vis a vis the usual invasive coronary angiography ? or vis a vis treadmill stress test?

Well, a negative test is highly reliable. In other words, if your CT coronary angiogram is normal, there is about 98% likelihood that it is truly normal. On the other hand a “positive” test result is not so reliable – which means that if there are blockages, these may be over or under diagnosed and an invasive angiogram MAY be necessary if the physician so feels.

But the advantage of this test is not only that it is convenient, non invasive and can be done in a few minutes on an out-patient basis, but that it also shows the state of coronary artery wall- whether it is thickened due to “plaque” or fat build up on the inner lining. This can tell whether the patient is at a future risk of a heart attack caused by rupture of that “plaque” and clot formation on top of it.

A treadmill stress test does not tell you this and there is the issue of lot of false positives and false negatives in a treadmill test.

So the million dollar question is whether to subject all above 40 years to CT coronary angiography, given the high propensity of the disease in young Indians ? (Almost 4 times our western brothers).

That brings us to the disadvantages of the test. Firstly, it exposes the individual to radiation which is potentially carcinogenic. Secondly it exposes the individual to the “dye” load which can harm kidneys if they are already compromised. Finally the cost (Rs 8000 to 12000) may prohibit usage on a mass scale.

Hence selection of the test for only some high risk individuals is the key. At present, due to its inherent dangers, recent “appropriateness criteria” from bodies such as the American Heart Association mention that the test is definitely ‘inappropriate’ for low or intermediate risk patients but its value is “uncertain” for high risk individuals. *

“Uncertain” means that the authors were equally divided between agreeing and disagreeing with the appropriateness of the test and opine that the test “may be generally acceptable and may be a reasonable approach for the indication”.

So, on the one hand we have a test which can easily tell us whether disease is present or not – a disease which takes away or damages young lives in India. On the other hand we may expose normal people (already exposed to a host of pollutants and radiation) to harmful radiation.

Although the balance is thus evenly placed, one would like to tilt it in favor of doing the test in high risk individuals especially young Indians who are inherently at a risk higher than western counterparts (to whom the appropriateness criteria properly apply).

So, to answer the question posed at the beginning: “Should all Indians above 40 years of age undergo screening with coronary CT angiography ?”

Well, not all, but only those at high risk of any age may undergo the test..

It may be very useful in a young man of 35 with risk factors, esp a strong family history of premature heart disease, while it may not be useful and cause more harm than benefit in a man of 60 with low risk.

Thus in view of the wide prevalence of severe coronary artery disease in young Indians, coronary CT angiography may be used for “routine screening” of high risk individuals based on the number and severity of risk factors such as diabetes, hypertension, abnormal lipids and family history of premature heart disease (below age 56 in brothers or father and below 65 yrs in mother or sisters). Then, if presence of disease is confirmed by the test, vigorous life style changes and even preventive medications like statins and aspirin may make a difference between life and death for these individuals.


*People are divided into low, intermediate or high risk for heart attack in next ten years based on the presence and severity of ‘risk factors’ in them.
Low risk correlates with a 10-year absolute CHD (coronary heart disease) risk <10%, intermediate risk correlates with a 10-year absolute CHD risk between 10% to 20% and high risk is defined as a 10-year absolute CHD risk of >20%, the presence of diabetes mellitus in a patient 40 years of age, peripheral arterial disease or other coronary risk equivalents (prior angina, heart attack etc) This ‘scoring’ of risk is done by noting risk factors in an individual like hypertension, diabetes, abnormal cholesterol levels, smoking, family history of premature heart disease etc. and logging on to :
http://www.framinghamheartstudy.org/risk/coronary.html
http://hp2010.nhlbihin.net/ATPiii/calculator.asp