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

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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!”