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HEALTH GUIDE

Indian Doctors Forum Kuwait

HEALTH GUIDE

Indian Doctors Forum Kuwait

Editors-in-Chief Christus Thomas Suhail A. R. Doi Editorial board Devarajan Viswanathan K. M. Sharfuddin K. V. Johny Mariam Chishty Riaz Ahmed Khan Rameshwar Lal Bang Uppal Singh Vinod Grover Office Bearers President: Ramesh Pandita Adviser & Ex-President: Narayanan Nampoory Vice-Presidents: Riaz Ahmed Khan, Saroj Bala Grover Gen. Secretary: Amir Ahmed Kanjarandy Joint Secretary: Sajid Mohd Saleh Burud (Finance) Rajendra Kumar Mishra (Membership/Public Relations) Tahseen Saadath Khan (Socio Cultural Events) Unni Krishnan R (Community Activities) Treasurer: D. S. Rao Joint Treasurer: Bhaskar Ramgopal Gupta Website: Muzafar Gani (Administrator), Cherian Thomas (Moderator)

President's letter

The Indian Doctors Forum (IDF) under the guardianship of the Kuwait Medical Association (KMA) has grown into a vibrant organization furthering the long-established Indo­ Kuwait friendship. The IDF complements the health education efforts of the Ministry of Public Health and the KMA by conducting free medical camps, open houses, interactive `meet the specialist' health seminars and school health programs. These programs have been highly successful with enthusiastic public participation and remarkable support from the KMA, the Kuwait Diabetic Society and various voluntary organizations. In 2006, the IDF instituted the annual IDF­KMA oration award to recognize the contribution to medical education and research by physicians in India. The first award was given to Professor Mamen Chandy for his contribution in the field of hematology and bone marrow transplantation. The IDF is pleased to publish the third volume of its widely acclaimed health guide. This volume focuses on lifestyle associated diseases. Lifestyle plays an important role in heart disease, obesity, diabetes, stress, cancer, acquired immunodeficiency disorders and other diseases. Lifestyle modification can therefore reduce the risk and consequences of these diseases. I wish to thank the Chief Editors, Dr Suhail Doi and Dr Christus Thomas, the editorial board and the contributors for producing an important source book for the public. We are grateful to our sponsors for making this project a reality. Indian doctors have carved out a niche for themselves by their humane and high quality professional service. The IDF thanks the Government and people of Kuwait for giving us this opportunity. The IDF has been able to conduct its activities successfully due to support from the Ministry of Public Health, the Kuwait Medical Association, Faculty of Medicine, Kuwait Institute of Medical Specialization, The Embassy of India and citizens and residents of Kuwait. I thank all of them for their support. The IDF members and their families have shown tremendous enthusiasm. I am sure the IDF will work with greater vigor to reach out to the community and its members and their families. Dr Ramesh Pandita President, Indian Doctors Forum

Copy edited and typeset by authorserv.com 2007

Table of contents

Editors' note Healthy diet and obesity S. A. R. Doi and M. Naushed Physical activity A. J. Rajendran Yoga C. Ambalavanan Stress A. J. Rajendran Headaches S. Moorthi Alcohol T. Solomon Tobacco B. Jayakrishnan Maternal lifestyle B. Gupta Osteoporosis S. A. R. Doi Eating disorders S. Narayanan Obesity and the metabolic syndrome A. Chattopadhyay

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Type 2 diabetes mellitus H. A. Khan Cholesterol C. G. Suresh Hypertension T. K. George Coronary artery disease C. S. Thomas Stroke S. Lamdhade Lung disease P. C. Nair Gastrointestinal and liver disorders M. Naushed Chronic kidney disease R. K. Gupta The hospital care of accident victims V. K. Grover

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Editors' note

The focus of this volume of the Indian Doctors' Forum Health Guide is on lifestyle-related disorders. Health as we know it is not just the mere absence of disease. Wholesome health involves integrating the spirit, soul and body, releasing energy and creating a sense of wellbeing that goes far beyond physical fitness. A particular lifestyle is a habit that is established over a period of time. It is a result of a series of deliberate choices by the individual made over a period of time. Choices are in turn made based on the information available to us. This emphasizes the importance of the information we receive. This third volume of the IDF Health Guide is a sincere attempt to provide scientific facts in a way that is easily understood by the public. We also believe that our readers are going to make healthy decisions and lifestyle changes based on the facts provided in this guide since lifestyle choices play a large role in determining our overall level of health. The geentics that we inherit from our parents are certainly part of the equation, but it is empowering to know that our conscious actions can make a real difference in our physical and emotional state. Even small changes in certain habits and behaviors can lead to big improvements in overall health and wellbeing. It is important to remember that you can take charge of your life. Here we provide you with the information to help you change your lifestyle for the better. Some of the important aspects of lifestyle covered in these articles are: diet, activity and exercise, relaxation, stress, addictions, attitude and motivation. As you go through the articles look for information that will help you make improvements in these areas. Although the general layout and presentation of the guide remain similar to the previous two issues, a few changes have been made this year. First, we have changed the title to "Health Guide" rather than "Key to Good Health" in an attempt to standardize the presentation of this annual publication. We have also reached the decision that the cover outline will remain unchanged from this issue onwards with only the background graphics and theme title changing each year. We have also formalized the process of review and editing by creating a formal editorial board to support the editors-in chief and to standardize the contents of the guide. We have also utilized professional copy editing services for the first time (authorserv.com). Finally, we appreciate the sincere efforts of the authors who have contributed to this Health Guide. We thank our honorable President Dr Ramesh Pandita and all the executive committee members of the IDF who have advised us and supported us in this venture. We also acknowledge the significant role played by the companies advertising within this Health Guide. Enjoy reading, make good decisions, and march forward into wholesome living. Christus Thomas Suhail A. R. Doi Editors-in-Chief Health Guide 2007 Email: [email protected]

Healthy diet and obesity

Suhail A. R. Doi and Mohamed Nausheda

Recommendations for a sensible diet include the following.

Carbohydrates

A diet high in fruits and vegetables is supported by the health benefits of reduced cardiovascular risk. Eat a healthy diet with a lot of vegetables, fruits, and whole grains and a limited amount of red meat. Get at least five servings of fruits and vegetables every day. More is even better. Tips for achieving this goal include: · Make fruits and vegetables part of every meal. Frozen or canned can be used when fresh is not convenient. · Put fruit on your cereal. · Eat vegetables as snacks. · Have a bowl of fruit out all the time for kids to take snacks from. It is not just the quantity of carbohydrates, but rather their quality, that is important. It is now well established that even when foods contain the same amount of carbohydrate, there are clinically significant differences in their glycemic effect. These differences led to the development of the concepts of glycemic index (GI) and glycemic load (GL):

Dr Suhail Doi is an Endocrinologist (Mubarak Hospital) and Dr Naushad is a gastroenterologist (Al-Amiri Hospital). Email: [email protected] and [email protected]

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· Glycemic index is a measure of the relative impact of carbohydrate-containing foods on blood glucose. · Glycemic load is the product of the GI value of a food and its carbohydrate content. The concept of the GL was developed in response to concerns that the GI cannot capture the entire glucoseraising potential of dietary carbohydrates because the blood glucose response is influenced not only by the quality of the carbohydrate consumed (i.e. the GI), but also by the quantity of carbohydrate consumed. The GI and GL may have health implications since diets high in GI and GL are associated with increased risk of developing type 2 diabetes mellitus (DM), coronary heart disease (CHD), and some cancers. Although not all studies are in complete agreement, and further research is clearly needed, the majority of evidence supports the clinical utility of these nutritional concepts. There are several means to achieve a lower dietary GL: · · · · Replace carbohydrate with protein Replace carbohydrate with fat Substitute a low-GI carbohydrate for a high-GI carbohydrate Combine all three methods

Precisely which strategy works best for healthy weight control and reduction in risk of type 2 DM and CHD remains uncertain. Nevertheless, the available evidence is in support of a diet with an overall low GL in which carbohydrate sources are mainly comprised of fruits, vegetables, and whole grains. These dietary approaches to risk reduction may be particularly effective among those who are already overweight. The GIs and GLs of several foods are available on the web at http://www.glycemicindex.com. This site allows the user to enter many different foods and determine both the GI and GL. It also has general suggestions for maintaining a diet with low GI and GL. The following values are generally applied for defining the GI of a particular food:

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· Low GI 55 or less · Medium GI 56­69 · High GI 70 or more The following values are generally applied for defining the GL of a particular food: · Low GL 10 or less · Medium GL 11­19 · High GL 20 or more The following values are generally applied for defining the GL per day: · Low GL · High GL less than 80 more than 120

We must remember that if we are on a low-carbohydrate diet, healthy choices for fat (mono- and polyunsaturated fats) and protein (fish, nuts, legumes, and poultry) are encouraged because of the association between saturated fat intake and the risk of CHD. Other elements of the diet, including vitamin supplements, may be important for other reasons as mentioned below.

Fats

Trans fatty acids and saturated fats should be avoided and replaced with monounsaturated and polyunsaturated fats. The major sources of trans fats include margarines and partially hydrogenated vegetable fats. These fats are present in many manufactured foods (e.g. store-bought bread and cookies). Another major source is oils that are maintained at high temperatures for a sustained period of time, such as in fast food venues where oils are used to fry meat and potatoes repeatedly; thus these foods should be avoided. It is important to cut down on bad fats (trans fatty acids and saturated fats) and consume good fats (polyun-

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saturated and monounsaturated fats like olive oil and canola oil). Tips for achieving this goal include: · Choose chicken, fish, or beans instead of red meat or cheese. · Cook with oils that contain a lot of polyunsaturated and monounsaturated fats, like olive oil and canola oil. · Choose margarines that do not have partially hydrogenated oils. Soft margarines (especially squeeze margarines) have less trans fatty acids than stick margarines. · Eat fewer baked goods that are store-made and contain partially hydrogenated fats (e.g. many types of crackers, cookies, and cupcakes). · When eating at fast food restaurants, choose items like broiled chicken for yourself and your family. Supplement use, most often in the form of a multivitamin, provides folate which is highly bioavailable, and it is supported by evidence for several chronic conditions. Specific supplements of vitamin E for the primary prevention of CHD do not appear to be of benefit. Calcium supplements, may be useful to prevent loss of bone density among older women and men. Get enough folate every day (400 micrograms per day). Tips for achieving this goal include: · Take a daily multivitamin containing 400 micrograms of folate. · Eat breakfast cereal that is fortified with folate. Check the label to be sure. · Eat fruits and vegetables that are rich in folate, such as oranges, orange juice, and green leafy vegetables. Avoid alcohol. Tips for achieving this goal include: · Choose non-alcoholic beverages, such as juices and sodas at meals and parties. · Avoid occasions centered around alcohol. · Avoid making alcohol an essential part of family gatherings.

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Obesity and overweight

Obesity refers to excessive fat deposition in the body. The prevalence of obesity is a serious health problem reaching epidemic proportions in most developed and developing countries. The most common measure of obesity is the body mass index or BMI calculatied by dividing weight in kilograms by the square of height in meters. A person with a BMI between 25 and 30 is defined as overweight and a BMI greater than 30 is called obese. Obesity occurs when a person consumes more calories than he/she burns: eating too much and exercising too little. Energy that is not consumed must be stored. Obese persons become more obese because of cumulative excess in energy intake. One of the most important factors in weight gain is a sedentary lifestyle. People are much less active today than they used to be. The growing prevalence of obesity is probably the natural consequence of changes in our environment. Metabolic demands have declined as computer technology and prosperity have eliminated many of our routine day to day physical activities that burn energy. Leisure time once devoted to outdoor activities is now more commonly spent watching TV or playing on a computer. If food intake is not reduced appropriately to meet the reduced demands, weight gain can occur. Many modern-day parents are too over-enthusiastic about the "growth" of their kids and overfeed them with a highly nutritious, high calorie diet resulting in the proliferation of adipose tissue. Over indulgence in junk foods with high calorific value and a relative lack of physical activities, etc. contribute a lot to excessive fat accumulation.

Health problems associated with obesity

Obese persons are at higher risk of developing serious medical problems such as high blood pressure, diabetes mellitus, high cholesterol, coronary heart disease, strokes, gallstones, etc. They are also at higher risk of developing degenerative arthritis in the major weight-bearing joints due to extra wear and tear.

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Lifestyle modifications to control obesity

The best way to avoid obesity is to maintain a healthy weight. The key to a healthy weight is regular exercise and good eating habits.

Exercise

To stay active try to exercise for 30­60 minutes daily. Walking, swimming, cycling and stretching are all good to burn calories. Go outside for a walk. Take the stairs instead of using the elevator. Walk to nearby places such as school or a relative's house instead of driving. Park your car farther away than you need to and walk the extra distance. Get actively involved in home making. Do it yourself ­ cleaning the house, vacuuming, washing the bath room, hand washing your clothes, washing your car yourself ­ all these help you to burn a lot of calories. Limit your time watching TV.

Eating habits

1. Restrain your eating and do not overeat. Many people have a pattern of conscious limitation of food intake termed "restrained" eating. This restraint pattern is common in many, if not most, middle-aged women who are of "normal weight". It may also account for the inverse relationship between body weight and social class; women of higher socioeconomic status more often maintain their weight. Overeating relative to energy expenditure will uniformly cause obesity; most obese subjects have lost control of their eating (disinhibition). 2. Avoid fast food restaurants Frequent fast-food consumption may be associated with weight gain and risk of type 2 diabetes. This was illustrated by the CARDIA study which found that,

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compared to subjects who ate fast food infrequently (less than once per week), and after adjustment for other lifestyle factors, subjects who consumed fast food frequently (more than twice per week) at baseline and follow-up gained an extra 4.5 kg of weight and had a twofold increase in insulin resistance. 3. Avoid fruit juices and soft drinks. 4. Eat when you are hungry ­not when you are bored. Avoid binge eating. Binge-eating disorder is a psychiatric illness characterized by uncontrolled episodes of eating that usually occur in the evening. The patient may respond to treatment with drugs that modulate serotonin release or reuptake. Please consult your doctor. Recognize a progressive increase in eating. A small number of subjects begin to be overweight in childhood and then have relentless weight gain, and usually weigh more than 140 kg (300 lb) by age 30 years. Because about 22 kcal/kg is required to maintain an extra kilogram of body weight, their energy requirements increase year by year; this means that weight gain must result from progressive increases in caloric intake. 5. Pay attention to portion sizes. Serve food portions on smaller plates. The food then appears to be a larger helping. The frequency of eating changes lipid and glucose metabolism. When normal subjects eat several small meals a day, their serum cholesterol concentrations are lower than when they eat a few large meals each day. Similarly, mean blood glucose concentrations are lower when meals are frequent. One explanation for the effects of frequent small meals versus a few large meals could be the difference in insulin secretion associated with these meal sizes (i.e. increased with large meals). 6. Don't eat meals or snacks while watching TV.

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This usually occurs at night. Night-eating syndrome is defined as consumption of at least 25% (and usually more than 50%) of energy between the evening meal and the next morning. It is a well-known pattern of disturbed eating in the obese. It is related to sleep disturbances and may be a component of sleep apnea, in which daytime somnolence and nocturnal wakefulness are common. 7. Avoid excess dietary fat & carbohydrate intake. Epidemiological data suggest that a diet high in fat is associated with obesity. The relative weight in several populations, for example, is directly related to the percentage of fat in their diet. However, a high fat diet, which often results from the introduction of palatable foods into the diet, may result in overeating to obtain enough carbohydrate and this may be the ultimate cause of the weight gain as high fat intake per se is self-limiting. Generally, longer term weight loss trials have found no significant difference in net weight loss between persons on low-fat versus other weight-reducing diets, suggesting that fat reducing-diets are no more effective than calorie-restricted diets in achieving longterm weight loss.

Physical activity

A. J. Rajendrana

If only I could be a little stronger, I would look lovely thought Treesa for the umpteenth time as she kept gazing at herself in the mirror sporting a new pair of jeans. But for the few health conscious, regular exercise takers, most of us would have thought along similar lines at sometime or other. Well, time and again, we read in newspapers, health magazines and books that physical activity is beneficial and that it improves our physical and mental wellbeing. There is more to it ­ more news, both good and bad. The bad news is that "physical inactivity is harmful" say recent studies and the good news is that physical activity need not be strenuous to achieve health benefits. The World Health Organization says:

Physical inactivity is a serious worldwide problem. It poses a public health challenge for reducing the burden of unnecessary illness and premature death. Prevention of diseases through physical activity and healthy lifestyles is the most cost effective and sustainable way to tackle these problems and to support positive social development.

The WHO logo is: "MOVE FOR HEALTH". Decades of research suggest that people who are usually inactive can improve their health and wellbeing by becoming even moderately aca

Dr AJ Rajendran, specializes in Rehabilitation Medicine and has pioneered the concepts of Cardiac Rehabilitation at leading hospitals in Chennai, India. He currently works at the Physical Medicine & Rehabilitation Hospital, Ministry of Health, Kuwait. Email: [email protected]

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tive on a regular basis. Also, greater health benefits can be achieved by increasing the amount (duration, frequency, or intensity) of physical activity. Regular physical activity performed on most days of the week reduces the risk of developing or dying from some of the leading causes of illness and death. More energy, less stress, healthy weight control, healthier arteries, better defenses against flu or colds, and most of all a sharper mind, are some of the many benefits of exercise. "Nothing else you can do for yourself has more benefits than regular exercise" is the unanimous message from the experts in exercise physiology. Now that the importance of physical activity in the maintenance of optimum health is recognized, the question is how to get started and keep going. To start with people can select an activity that they enjoy and that which fits into their daily lives. Longer sessions of moderately intense activities can yield the same benefits as shorter sessions of more strenuous activities. Moderate activities would include washing and waxing a car, washing windows or floors, gardening, cycling, walking, swimming, rowing, playing a game of your choice and stair walking. No one exercise is better than another. Your only goals are to move your body, pump up your heart rate and have fun doing it. How you choose to do it is only a matter of preference. A moderate amount of physical activity is roughly equivalent to physical activity that uses approximately 150 Calories (kcal) of energy per day, or 1000 Calories per week. You do not need a gym membership and you do not need to invest in costly machines to do beneficial activities. To avoid soreness and injury, individuals contemplating an increase in physical activity should start out slowly and gradually build up to the desired amount to give the body time to adjust. People with chronic health problems, such as heart disease, diabetes, or obesity, or who are at high risk for these problems should first consult their physician before beginning a new program of physical activity. Also, men over age 40 and women over age 50 who plan to begin a new program should

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consult a physician first to be sure they do not have heart disease or other health problems. A basic exercise plan should include breathing exercises, warm up time, the aerobic activity where we move the large muscle groups, and the cool down period. Stretching and strengthening plans could be an add-on for fitness. The value of breathing exercises incorporated into our everyday routine is immense. A few nice deep breaths can be so relaxing. This can be done anywhere, anytime and is not obviously visible to others. Word has it that when people are stressed, they tend to take short little breaths rather than deep, relaxing ones. Most of us do not know that if we "learn" to breathe effectively, we can control stress in our life. The American Heart Association advocates abdominal breathing techniques, in which we are asked to take a deep breath in, while allowing the abdomen to move out, and to breathe out through a pursed lip, slowly and steadily for a longer time as the abdomen moves inwards. The same technique, if done for a few minutes adds more energy to a person who has increased his/her physical activity. Range of motion exercises are exercises in which each major joint in the body is excursed to its full range. It is beneficial even in older adults and in patients with diabetes. This helps to prevent stiffness in the joints that are beyond everyday functional usage. In general, it helps to improve the flexibility of the joints. This allows for easier movements and reduces wear and tear in joints so that it is also easier to perform the daily activities of independent living. By adding stretching to our daily physical activity plan, we can help keep our joints flexible which will help us to move better. Aerobic activity (also known as cardiorespiratory or cardiovascular endurance activity) is the most important. It keeps the heart healthy, lowers blood pressure, and relieves anxiety and depression. A simple walking plan is to start walking slowly with a gradual increase in pace every minute for 5 minutes (warm up), followed by brisk walking for 5

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minutes, at an enjoyable speed and talking comfortably to our partner. Another 5 minutes of slow walking, with gradual decrease in pace every minute, completes the cool down time. The brisk walking period, alone, can be increased by 2­3 minutes every week. This plan leads to a 30-minute brisk walking program in 12 weeks. The same plan is advocated by the American Heart Association even for patients recovering from heart ailments and is therefore extremely safe for beginners. After a good work out give yourself some time to relax. Sit in the shade and rest your eyes; feel pleased with your accomplishments. Sip a healthy drink and just enjoy the beauty around you. Once aerobic activity is an established routine, we should add a mild strengthening program, popularly known as pumping iron. The strengthening program should be started slowly. It is vital to rest for one full day between the strength training of each muscle group and to stop if it hurts. Strength training is recommended for all adults, but it is a vital link to health for older adults. The reason is that strength training prevents sarcopenia, the muscle deterioration that comes with aging, and also helps maintain bone mass. "Stronger people have better health outcomes", notes Dr David Buchner, renowned gerontologist. If you can't find a steady schedule of workouts, don't feel you have failed. Instead look for opportunities to make movement a part of everyday life and you will find them. Studies show that taking a lifestyle-based approach to exercise can improve fitness almost as much as a structured program. Sedentary people will benefit this way. Become active throughout your day and encourage your family to do the same. Take the stairs and park your car further away and walk. When you move, you now know that you are improving your health. The Centre for Disease Control and Prevention and The American College of Sports Medicine, jointly established a planning committee of five scientists. They, in turn, selected fifteen other specialists on the basis of their research expertise in issues related to the health implications of physical activity. Major issues related to physical activity and health were drafted with inputs from several relevant professional, scientific organizations and federal agencies. A concise "public health

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message" was developed and it read "Every US adult should accumulate 30 minutes or more of moderate intensity physical activity on most, preferably all, days of the week". With all this in mind, what are we waiting for? Let's get started and give our self a healthy body and a healthy mind so that we are the best we can be.

Yoga

C. Ambalavanana

Yoga, the word derived from Sanskrit, means the joining of the body, mind, and spirit. It has been practiced for more than 2000 years. The Indian sage Patanjali, known as "The Father of Yoga", in Yoga Sutras, defined yoga as "that which restrains the thought process and makes the mind serene". He emphasized that yoga provides a psychological approach to healing the body and achieving self-realization. Persons would be able to cleanse their bodies' organs and systems and achieve a higher state of consciousness by performing postures, known as Asanas, and by controlling breathing, known as pranayama, People who acknowledge the role of the mind in healing are practicing a yogic philosophy.

What is Yoga

· It is an applied science of mind and body. · It harmoniously integrates body, mind and spirit. · It offers instruction and insight into every aspect of an individual's life. · It is an ancient science (practiced for more than 2000 years). · One of the oldest forms of healing therapy. · Now studied by scientists all over the globe for its therapeutic effects (healing and relaxation).

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Dr Ambalavanan works with the Physical Medicine and Rehabilitation Hospital, Ministry of Health, Kuwait. Email: [email protected]

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Asana

Asana is a way to sit and to relax. Asana is a great way of sitting to think realities. Asana is one of the great divine tonics for curing ailments. Postures are gentle stretching movements designed to rejuvenate the brain, spine, glands and internal organs. · Increases blood circulation and life force (prana) into the specific target organs. · It often produces slight squeezing of the organ or gland. · · · ·

Pranayama

· It is a specially developed breathing technique. · It produces a huge store of energy and vitality. · Improves cardiopulmonary compliance.

Meditation

· The benefits of the postures are greater if we concentrate on the healing action. · For this we can incorporate a variety of affirmations. · When we concentrate our mind on affirmations the power of prayer is obtained and healing is ensured.

Sequence

· · · · · Sun salutation Asanas Relaxation Pranayama Meditation

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Why Yoga?

· Yoga works on the mind and the body at the same time. · It places emphasis on the inter-relationship of the mind and body.

General rules for performing yoga

· Asanas should be done on empty stomach or at least 4­5 hours after food. · The routines are done very slowly, gracefully and with out being tense. · It is advisable to relax for a few seconds between two different poses and do deep breathing 5­10 times before the next pose. · Rest for 10 minutes when you finish asana in savasana or corpse pose in order to relax your body and mind. In the beginning you may find tightness in various muscles. This is due to biological shortening of the ligaments. · You have to practice for at least 6­12 months to obtain benefit from yoga. · Regularity is the most important factor. · The simplest way to find out about yoga is to practice it with faith, courage and awareness. · Therapeutic yoga is tailor-made and it should be practiced with the help of qualified yoga professionals.

Recommendations for practicing yoga

1. It involves control at all levels, such as physical, emotional, mental, intellectual and spiritual, recognizing the effects of stress, emotional imbalance, and dietary and living habits. 2. Exercise tolerance should be measured before beginning a program. Start with simple movements and positions before progressing gradually to complicated postures.

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3. It is better to practice the prescribed yoga in the morning or in the evening for 40­60 minutes according to one's capacity. Practice before meals, but 30 minutes after consuming liquids. 4. Perform the movements slowly and smoothly, stretching the limbs and joints, and gently compressing the abdomen, without straining. Avoid exertion and heavy muscular activity. Maintain the postures for a comfortable length of time. Depending upon the posture and capacity of the patient, the maintenance period of postures should be increased gradually from 5 seconds to one minute, or even longer. 5. It is essential to focus on breathing during the maintenance period of the posture, with the eyes closed, as a means of learning to focus the mind and to manage stress and tension in the body. 6. Systematically relaxing all of the parts of the body in savasana at the end of the session is mandatory, or after completing several postures, if one begins to feel fatigued. 7. The practice of Udiyana bandam, or the abdominal squeeze, has also been found to be useful. 8. Meditation practices have been shown to help the endocrine glands through relaxation of the sympathetic nervous system.

Conclusion

1. Yoga is easy to learn and practice from a qualified yoga therapist. 2. It can be practiced at all ages. 3. It is cost effective and does not require any specific equipment to practice. 4. A calm and environmentally friendly atmosphere is sufficient. 5. Studies have confirmed that yoga stimulates insulin-producing cells in the pancreas, thus helping to control and prevent diabetes. The simplest way to find out about yoga is to practice it with faith, courage and awareness.

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Examples of yoga procedures and their benefits

1. Surya Namaskar (Sun Salutation)

This exercise is to be done at the beginning. It loosens up all the joints and muscles and is a must before doing any other yogic techniques. 1. Stand up, hands together at chest level, feet together. 2. Raise the arms and the head as high as possible while inhaling deeply. 3. Bend the body forward so that the hands touch the ground at the side of the feet. The head should touch the knees, the legs remain straight. Exhale. 4. Throw the left leg to the rear with the knee touching the ground. Raise the chin as high as possible. Inhale. 5. Throw the right leg back and let the legs form a straight line, arms extended. Hold the breath.

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6. Bend the arms and let the body rest on the ground; only the forehead, chest, hands, knees and toes are in contact with the ground. Exhale. 7. Raise the head and push on the arms to bring the trunk upright, the legs and pelvis staying on the ground. Inhale. 8. Without moving the feet and hands raise the entire body again, arching the back. Exhale. 9. Bring the left leg forward again to repeat the reverse of position 4. Inhale. 10. Stretch the legs, letting the hands remain on the ground as in position 3. Exhale. 11. Return to position 2 and inhale. 12. Drop the arms and relax. Exhale.

2. ArdhaMatsendrasana (Spinal Twist)

Sit down bending the left leg so that the left heel is under the buttocks. Pass the right leg over the left thigh, the foot flat on the ground. Pass the left arm behind the left knee and grasp the right foot with the left hand. Turn the entire body and the head towards the right side. Breathe 6­8 times. Repeat this to the left. Return slowly in reverse order. Repeat twice on each side.

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3. Dhanurasana (Bow Pose)

Lying on the stomach, fold the legs backward. Catch hold of the ankles with the hands. Raise the knees and thighs up, pushing the heels away from the buttocks. Do not bend the elbows. Raise your chin and chest up. Look up. Breathe 8­10 times. Return in the reverse order. Repeat twice.

4. Paschimottasana (Head to Knee Pose)

Sit in the long sitting position. Take your hands towards your toes as you lean forward. Catch hold of your toes with your hands and take your forehead down to touch the knees. Do not bend the knees. Breathe 6­10 times. Return slowly in reverse order. Repeat twice.

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5. Halasana (Plough Pose)

Lie on your back full length, legs together, arms pressing down to the sides. Raise legs through 30 degree, 60 degree and 90 degree angles. Lift the trunk and touch the toes on the ground beyond your head. Keep the knees straight. Press the chin against the chest. Breathe 6 to 10 times. Return slowly in reverse order. Repeat twice.

6. Trikonasana (Triangle Pose)

Stand up legs apart, arms stretched out at shoulder height. Inhale. Bend your body to the side so as to touch the toes with the hand, arms and legs extended. Exhale. Come back to the first position inhaling again. Do the same movement alternately to right and left. Repeat 4­6 times.

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7. Padmasana ( Lotus Pose )

Sit with the legs stretched fully forward. Then bend the right leg at the knee joint and folding it, rest the right foot on the left thigh with the sole turned up. Let the right knee touch the floor. When the right knee touches the floor, fold the left leg so that the left heel rests on the right thigh with the sole turned up. Stretch the arms resting the wrists on the corresponding knees, with the palms turned up and index finger and thumb touching each other. Keep the head, neck, and the trunk in a straight line. Breathe normally.

8. Vajrasana

Fold one leg at the knee joint and place the sole under the buttock of the same side by turning it upward. Place the other sole in the same way. The toes should touch and the soles be apart. The knees should be together. Place the palms on the respective thighs. Keep the head, neck, and the trunk in a straight line. Breathe normally.

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9. Savasana (Relaxation)

Lie flat on your back. Stretch the legs so that the heels are a little apart and the feet fall outwards. Let the arms rest alongside the body on the floor, the palms facing upwards and the fingers limp and slightly curled. Close your eyes and relax completely. Take some time to become calm and steady. As you breath in feel calmness diffusing through the whole body. As you breathe out say to yourself mentally r-e-l-a-x.

10. Pranayama

The postures recommended for Pranayama are Pasmasana, Sukkasana Vajrasana 1. Bhasthrika pranayam ­ Inhaling and exhaling through the nostrils with mouth closed for 2 minutes or 30 times. 2. Kapal Bhathi ­ Simply blow the nose slowly and effectively for 5­10 minutes or 300­600 times. 3. Anuloum-Vilom ­ Inhale and exhale by closing one nostril and the other intermittently and slowly for 150­300 times. 4. Bahayu ­ First inhale and forcefully exhale through the nostril, pull the abdomen in and hold the breath for 10 seconds. 5. Agnisar ­ Repeat and shake the abdominal wall for 20 times after holding the breath.

Stress

A. J. Rajendrana

Why is this word giving us tremors, setting our hearts racing and our lungs panting harder? In day to day life, stress comes from a number of sources, e.g. worries about situations beyond our control, fears of illness or financial ruin. Mostly, the factors that cause stress are unavoidable and knowing what they are and how they work, can lessen their strength. Take for instance, a 30-year-old Mr D in the prime of his life, an executive in a multinational company and an expectant father. One day he presents with symptoms of giddiness and blurred vision and it turned out to be "hypertension". This was due to the fear of being retrenched because of the recent merger of his company with a bigger one. Mr K was leading a happy married life. He happened to befriend a woman and as time went on, the relationship grew very intimate. He now went to great lengths to please her, to the extent of sacrificing his foreign assignments to be with her. Subsequently he realized that his so-called friend had a darker questionable side. What do you think was the impact on him? "A total nervous breakdown". A closer look at his family showed that his wife and father, who were aware of the entire scenario, had very high stress levels too. In the instances cited above, "stress'' was the major destructive power causing havoc in their lives. Stress comes in all shapes and sizes and

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Dr A J Rajendran, specializes in Rehabilitation Medicine, and has pioneered the concepts of Cardiac Rehab in leading hospitals at Chennai, India. Email: [email protected]

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has become so pervasive that it seems to permeate everything and everybody. It is hard to get through the day without hearing or reading something about stress. It is a common misconception that stress is due to a bad change and is most often correlated with negativity in life. However, the truth is that anything "good" or "bad" that causes a change in life is stressful. It may be what is called "eustress" or "distress". For instance, events like promotion, marriage, pregnancy, etc., which are usually welcome changes in one's life, can cause stress. It is not the "acute tension" that does the actual harm, but its accumulation over a prolonged period that is destructive. International researchers have proved that overall individual life stress has increased by 45% over the past 40 years.

Stress by itself can kill

One of my favorite researchers in Stress Medicine is Dr Robert S. Elliot, MD, Director of the Institute of Stress Medicine, Nebraska, USA. In his book "From Stress to Strength", he explains how he realized the fact that stress by itself can kill and the importance of effective stress management. In spite of being a cardiologist, and having tested negative for possible coronary artery disease, he suffered from a "totally unpredictable heart attack". It was then that he realized that coronary artery disease is not the only cause of heart attacks; he had been what he now calls a typical "hot reactor" for a period of more than 20 years prior to the attack. "Hot reactors", he says, "are those individuals who exhibit extreme cardiovascular arousal in response to standardized stress test." Here are a few excerpts from the book that I am sure will help the reader realize that stress is a silent killer.

Sudden death at NASA

In 1968, when Dr Robert Elliot was asked to be a Consultant to the National Aeronautics and Space Administrations Installation, at Cape Canaveral, he discovered a fatal side effect to the space program. Strong and healthy aerospace engineers and scientists, mostly aged between 28

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and 35, were dropping dead for no apparent reason. His task was to investigate the puzzling rise in the numbers of people suffering from sudden cardiac death (SCD) at the space centre. A look at the medical histories of the NASA workers revealed nothing to explain the high rate of SCD. He then began analyzing the autopsies of the former space workers. Even though their coronary arteries were rarely blocked, mysterious microscopic lesions appeared in the fibers of the heart muscle themselves. He then wondered if these lesions could have led to electrical short circuits and fatal heart rhythms. Years later, his theories were confirmed when he discovered that large doses of adrenaline-like chemicals normally released during stressful situations could produce these lesions now called "contraction bands". When he broadened his search for the risk factors, he discovered that "environmental instability" was the only factor all the workers had in common. Further analysis showed that for most of the SCD victims, the greatest source of instability came from the work site. At this time the customary procedure at NASA was to reduce staff drastically as soon as a rocket program was completed. Typically, 15% of those specialized aerospace workers who had made the launch possible were laid off. The technical expertise these engineers possessed was of no value outside the space programme. In order to feed their families, they were forced to move from their area, take up mundane lower paying jobs with the hope if catching a ride on the next space program. This sense of impending personal catastrophe, coupled with the rigors of the work itself, meant that these engineers and scientists were living in a work environment characterized by a loss of control. Anxiety, depression, anger and a sense of helplessness were their daily companions. Both those laid off and the managers who had to do the firing were dying from stress.

Death due to stress

Death due to stress is as primitive as our civilization. Quoting a typical example from the popular Indian history of Kannagi and Kovalan, the glorious ruler of the Pandiya Kingdom, Nedunchezian and his wife Koperum Devi collapsed the minute they realized they had convicted

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an innocent man. It was not the deed of the Gods but sudden cardiac death due to stress by guilt. Have you heard of the stirring tale of the professor who was held in high esteem for his knowledge and dedication and was hailed by his students as a paragon of virtue? But unfortunately, he fell into the clutches of a nightclub singer and became her willing slave. Soon after marriage, she started to debase him and the stunned professor became nearly insane and went back to college to recapture the past. He died in a vacant classroom thinking of his past glory. This is the well-known classic movie "The Blue Angel" which catapulted Marlene Dietrich of to fame in the 1930s. This is a classic example of how repeated negative and stressful thoughts can act as a slow poison, finally leading to death. We can now test ride the heart under conditions of mental stress by challenging a person to a series of mild stressors. The new Cardiac Performance Lab (CPL) developed at the Institute of Stress Medicine consists of three stages: the mental arithmetic challenge, the competitive video game and the cold pressure test.

Stress management

"Don't add the fear of stress to the stresses in your life," say the American Heart Association (AHA) and the American Cancer Society in Living Well, Staying Well. Stress is a perfectly normal aspect of the human condition experienced by us all. "Stress isn't necessarily a bad thing ­ it's more of how you handle it." The anxiety relieving strategies and solutions based on the AHA protocols are called positive coping techniques, consisting of progressive muscle relaxation, deep breathing exercises and meditation.

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Relaxation and meditation

An important study by Herbert Benson, MD, and Dean Ornish, MD, has clearly demonstrated that meditation and relaxation can be important, not only in reducing blood pressure and reversing arteriosclerosis, but also in enhancing the quality of your life and performance. Meditation and relaxation are strong antidotes for the fight or flight (alarm) reactions. They produce a reduction in physical levels of adrenaline-like substances and relaxation of muscle tension. The blood vessels open and blood pressure drifts down.

Conclusion

Good health is more than just the absence of illness. Rather, it is a robust state of physical and emotional wellbeing that acknowledges the importance and inseparability of mind and body relationships. It is very important for all of us to join the pursuit of learning how to harness stress and make ourselves more productive rather than selfdestructive. Stress is an unavoidable part of life but it does not have to be a disabling one. The more we know about how it affects us, and why, the less opportunity it has to take hold of us, and the more opportunity we have to either circumvent it altogether or put it to work on our own behalf. We can change our situation. We can change the way we view it.

Headaches

Santham Moorthia

Headaches are undoubtedly the most common reason for medical consultation. Why so many pains are centered in the head is a question of some interest. At least two explanations come to mind: · The face and coverings of the head are more richly supplied with pain receptors than other parts of the body, perhaps to protect the contents of the head. · Four important delicate, highly sensitive structures that reside here must also be protected (eyes, ears, nose, mouth and throat). Frequent headaches can interfere with your daily life but healthy lifestyle choices can help to prevent headaches.

Types of headaches

It is worth knowing about the types of headaches before dealing with lifestyle changes to prevent headaches.

Migraine

Familial disorder, characterized by one-sided headaches, begin in childhood, adolescence or early adult life. A throbbing pain may last for 4­24 hours. Vomiting may also occur. Bright light, noise, tension, and menstrual periods might aggravate the headaches. Darkness and sleep may relieve it.

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Dr Moorthi is a neurologist with the Ibn Sina Hospital, Kuwait. Email: [email protected]

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Cluster headaches

Cluster headaches commonly occur during the night and can occur daily for a period of several weeks to months. If it recurs after many months or years the patient might also notice watering of the eyes, a blocked nose or redness of the eyes.

Tension headache

Pain is felt over the entire head, neck or sometimes the back of the head. The patient feels pressure or tightness of the head, and might also feel worried, anxious or depressed.

Headache due to problems with the eyes, ears, nose, mouth and throat

· · · · · Eye: commonly short sight, long sight or infections of the eye Ear: infection of the ear Nose: sinus troubles Mouth: toothache Throat: throat infection

Lifestyle changes that will prevent headaches

Migraine headaches

· Avoid bright light, loud noise · Dietary items may produce headaches. Avoid items such as chocolate, cheese, fatty foods, oranges, tomatoes · Avoid alcohol

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· Avoid tension · Take medications to relieve the attack and take daily medication to prevent further attacks.

Tension headaches

· Stress: establish what the problem is: self, family, job or otherwise. Solve the problem(s). · Headache diary: maintain a headache diary. Record the number of attacks, how long they last, relation to diet. It helps to establish possible triggers to assist with management in the future. · Medication: avoid taking medications on your own. Get professional advice. · Habits: reduce alcohol, stop smoking. · Exercise: Go for a brisk walking daily to get some fresh air, lose weight, and condition your body. · Sleep: go to sleep at the same time each night, and sleep for at least 8 hours. Stop self-talk and thinking too much especially at night. · Relaxation: Find a regular relaxation method that works for you and practive it daily, e.g. deep breathing, listen to melodious music, yoga. · Diet: reduce intake of coffee and artificial sweeteners. Do not skip meals especially breakfast and avoid hunger. Drink plenty of fluids. Maintain dental hygiene, brushing the teeth morning and night every day.

Eye, ear, nose, mouth, throat troubles

· Eye sight: problems needs to be corrected with glasses. · Ear, nose throat: avoid infection, see a doctor · Sinus troubles: consult an ENT specialist.

Alcohol

Thilak Solomona

The cost to society

In the US, one in four families experience alcohol-related problems. It is estimated that 20­ 25% of all hospital costs result directly from alcohol misuse and abuse. We often read and hear tragic stories of lost lives and health because of alcohol abuse. About 100,000 deaths per year can be wholly or partially attributed to drinking, and alcoholism reduces life expectancy by 10­12 years. Next to smoking, it is the most common preventable cause of death in America and developing countries are not far behind. Although studies indicate that adults who drink moderately (about one drink a day) have a lower mortality rate than their non-drinking peers, their risk for untimely death increases with heavier drinking.

Genetic factors

Genetic factors play a significant role in alcoholism and may account for about half of the total risk for alcoholism, although alcoholism is so complex that it is unlikely that any single gene will ever be identified as a major culprit.

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Dr Thilak Solomon is a Neurologist with the Ibn Sina Hospital, Kuwait. Email: [email protected]

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Alcohol: the facts

Experts are now defining alcohol use by levels of harm that it may cause. This information is useful to determine possible interventions at earlier stages. The following categories of alcohol use and abuse use a definition of one drink as 12 oz of beer, 5 oz of wine, or 1.5 oz (a jigger) of 90% proof liquor. Alcoholism, which is also known as "alcohol dependence syndrome", is a disease that is characterized by the following elements: · Craving: a strong need, or compulsion, to drink. · Loss of control: the frequent inability to stop drinking once a person has begun. · Physical dependence: the occurrence of withdrawal symptoms, such as nausea, sweating, shakiness, and anxiety, when alcohol use is stopped after a period of heavy drinking. These symptoms are usually relieved by drinking alcohol or by taking another sedative drug. · Tolerance: the need for increasing amounts of alcohol in order to get "high".

Restoring pleasure

Alcohol releases the following neurotransmitters (chemical messengers in the brain) and other chemicals that produce pleasurable feelings: · Dopamine: produces euphoria and a sensation of being rewarded. Repeated alcohol use increases sensitivity to dopamine. · Serotonin: produces feelings of wellbeing. · Opioid peptides: important for wellbeing.

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Over time, however, heavy alcohol use appears to deplete the stores of dopamine and serotonin. Persistent drinking therefore eventually fails to restore mood, but by then the drinker has been conditioned to believe that alcohol will improve spirits (even though it doesn't), the reason behind addiction!

Excess alcohol and binge drinking

Excess alcohol consumption can lead to serious health problems, such as: · Cancer, such as gastrointestinal, oral, pharynx, larynx, esophageal and liver cancers, as well as breast cancer in women · Chronic pancreatitis, especially in people with high levels of triglycerides in their blood · Elevated levels of triglycerides in the blood · High blood pressure · Miscarriage · Injuries due to impaired motor skills (e.g. driving, operating machinery etc.) · Sudden death in people with cardiovascular disease · Heart failure · Stroke · Alcoholic cirrhosis of the liver in10­20% · Fetal alcohol syndrome in an unborn child, including slow growth and nervous system problems · Suicide

General effects on the body

Alcohol can affect the body in so many ways that researchers are having a hard time determining exactly what the consequences are from drinking. It is well known, however, that chronic consumption leads to many problems, some of them deadly.

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· Alcoholism can kill in many different ways, and, in general, people who drink regularly have a higher rate of death from injury, violence, and some cancers. · Frequent, heavy drinking is associated with a higher risk for alcohol-related medical disorders (pancreatitis, upper gastrointestinal bleeding, nerve damage, and impotence) than is episodic drinking or continuous drinking without intoxication. · As people age, it takes fewer drinks to become intoxicated, and organs can be damaged by smaller amounts of alcohol than in younger people. In addition, up to one-half of the 100 most prescribed drugs for older people react adversely with alcohol. · Alcohol abusers who require surgery also have an increased risk of postoperative complications, including infections, bleeding, insufficient heart and lung functions, and problems with wound healing. Alcohol withdrawal symptoms after surgery may impose further stress on the patient and hinder recuperation.

Do you have signs of alcohol dependence?

Signs and symptoms in the early stages of alcoholism include increased tolerance to the effects of alcohol, low tolerance for anxiety, need for alcohol at the beginning of the day, or at times of stress, insomnia, nightmares, habitual Monday-morning hangovers, and frequent absences from work, preoccupation with obtaining alcohol and hiding drinking from family and friends, guilt or irritability when others suggest drinking is excessive. The earlier a person begins drinking heavily, the greater their chance of developing serious illnesses later on. Once one becomes dependent on alcohol, it is very difficult to quit. In one study, after 5 years, twothirds of people with alcoholism were still dependent.

Binge drinking

It is not chronic heavy drinkers who have the highest risk of alcoholrelated injuries, it is the moderate drinkers who sometimes drink heav-

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ily who are more like to suffer injuries, especially while they are drinking. How you drink alcohol can influence the risk of heart disease by affecting the accumulation of abdominal fat ­ a body characteristic shown to be an important risk factor for cardiovascular diseases.

Drinking in the elderly population

Although alcoholism usually develops in early adulthood, the elderly are not exempt. A survey of 5000 adults over 60 years reported that 15% of men and 12% of women were hazardous drinkers, and 9% of men and 3% of women were alcohol-dependent. In another study, the prevalence of problem drinking was as high as 49% among nursing home patients. Alcohol also affects the older body differently; people who maintain the same drinking patterns as they age can easily develop alcohol dependency without realizing it. Physicians may overlook alcoholism when evaluating elderly patients, mistakenly attributing the signs of alcohol abuse to the normal effects of the aging process.

The children

By the time they turn 14, 30% of boys and 22% of girls drink alcohol, many weekly or even daily. Alcohol-related trauma is the leading cause of death for those aged 1­19. Children who have older brothers or sisters who smoke and drink are three to five times more likely to use tobacco and alcohol, because research has found that siblings are a more powerful role model than friends or parents.

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Women and alcohol

Women who abuse alcohol, or even occassionally drink to excess, face greater risks to their health than their male counterparts. Women get drunk a lot faster than men. Women are not only more sensitive to alcohol, may become addicted sooner, may develop alcohol-related problems more quickly, and many die younger than men with similar drinking habits. The latest studies show that females face more brain damage and memory loss than men who drink the same amount for the same period of time.

At a glance: effects of alcohol

Medical problem Liver disorders Gastrointestinal problems Light­moderate drinking Binge drinking and hangovers Changes in liver function Diarrhea Heavy chronic drinking Alcoholic hepatitis, cirrhosis Diarrhea, hemorrhoids, pancreatitis, bleeding in the intestines and stomach, tears in the esophagus from violent vomiting High blood pressure, weakened heart muscles leading to failure Hemorrhagic stroke

Heart disease

Beneficial. May help reduce risk for heart disease caused by blocked arteries Beneficial. May help reduce risk for ischemic stroke (strokes caused by

High blood pressure, increased heart rate, heart rhythm disturbances Hemorrhagic stroke

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Medical problem Light­moderate drinking blockage in the arteries to the brain) Cancer Associated with higher risk for breast cancer in women Binge drinking and hangovers

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Heavy chronic drinking

Cancers in the head and neck, esophagus, stomach, liver, pancreas, and cervix and vagina (in women). The effect of heavy drinking on breast cancer is unclear Memory impairment and problems in thinking and concentration Nerve damage from severe vitamin deficiencies; impairment in mental functioning and memory; emotional disorders, psychosis Impotence in men. Menstrual disorders and infertility in women. Drinking during pregnancy increases risk for birth defects Increased susceptibility to infections Osteoporosis, muscular deterioration, skin sores, itching, peripheral neuropathy

Neurologic or mental disorders

Insomnia, headache

Genital and reproductive problems

Increase sexual drive (although even modest drinking can cause impotence in men). Even moderate drinking during pregnancy increases risk for birth defects

Any drinking during pregnancy increases risk for birth defects

Immune system

Skin, muscle, and bone disorders

Diabetes

Possibly beneficial, though associated with hypoglycemia

Hypoglycemia

Hypoglycemia

Lung disorders

Acute respiratory distress syndrome, pneumonia

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Can a person prevent these ill effects alone? The answer is no! Studies have shown that alcoholics do not accept that they are dependent and therefore they need help.

Conclusion

No one plans to become an addict. No one can safely assume he or she is immune from the seductive and addictive nature of ethyl alcohol. This is especially true if one has a history of family alcoholism. Not drinking at all is the one guaranteed way to avoid becoming an alcoholic.

An element of abstention, of restraint, must enter into all finer joys. Vida D. Scudder

Tobacco

B. Jayakrishnana

Smoking is the most preventable cause of death and illness in our society. This harms nearly every organ of the body, causing many diseases, and reduces quality of life and life expectancy. Currently, there are around 1.3 billion smokers in the world and almost every eight seconds one of them dies from tobacco use. This will kill approximately 5 million people in 2006 and if the present consumption patterns continue the annual death rate will double by 2020. These days, no one, not even smokers, disputes the fact that smoking is harmful to one's health. Still they continue to smoke, why? This is not an easy question to answer as there seems to be a lot of factors. For some, cigarettes provide a "comfort", a "friend" in times of stress and a "benefit" that outweighs all the other consequences. A large fraction of adult smokers begin before the age of 16. Stress, anxiety, pressure from friends, misleading advertisements and a desire to experiment are the major reasons why adolescents begin to smoke. More than 5 million children living today will die prematurely because of a wrong decision they make now ­ the decision to smoke cigarettes.

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Dr B. Jayakrishnan MD, DTCD, DNB, MRCP (UK), FCCP is a Consultant Chest Physician with the Al Rashid Allergy Center, Kuwait. Email: [email protected]

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Harmful effects of smoke

Smoking generates more than 6000 components including 50 or more cancer causing chemicals. The major toxins are nicotine, tar, carbon monoxide, cyanide and ammonia. Nicotine is extremely addictive and once hooked a person needs to smoke regularly to feel normal. The list of conditions related to tobacco consumption has grown over the years. In fact for every death caused by smoking, approximately 20 smokers are suffering from a smoking-related disease. Remember that smoker's face the risk of developing various diseases at the same time. Most die from one of the three main diseases associated with cigarette smoking: lung cancer, coronary heart disease and chronic obstructive lung disease.

Lung cancer

Tobacco is the primary cause of 90% of all lung cancers. Men who smoke one pack a day increase their risk by10 times and those who smoke two packs a day increase their risk by 25 times compared with non-smokers. Smoking low tar (light) cigarettes does not reduce the risk for lung cancer.

Heart disease and stroke

Heart attacks and strokes are more common in smokers. Smoking contributes to hardening of the arteries which then become blocked easily, leading to a reduced or absent blood flow to the organs. Thus, if the blood flow is compromised in the heart muscles, a heart attack is the result and if the same happens in the brain, it will end in a stroke. Smokers are twice as likely as non-smokers to have heart attacks and about 30% of all heart disease deaths are due to smoking. Even people who smoke only a few cigarettes a day--half a pack or less--have an increased risk of dying of heart disease.

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Chronic obstructive pulmonary disease (COPD)

The lungs come into direct contact with the smoke and so get damaged more. Other than lung cancer, the two major lung diseases that develop in smokers are chronic bronchitis (daily cough and sputum) and emphysema (breathing difficulty especially on exertion). As the disease advances the person becomes progressively breathless on exertion and in the late stages may need continuous oxygen even at home. So a "smokers cough" may not be as simple as it seems.

Other cancers

Smoking also causes cancers of the larynx, esophagus, mouth, and bladder, and contributes to cancers of the cervix, pancreas, and kidneys.

Circulation

Smoking can damage other blood vessels as well those of the heart and brain. It can then lead to a reduction of blood flow to the legs (peripheral vascular disease) which manifests as leg pain during walking.

Other effects

Smokers are more likely than non-smokers to become impotent in middle life. Smokers have more wrinkles in their skin and so will look much older. They are more likely to develop gum disease, tooth loss, osteoporosis (thinning of the bone leading to fractures), pneumonia and cataracts. If women smoke during pregnancy the chances of miscarriage and premature delivery increases. They may give birth to low birth weight babies with poorer long-term growth. Moreover, smoking can worsen asthma, the common cold, flu, chest infections, chronic rhinitis, diabetic eye disease and hyperthyroidism.

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Passive smoking

Smokers are not the only people exposed to its bad effects. Millions of people, including one-half of the world's children, are exposed to second-hand tobacco smoke. Children and babies who live in the house of a smoker are more prone to ear, nose and chest infections and asthma and in the long term are at increased risk of developing chronic obstructive pulmonary disease and cancer as adults. Moreover, they are more likely to become smokers themselves later in life. Adults who inhale the side stream smoke also have an increased risk of lung cancer, heart disease and other respiratory illnesses.

Quitting

The benefits of quitting smoking begin almost immediately. The risk of developing any serious disease is reduced irrespective of the age one gives up. Assisting persons to quit smoking is complex and requires a systematic and multifaceted approach. Some people can give up easily. Willpower and determination seems to be the most important determinants for success. However, nicotine is a drug of addiction and many people do find giving up a struggle. Clearly the best situation is for a smoker to decide to give up smoking one day and continue not to smoke.

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But such decisions made, for example, as a New Year resolution, are seldom followed. A decision made following a personal illness or a major illness of a close associate is more serious. Cutting down on the number of cigarettes smoked can be a helpful first step on the road to giving up altogether.

Self-help treatment

Smokers can try to stop smoking on their own without the help of a health care professional. Self-help manuals are available from social organizations, hospitals or can be downloaded from the internet. In this situation the person must be well aware of the initial problems and withdrawal symptoms. The first 3 days of abstinence are usually the most difficult. They should get the support of a close associate, either a friend or spouse, to help them over the difficult periods. Sporting activity or exercise help a lot in reducing the craving for a cigarette.

Professional help

Many a time one has to seek professional help. Group quit smoking programs can help. Better still, get a doctor to help one break this habit. Pharmacological agents as described below may help. · Nicotine replacement therapy may be needed for a heavy smoker to counter the withdrawal symptoms. Nicotine gum, sprays, patches, tablets, lozenges, and inhalers are available. · Zyban or bupropion is a drug used to reduce the symptoms of nicotine withdrawal.

Conclusion

There are no physical reasons to start smoking. The body does not need tobacco the way it needs food, water, sleep or exercise. It gives you ailments, shortens your life and can affect others around you. So if you are

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a smoker think of quitting and if you are a non-smoker try to convince, encourage and support a smoker to quit.

Further reading

1. 2. 3. 4. 5. 6. 7. Knut-Oalf Haustein, "Tobacco or Health?" Physiological and Social Damages Caused by Tobacco Smoking. Springer, Berlin, 2003. Many useful pamphlets can be downloaded from http://www.who.int/tobacco/ resources/publications/en/. Surgeon General's Report, 2004. Health Consequences of Smoking. http://www. cdc.gov/Tobacco/sgr/sgr_2004/index.htm. Facts you should know about smoking, a clear explanation of the Surgeon Generals report: http://www.cdc.gov/tobacco/sgr/sgr_2004/consumerpiece/index.htm. A useful resource for advice, information and support for persons deciding to quit smoking: http://www.givingupsmoking.co.uk/home/. Self help guide. http://www.nursing-standard.co.uk/archives/ns/residentpdfs/ patientcards/1smokinginfocard.pdf. Summary of benefits of stopping smoking, immediate and long term: http://www. patient.co.uk/showdoc/27001051/.

Maternal lifestyle

Bhaskar Guptaa

It has been known for some time that the origin of many adult diseases is related to maternal lifestyle and its effect on the growing fetus. Exposure of the fetus to certain maternal factors influences not only growth but later health problems and neurodevelopment. There are many hypotheses regarding fetal growth and its later outcome, but a long term epidemiological analyses is needed to confirm them. Behavioral, lifestyle and socioeconomic factors are closely linked to fetal and infant growth ­ abnormal programming and adaptation of the fetus can result in the origin of certain adult diseases in fetal life itself. The fetus is exposed to a variety of factors through the mother such as maternal size, malnutrition, complications during pregnancy, maternal smoking. All of these can cause short and long term complications. The fetus needs a supply of nutrients as well as oxygen to grow, so a suboptimal maternal diet may be responsible for restricted fetal growth. The average birth weight of babies born during the famine period was almost 300­400 grams less than normal and as adults this group had poor glucose tolerance tests compared to

Dr Bhaskar Gupta is a Specialist Pediatrician and Neonatologist, Yiaco Apollo Medical Center, Salmiya, Kuwait. Email: [email protected]

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the normal population. The common effects before birth that have an influence on later outcomes are as follows:

Exposure 1. Low socioeconomic group 2. Poor maternal nutrition Short term influence Low fetal growth Poor growth and development 3. Maternal smoking Low birth weight; Impaired respiratory function; Sudden infant death 4. Gestational diabetes 5. Maternal hypercholesterolemia 6. Maternal blood pressure Fetal abnormalities; large fetus Fatty streaks in the wall of the aorta Impaired growth Long term influence Risk of adult cardiovascular diseases Effect on bone development; impaired brain development and cognition Adult cardiac disease; poor bone mineralization; impaired intelligence Later obesity; risk of cardiac diseases; impaired cognition Atherosclerotic changes and cardiac diseases Hypertension in later life

Other common disorders with fetal association are: · Coronary heart disease: highest incidence of death from heart diseases is seen in men who were thin at birth and infancy but then had accelerated weight gain in childhood. Hypertension and stroke are also associated with thinness at birth. · Ovarian and breast cancer: these have been linked to high birth weight and increased weight at 1 year of age. It has been suggested that this is due to alteration of fetal circulating estrogen levels and gonadotrophin secretions. · Early menopause: children born with shorter height have been noted to have early menopause. This is thought to be due to undernutriton for long periods in utero resulting in less nutritional supply to less important organs during growth. · Other diseases: chronic bronchitis due to impaired lung growth in utero and infancy; obese children have been reported to have diabetes mellitus, prostate cancer and infertility later in life.

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All these risk factors confirm the importance of a better understanding of fetal and infant nutrition for their long term effects. Thus, good antenatal care, control of pregnancy-related diseases along with proper nutrition of the mother and child definitely affect lifelong growth and development.

Osteoporosis

Suhail A. R. Doia

In developed countries, about a quarter of women over the age of 50 suffer from osteoporosis (weak bones), resulting mainly in hip or spinal vertebrae fractures. When this affects the hip, one-fifth will die, half will end up with impaired mobility and another fifth will lose their independence as a result. Hence, osteoporosis is indeed a serious problem. Osteoporosis is defined in terms of low bone mineral density (measured by a DEXA machine) in relation to the average density found in young adults. A reduction of one standard deviation is considered "low bone mass" and a reduction of 2.5 or more is considered to be "osteoporosis". However, any reduction in the presence of "fragility fractures" is also considered to be "osteoporosis".

Lifestyle factors

There are risk factors for fracture that we cannot change like our sex or age. However, there are many aspects of our lifestyle that we can change to lower the risk for osteoporosis. In many cases, changing our lifestyle in certain areas will also help prevent other diseases.

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Dr Suhail Doi FRCP, PhD, is a Consultant in Endocrinology at the Mubarak Al-Kabeer Teaching Hospital. Email: [email protected]

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Smoking

Smokers have been shown to go through the menopause as much as five years earlier than non-smokers. Those who smoke are usually thinner and have less fat cells making the substances needed for estrogen production. Smoking also changes the capillaries of the bloodstream which interferes with nourishment to bone tissue. This problem occurs with current use as well as past use of tobacco.

Alcohol

Heavy drinkers usually have poor eating habits. In addition, alcohol decreases calcium absorption and it increases calcium losses through the urine. More than 7 oz. of alcohol per week can increase the risk of hip fractures.

Exercise

Weight-bearing exercise keeps bones strong and can help prevent osteoporosis. Bone mass is dependent on the stress, or weight, placed on bones. The more our bones are used to walk, run, lift weights, the heavier and stronger these bones will be. Engaging in regular weight-bearing exercise can also reduce the rate of bone loss. Such regular physical activity can also improve strength, coordination, and balance--which in turn can lower the risk of falling and suffering a fracture. Doctors can help you plan a safe and effective workout routine and before beginning any new exercises or physical activities, check with your doctor, as an elderly person might get a fracture doing weight-bearing exercise, because her bones are weak. Once you get the go-ahead from your doctor, try walking more and taking stairs, or jogging and playing racquet sports. Weight-bearing and strength-training exercises can help you stay fit and lower the risk of fractures. Studies have shown that even men and women in their 90s have benefited from a gradual, personalized weight-training program.

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Dietary measures

Calcium can help slow the loss of bone mass. About 500­600 mg of calcium is usually present in a normal diet, largely from dairy products. Unfortunately that is not enough. Most people only get about 400 mg of calcium per day when they should be getting about 1000 to 1300 mg. Experts advise adults older than age 50 or postmenopausal women (and men with osteoporosis) to consume 1200­1500 mg of calcium daily from food and/or supplements. This is the same as drinking four to five glasses of milk each day (which has 300 mg of calcium per glass). That is hard for many people to do, so they may opt to supplement their diet with calcium in tablet form. However, it is best to get calcium from food. Good sources include: dairy products, calciumfortified orange juice, dark-green, leafy vegetables, such as broccoli, kale, and collards, calcium-fortified breads. If you are not getting enough calcium from food, then you may need a supplement. Another key nutrient for people with osteoporosis is vitamin D. Your body needs vitamin D to maintain normal levels of calcium in the blood and to absorb calcium properly. Fortified milk, egg yolks, liver, saltwater fish and fish oils contain vitamin D. Sunlight on your skin can activate the process in your body that makes vitamin D. Most people need about 400­800 IU of vitamin D each day. Women and men over 65 years of age should get about 800 IU per day of vitamin D from a multivitamin or vitamin D supplements. Being outside in the sun for a half hour supplies enough vitamin D for a day. Check with your doctor to see how much vitamin D you should be getting--and whether you need a supplement.

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Observations from epidemiological studies done in different countries confirm that the higher the dietary intake of animal protein, the more common is osteoporosis. Eskimos, who consume a high protein diet (250­400 g per day from fish, walrus and whale meat), along with an extremely high intake of calcium (2000 mg or more from fish bones) and despite being physically active, have one of the highest rates of osteoporosis in the world. Thus, a diet balanced in protein and carbohydrates is required to avoid osteoporosis. High caffeine intake (more than two to three cups of caffeinated coffee each day) is also considered a risk, especially if you have a low calcium intake.

Medication

Several medicines can help increase bone density, slow or stop bone loss, and lower the risk of fracture. But they can have risks as well as benefits. Your doctor can help you decide whether medicine might be appropriate for you.

Adjustments to the living space

Help protect yourself against broken bones which can lead to other health complications and death in older adults. Keep your stairways and living areas well lighted. Clear away clutter and repair any loose floorboards or carpeting. Tack or tape down throw rugs. Install grab bars in showers, bathtubs and beside the toilet. Don't stand on stools or chairs to get those out-of-reach items; keep things you use regularly where you can get to them easily and safely. Preventing fractures is important at any age. The main areas to watch out for are floors, bathrooms, kitchens, stairs and the lighting within the house.

Eating disorders

S. Narayanana

What are eating disorders?

Eating disorders are complex conditions, resulting from an interplay between biologic, social and psychologic issues. There are predisposing, precipitating and perpetuating factors. The medical terms for these disorders are: · Anorexia nervosa · Bulimia nervosa · Binge eating disorder Some patients may have an overlap of the three disorders and may not fulfill all the criteria for a clear diagnosis; they are categorized to have "eating disorder, not otherwise specified".

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Dr. S. Narayanan M.D, FRCP is a Consultant Physician and Head of Unit at the Department of Medicine, Amiri Hospital. Email: [email protected]

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What is anorexia nervosa?

People with anorexia nervosa (literally means loss of appetite) try their best to become excessively thin, by restricting food intake. Severe forms of the disease result in starvation and malnutrition with serious health consequences and even death. Anorexia nervosa is not simple dieting. There is a distorted perception of the body image in this illness with an intense fear and anxiety of weight gain; patients think they are very fat. In fact, they may be unaware of the problem, until late into the illness. Anorexia can last a lifetime; however, full recovery is possible with proper treatment. The exact cause is unknown. Certain professions (modeling, ballet) are at increased risk. The predisposing factors include: · Females (more than 90% are females) · A family member with an eating disorder · Having a perfectionist and anxious personality; inability to communicate negative feelings · Having difficulty resolving conflict · The precipitating factors are associated with onset of adolescence; 75% of eating disorders start in the teens. Puberty and maturation are associated with a growth spurt and may evoke fear of weight gain. Perpetuating factors contribute to maintain the disorder once it is established. These include biologic (problems of starvation) and psychologic influences (such as denial, resistance and anger at being treated). Young impressionable minds exposed to the modern-day media blitz can become obsessed with being thin.

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How is anorexia recognised?

The patient (or others) may notice: · · · · · · Excessive fear about weight gain Weight less than 85% of the expected weight Seeing one's body as fat, even though the person is thin Over exercising Avoiding food Refusing to discuss the problem with eating.

Other features include: · · · · · · · · Thin hair, brittle nails, dry skin Constipation Stopping of menstrual cycles Low body temperature Slow heart beat and low blood pressure Poor circulation in limbs, resulting in purplish skin Swelling of hands and feet Destruction of the enamel of the teeth due to repeated vomiting

What are the diagnostic tests conducted in anorexia?

There are no confirmatory laboratory tests for anorexia. The laboratory abnormalities are as a result of poor dietary habits or its complications and due to starvation. Heart and bone problems can occur in long standing illness.

What is the treatment and outlook?

Patients may not seek treatment on their own. Early recognition and treatment improves the chances of a complete recovery. Anorexia is not a purely psychiatric disorder. The treatment aims at educating the pa-

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tient about good, healthy eating habits, with measures to recover and maintain a healthy weight. This is accompanied by counseling. There are no specific medicines which work against anorexia nervosa. Antidepressant drugs are sometimes given to treat the accompanying symptoms of depression. Extreme weight loss or life threatening problems can necessitate hospitalization. Even with early treatment, anorexia may last anything from 6 months to 2 years or more; expectations for a quick recovery are often misplaced. Those with a long duration of illness, disturbed parent­child relationships, an associated personality disorder and the presence of vomiting, etc. can be expected to have a poor outcome. The degree of weight loss is not a predictor of the prognosis. There is a risk of suicide in anorexia nervosa.

Bulimia nervosa

People with bulimia (literal meaning: oxhunger) get uncontrollable urges to consume large quantities of food in a very short time (known as binging). Then they may induce vomiting or use medicines like laxatives or exercise to get rid of the food (known as purging). These people get comfort and satisfaction initially when they binge eat; however, a sense of guilt soon follows, resulting in purging. This cycle of events has serious health consequences.

What causes bulimia ? Who gets it?

Here again the exact cause is unknown, but a variety of factors are known to be the triggers; these include certain personality traits like perfectionism, family history and social factors. Bulimia is also more prevalent in females, with the disorder starting in adolescence. Most patients belong to the middle class to upper middle class strata.

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What are the features of bulimia?

· Regular bouts of binge eating; can lead to bloating, lethargy · Absence of control over the amount of food intake · Purging in one or more ways (vomiting, using laxatives, enemas or diuretics, excessive exercise) · Self-evaluation based on body weight and shape · Likely to be impulsive; may use other drugs or induce self-harm/ mutilation; may have other features of personality disturbance including guilt, depression and anxiety. · Anorexia and bulimia are not mutually exclusive. About 40% of patients with anorexia nervosa go through a bulimic phase.

How can you know if someone has bulimia?

People with bulimia may have normal weight. They may binge secretively and deny that they are purging. This can make it difficult for someone to suspect that the person has an eating disorder. There are some helpful clues. A young girl may have bulimia if she: Eats excessively without weight gain Goes to the bathroom soon after eating Is secretive about eating in front of others Exercises excessively and discusses the shape of her body, weight and dieting · Is known to use laxatives often · Has teeth marks or calluses on the back of her hands (caused by repeated vomiting) · · · ·

What is the treatment and outlook for bulimia?

Early detection and treatment facilitates faster recovery. The mainstay of therapy is counseling (psychological and nutritional). Other health problems like depression need to be detected and treated with appro-

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priate medicines. It can take a long time to recover from bumimia and it is common to see patients slipping back into unhealthy eating habits; occasionally these patients need hospitalization. The course is variable. The psychiatric disturbances are more severe compared to anorexia nervosa and the risk of suicide is higher. It is estimated that relapse occurs in 65% of patients, after one year of recovery and 40% of treated patients remain bulimic after 18 months of treatment.

What is binge eating disorder?

This is characterized by episodes of binge eating, i.e. excessive amount of food intake in a short period of time, with lack of control over eating and marked emotional distress about the over eating. These people have: · · · · · A tendency for rapid eating Eating until becoming uncomfortably full Eating large amounts when not hungry Eating alone because of embarrassment Disgust, guilt or depression because of eating patterns

Conclusion

Eating disorders are associated with complex health problems. It is too simplistic to assume that these are purely psychiatric disorders; awareness of the medical aspects can help in avoiding the social stigma. It is better to emphasize healthy habits, rather than mental dysfunction when talking to the patients afflicted with eating disorders. A team approach comprising the primary physician, the dietitian, mental health provider and the internist is the ideal way to tackle the problem; the family members also have a contributory role to play in this team effort. The aim should be to win over the trust of the patient so that a normal nutritional and physiologic state can be restored as early as possible.

Obesity and the metabolic syndrome

Arijit Chattopadhyaya

Introduction

It is nearly impossible to watch television, listen to the radio, or surf the Internet without seeing advertisements for weight-loss programs or news on obesity. Overweight and obesity are chronic diseases the origin of which can often be traced to habits developed during childhood, and the continuation of which is rooted in the modern environment. Gerald Reaven uses the term metabolic syndrome (MS) or insulin resistance syndrome (IRS) to describe the clustering of common conditions like hyperglycemia, hypertension, and dyslipidemia. This clinical entity reflects the major role that obesity, especially visceral adipose tissue (VAT), plays as a determinant of insulin resistance which in turn results in adverse clinical consequences of hypertension, atherosclerosis, and finally, abnormal glucose tolerance (IFG/IGT) and diabetes (Fig. 1). Other important diseases strongly associated with MS/IRS are fatty liver/non-alcoholic steato-hepatitis (NASH) and polycystic ovary syndrome (PCOS). Obesity and metabolic syndrome is a rising clinical challenge and has received a great deal of attention in the past few years due to the fact that it has been linked to the development of cardiovascular disease (CVD) and type 2 diabetes (T2DM). In the past, obesity was seen in great numbers only in Western countries but the prevalence is now increasing in India with the growing Indian economy.

Dr Arijit Chattopadhyay, MD, DM is a Senior Registrar with the Endocrine Unit, Al Sabah Hospital, Kuwait. Email: [email protected]

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Central obesity Genetic predisposition Lipotoxicity Glucotoxicity Hyperinsulinemia Insulin resistance Pancreatic - cell dysfunction

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NEFA Adiponectin Adipocytokines

IFG/IGT

T2DM

Subclinical atherosclerosis Endothelial dysfunction

CVD and other atherovascular diseases Hypertension

Insulin resistance

Figure 1. Consequences of metabolic syndrome/insulin resistance syndrome. NEFA, non-esterified fatty acids; IFG, impaired fasting glucose; IGT, impaired glucose tolerance; T2DM, type 2 diabetes mellitus; CVD, cardiovascular disease.

Prevalence of obesity

India is currently facing twin epidemics: obesity and diabetes (diabesity). In the 1990s, the National Nutrition Monitoring Bureau (NNMB) documented the prevalence of obesity in Indian women to be 4.1% and the National Family Health Survey (NFHS) reported obesity prevalence rates ranging between 3.5% and 4.1%. Today, over 20% of men and 30% of women in urban India have generalized obesity and nearly 40% of women have abdominal obesity. It is further predicted that the prevalence of obesity in India will further increase by 89% in males and 82% in females between 2002 and 2010. One of the largest growing obese populations is school-going children with an overall prevalence of obesity of 11%. Simultaneously, the prevalence of diabetes in India is growing rapidly and recent studies have documented a 72% increase in the prevalence of diabetes in urban India in the last 15 years. Indeed, the number of subjects with diabetes in India is expected to double from the current figures of about 40 million to nearly 80 million by 2030.

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Measurement of obesity and the metabolic syndrome

Body fat distribution is classified as upper body/truncal fat and lower body fat. Distinction has been made regarding truncal fat distribution as abdominal VAT or abdominal subcutaneous fat. Compared to lower body fat, upper body fat was found to release more fatty acids and thus has a propensity to cause insulin resistance (IR) and emergence of other metabolic risk factors. The World Health Organization (WHO) have shown a simplistic relationship between BMI and the risk of co-morbidities in obesity. In Asian subjects, the risk association with T2DM and CVD occurs at lower levels of BMI when compared with the Caucasian population. Indians tend to have more abdominal VAT, causing higher insulin resistance, despite having lean BMI. It is generally recommended to con2 sider Indians as obese if BMI is >25 kg/m and overweight with BMI at 2 23 kg/m . The proposed waist circumference (WC) cut-offs are >90 cm in men and >80 cm in women. The corresponding waist­hip ratios (WHR) are 0.88 and 0.81, respectively. The National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) published their criteria for the diagnosis of metabolic syndrome in 2001. The presence of three of five risk factors (increased waist circumference (WC), low high-density lipoprotein (HDL), high triglycerides (TG), elevated blood pressure (BP), and impaired fasting glucose) fulfills the criteria for the diagnosis of MS. The American Heart Association/National Heart, Lung and Blood Institute (AHA/ NHLBI) accepted these criteria with minor modifications in 2005. Creactive protein (CRP), an inflammatory marker appears to have the predictive power to add prognostic information in metabolic syndrome.

Risk factors of obesity and metabolic syndrome

Certain ethnic groups such as South East Asians have a high risk of having inherent IR. The change in growth from fetal to postnatal life leads to a state of IR in the skeletal muscle to facilitate glucose use for "catch-up fat" and can lead to the development of MS later in life, the so-called "thrifty gene hypothesis".

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High-fat diets, especially fried foods, high carbohydrate intake, and empty-calorie (cola drinks) eating patterns are all dietary risk factors. The high carbohydrate content in traditional Indian foods further complicates the issue. Eating refined calorie-dense foods plus a sedentary lifestyle results in excess calories and excess fat. Chronic stress constitutes a great danger for obesity, MS, T2DM, and CVD. Diabetes seems come to the fore during the periods when people undergo great stress. Food marketing strategies intentionally targeting children who are too young to distinguish advertising from truth and attracting them to eat high-calorie, low-nutrient (but highly profitable) "junk" foods is an alarming sign. Various print and electronic marketing media such as television, toys, games, and movies, celebrity endorsementsm and less visible "stealth" campaigns involving word of mouth, cellular telephone messages, and the Internet, all aim to teach children to recognize brands and pester their parents to buy them.

Diagnostic approach to metabolic syndrome (Fig. 2)

Look for Central Obesity WC, BMI

Yes Check for HTN, FBG, lipid profile If > 3 factors; metabolic syndrome

Start TLC Educate patient on MS Nutrition and exercise info. Set targets for weight loss TG, HDL

If HTN

IFG Perform OGTT

Insulin resistance Inflammatory markers

Use JNC7 Guidelines

If T2DM

ASA as therapy CRP monitoring

Nutrition and exercise info. If TLC fails: Set targets for weight loss Orlistat Fibrates/Nicotinic acid Sibutramin Rimonabant Bariatric Surgery

If normal

If IFG/IGT

Treat accordingly

TLC with weight loss >7% May repeat in 1 yr. Discuss metformin

Figure 2. Approach to metabolic syndrome. WC, waist circumference; BMI, body mass index; TLC, therapeutic lifestyle changes; OGTT, oral glucose tolerance test; HTN, hypertension; FBG, fasting blood glucose; ASA, aspirin; CRP, C-reactive protein; TG, triglyceride; HDL, high density lipoprotein.

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Treatment of obesity and metabolic syndrome

Like all clinicians, the most common phrase that I use with patients is: "You really must lose some weight". But losing weight is far from easy in a society where high-calorie fast foods and energy-saving modern appliances are omnipresent. There is no one specific therapy that can constitute a sufficient answer to the complex and multifactorial challenge raised from obesity and metabolic syndrome. However, lifestyle modification is the first and most important therapeutic target for all subjects with or at risk for metabolic syndrome. Keeping patients close to a normal weight as possible may be the most effective initial strategy (Table 1). Advice regarding structured programs to lose weight, weight maintenance and meal replacement ideas are important (Table 2). Start with small goals like, for example: Take the stairs/slope instead of the elevators Park your car at the far end of the parking lot and walk back Get off the bus/train two blocks earlier and walk home Take a walk during your lunch break Form a group to engage in sports such as golf, swimming Exercise at home with safe equipment while watching a favorite TV program · Encourage a gradual increase in activity to achieve a total of 30 minutes per day. · · · · · ·

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Table 1. Potential health benefits of 10% body weight reduction in co-morbidities related to obesity

Mortality >20% total mortality >30% diabetes-related deaths >40% obesity-related cancer deaths Type 2 diabetes 50% in fasting glucose 15% in HbA1c Blood pressure 10 mmHg systolic 20 mmHg diastolic Lipids 10% total cholesterol 30% triglycerides 15% low density lipoprotein (LDL) 8% high density lipoprotein (HDL)

Diet

One of the most common questions that a physician is askes is, "What is the best diet for patients with obesity and metabolic syndrome?" Debate continues as to how severely saturated fat should be restricted in the diet with recommendations ranging from moderate (20­30% of total calories) to marked (5­10% of total calories) limits on fat intake. Clinical studies performed over the last 30 years have demonstrated that a diet low in carbohydrates and high in fat (Atkins diet) and protein produces a ketotic state that suppresses appetite. The major highlights on dietary modification are as follows: 1. Markedly decrease intake of simple carbohydrates. If weight reduction is not required, modest intake is allowed but an effort should always be made to substitute complex carbohydrates, such as beans, whole-grain foods, and nuts. Soyabean curd or tofu products are highly recommended sources of protein and complex carbohydrate. Ingest only modest quantities of foods containing plain sugar which initiates a strong insulin secretary response.

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2. Decrease or eliminate ingestion of animal fats. Emphasize lean cuts if you must eat red meat. Prepare by broiling or baking but never by frying. 3. Use liberal quantities of olive oil or peanut oil. These monounsaturated fats seem to have a beneficial effect on blood lipid levels. Polyunsaturated oils, such as canola oil, are second-best. Strenuously avoid hydrogenated or partially hydrogenated vegetable oils, also known as trans-fats. Trans-fatty acids are commonly found in commercially available baked goods and margarines. 4. Eat lots of fruits, vegetables, and nuts (especially almonds, walnuts, and hazelnuts). Most nutritional experts recommend six to nine servings of fruits and/or vegetables daily. A diet high in fruits and vegetables is also beneficial in preventing other diseases (e.g. cancer). 5. Use seafood as the main source of dietary protein, particularly oily fish from northern oceans. White meat from chicken and turkey is favored over red meat (beef, lamb, and pork) and the dark meat of chicken and turkey.

Table 2. Treatment for obesity and metabolic syndrome based on recent guidelines and evidence-based data

Risk factor All risk factors Lifestyle recommendations Diet ­ Five or more servings of fruit and vegetables/day ­ Six or more servings of grain including whole grain fiber intake of 25 g/day ­ Moderate calorie restriction; aim for a weight loss of 5­10% in one year Physical activity and exercise ­ Moderate increase in physical activity, approx. 30­40 min/day brisk walking on most days of the week (150 min/week) or at least 90 min /week of vigorous aerobic exercise Pharmacotherapy

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Risk factor Obesity Lifestyle recommendations ­ Referral to a professional for nutritional counseling ­ Reduced energy diets are more effective: 500­ 1000 calorie/day reduction ­ Behavioral change should emphasize setting goals, planning meals, reading food labels, eating regular meals, reducing portion sizes and avoiding eating binges ­ Refer to a structured program to help weight loss and increase physical activity Insulin resistance Dyslipidemia ­ LDL-C reduction: diet low in saturated fat, trans-fat and cholesterol; substitute grains, unsaturated fatty acids from fish, vegetables, legumes, and nuts. Change to low fat or no fat diary products, poly- and monounsaturated fats, soluble fiber, soy protein and sustained weight reduction ­ Raise HDL-C by increasing physical activity and avoiding weight gain ­ Lower TG by decreasing intake of sugars and refined carbohydrates, decrease alcohol intake, and increase omega 3 fatty acids, complex carbohydrates like whole grains Hypertension ­ Decrease salt intake to around 6 g/day ­ Moderate weight loss and weight maintenance ­ Limit alcohol intake to 2 drinks/day in men and 1 drink/day in women ­ Dietary approach to stop hypertension (DASH) diet recommends 5­9 servings of fruits and vegetables, 2­4 servings of low fat dairy products As above

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Pharmacotherapy Anti-obesity medication: Orlistat, Sibutramine, Cannabinoid (CB)-1 receptor blocker (Rimonabant)

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Metformin, Thiazolidinediones, Rimonabant

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Lipid goals based on NCEP ATP III recommendations; statins/Ezetimibe for LDL lowering; combination of statin and fibrates for combined dyslipidemia; fibrate therapy for TG/HDL abnormality; nicotinic acid if tolerated could also be used Should be based on the JNC 7 Guidelines; drug therapy based on the presence of co-morbid conditions; often ACEI/ ARB considered as the first line therapy

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Risk factor Diabetes Lifestyle recommendations The Diabetes Prevention Project (DPP) confirmed 58% risk reduction of developing diabetes in the intensive lifestyle group achieving weight loss of 7% or more Endothelial dysfunction, pro-coagulant milieu General lifestyle changes as suggested for all risk factors Aspirin 81 mg, TZD, ACEI, ARB, statins Pharmacotherapy Metformin, Acarbose, TZDs, ACEI

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LDL, low-density lipoprotein; TG, triglyceride; HDL, high-density lipoprotein; ACEI, angiotensin converting enzyme inhibitor; ARB, angiotensin receptor blocker; TZD, thiazolidinediones.

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Approved for use in specific situations under an endocrinologists' supervision.

Lifestyle modifications should be addressed at each clinic visit to motivate the patient towards therapeutic lifestyle changes (TLC). It is necessary to teach children about lifestyle modification through the school curriculum when they are most receptive to such advice. The various components of metabolic syndrome and their potential risk should be discussed thoroughly with all patients. Reducing stress through meditation, biofeedback relaxation, adopting a healthy lifestyle and giving up smoking are all important components for a successful healthy lifestyle campaign.

Preventing obesity pandemic

· School-based screening programs need to be developed to identify the high-risk child/adolescent population early to implement lifestyle modifications and other preventive measures. · Well-defined strategies for screening and guidelines are needed. Routine measurement of BMI and WC is mandatory as part of the vital signs. · Population-management approach: the high-risk population can be targeted for risk modification, through lifestyle modification or pharmacological interventions.

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· Prevention of the obesity and metabolic syndrome is now of utmost importance to avert an epidemic of diabetes and cardiovascular disease in the world.

Further reading

1. 2. 3. 4. 5. Nestle M. Food marketing and childhood obesity -- a matter of policy. New England Journal of Medicine 2006; 354: 2527-2529. Practical advice for family physicians to help overweight patients. An American family physician monograph, 2003. http://www.aafp.org. Misra A, Vikram NK. Insulin resistance syndrome (metabolic syndrome) and obesity in Asian Indians: evidence and implications. Nutrition 2004; 20: 482-491. Seshadri P, Iqbal N. Low carbohydrate diets for weight loss: historical & environmental perspective. Indian Journal of Medical Research 2006; 123: 739-747. Internet resources: · http://www.health.gov/dietaryguidelines/dga2005/document/ ­ dietary change and physical activity · http://www.mypyramid.gov ­ MyPyramid, customized meal planning and physical activity tips · http://www.nhlbi.nih.gov/health/public/heart/obesity/lose_wt/index.htm ­ healthy weight interactive · http://www.cdc.gov/nccdphp/dnpa/physical ­ Centers for Disease Control and Prevention · http://familydoctor.org/351.xml?printxml ­ American Academy of Family Physicians · http://www.diabetes.org ­ American Diabetes Association

Type 2 diabetes mellitus

Hasan Ali Khana

Diabetes (DM) is a disease in which blood glucose levels are above normal. People with diabetes have problems converting food to energy. After a meal, food is broken down into a sugar called glucose, which is carried by the blood to cells throughout the body. Cells use the hormone insulin, made in the pancreas, to help them process blood glucose into energy. People develop type 2 diabetes because the cells in the muscles, liver, and fat do not use insulin properly. Eventually, the pancreas cannot make enough insulin for the body's needs. As a result, the amount of glucose in the blood increases and the cells are starved of energy. Over time, high blood glucose levels damage nerves and blood vessels, leading to complications such as heart disease, stroke, blindness, and kidney disease. DM is closely associated with our body mass index (BMI). We can all calculate our own BMI. Simply it is the combination of our weight and height. If you multiply your height × height (in meters) and divide your weight by this number, the result is your BMI. For example: height 1.70 m, then 1.7 × 1.7 is

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Dr. Hasan Ali Khan, M.D. is an Internist with a special interest in Cardiology at the Al-Jahra Hospital, Kuwait. Email: [email protected]

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equal to 2.89; the body weight is 70 kg; divide 70/2.89 and the result is 24.2. This is your BMI. A BMI of 19­24 is normal, 25­29 is overweight and 30 and above is obese. So the aim of healthy living is to keep within the normal range of BMI 19­24. To maintain our BMI we need to take care of our lifestyle. The higher your BMI, the greater is your chance of developing type 2 DM. If you do develop DM then if you reverse your BMI, the DM can also be reversed. Therefore, first and foremost, lifestyle monitoring should aim to keep weight within the normal range of BMI. So, in other words: Is DM preventable? Yes it is! Research has demonstrated that people at risk for type 2 DM can prevent or delay developing type 2 DM by losing a little weight. The results of the Diabetes Prevention Program (DPP) has shown that moderate changes to diet and exercise can delay and prevent type 2 diabetes. The participants in this federally funded study of 3234 people at high risk for diabetes, in the USA, experienced a 5­ 7% weight loss. That is 10­14 pounds for a 200-pound person. (Divide by 2.2 to convert pounds to kilograms). The DPP tested two approaches in preventing diabetes: a program of healthy eating and exercise (lifestyle change), and the diabetes drug metformin. People in the lifestyle change group exercised about 30 minutes a day 5 days a week, usually by walking, and lowered their intake of fat and calories. Those who took the diabetes drug metformin received information on exercise and diet. A third group only received information on exercise and diet. The results showed that people in the lifestyle change group reduced their risk of getting type 2 diabetes by 58%. Average weight loss in the first year of the study was 15 pounds. Lifestyle change was even more effective in those aged 60 and older. They reduced their risk by 71%. People receiving metformin reduced their risk by 31%. The conclusion of this research is that lifestyle change is the best way to control the occurrence of DM. You are more likely to develop type 2 diabetes if you are overweight. if your BMI is greater than 25, you are 45 years old or older, you have a

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parent, brother, or sister with diabetes, your family background is African American, American Indian, Asian American, Hispanic American/Latino, or Pacific Islander, you have had gestational diabetes or gave birth to at least one baby weighing more than 9 pounds, your blood pressure is 140/90 mmHg or higher, or you have been told that you have high blood pressure, your HDL cholesterol is 35 mg/dl or lower, or your triglyceride level is 250 mg/dl or higher, you are fairly inactive, or you exercise fewer than three times a week. What are the lifestyle modifications we need to take? · · · · · · Reduce caloric intake Smaller portion sizes Reduce total fat to <30% of calories Increase intake of fresh fruit, vegetables, and dietary fiber Weight loss of 5­7% (minimum) of starting body weight Physical activity equivalent to brisk walking for 30 minutes daily

Here are a few intelligent tips: try them, they are practical. · · · · Take the stairs rather than an elevator or escalator Park at the far end of the parking lot and walk Get off the bus a few stops early and walk the rest of the way Walk or cycle whenever you can

In conclusion, lifestyle modification is the most effective, and should be the initial approach for all patients who are at risk for type 2 diabetes. Such interventions should ideally include input from professionals with nutritional and behavioral expertise. The goals should be a weight loss of at least 7% of initial body weight and moderate physical activity for 30 minutes a day. Educational support is necessary to maintain the weight loss. The results of lifestyle modification should be evaluated after 6­12 months, and additional intervention should be considered for patients who have been unable to achieve weight loss goals. Certain types of medication can then be started to prevent diabetes from occurring along with the lifestyle modification. As lifestyle modification is

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now well known to be an effective mode of prevention of type 2 DM, so also it is expected that it will lead to a reduction in the occurrence of the long-term complications of type 2 DM. There are millions of individuals in the groups described above who are likely to get type 2 DM, so an individual effort can and will make a big difference to the community at large. Prevention is better than cure.

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Cholesterol

C. G. Suresha

"Doctor, my cholesterol is high, what should I do?" The answer is not straightforward or easy and depends mainly on four factors. (1) The type of cholesterol; (2) level of cholesterol increase; (3) co-existence of other risk factors for coronary heart disease (CHD) in that individual; and (4) any evidence of CHD or atherosclerotic obstruction of arteries elsewhere in the body. I shall unravel the mystery surrounding blood cholesterol, as I try to explain in detail the above headings.

Figure 1. A picture of the heart showing the major coronary arteries.

Cholesterol is not always a villain! Some amount of cholesterol is essential for the body, to make essential hormones, to repair the nerves and the inside lining of the blood vessels, etc. Problems arises mainly when the level goes up, especially in combination with other risk factors for atherosclerosis.

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Dr CG Suresh, MD, FRCP (Lon), is a Consultant Cardiologist at the Mubarak Al-Kabeer Hospital. Email: [email protected]

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What is Atherosclerosis?

Figure 1 shows the anatomy of normal coronary arteries. Figure 2 shows the development of blockages in these arteries as cholesterol builds up. This deposition of fat (cholesterol) is called atherosclerosis and is accelerated by other risk factors. When these plaques are destabilized (due to stress, high blood pressure, etc), blood may clot at the site of the cholesterol deposit and completely block the blood vessel. This cuts off the blood circulation to a part of the heart muscle leading to heart attack. Atherosclerosis leading to heart attack and stroke is the major killer of mankind all over the world, including India and Kuwait.

Figure 2. Development of atherosclerotic plaques.

The manifestations of atherosclerosis other than heart attack (acute myocardial infarction) include angina, cerebrovascular disease (stroke), peripheral arterial disease (legs) and blockage of blood vessels in other parts of the body.

What causes atherosclerosis?

Atherosclerosis is often multifactorial. A combination of factors that increase a person's chance of getting atherosclerosis are often referred to as risk factors. The major known risk factors are listed in Table 1. Some of them are not treatable and are called non-modifiable risk factors; however, the majority of risk factors are treatable or modifiable.

Health Guide Table 1. Risk factors for heart disease CHD

Modifiable risk factors Lipids (cholesterol) Smoking High blood pressure Diabetes mellitus Obesity Dietary factors Sedentary lifestyle Non-modifiable risk factors Age Sex History of coronary heart disease among first degree relatives occurring before age 55 years

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A frequently asked question is why only some people with these risk factors get heart attacks. That depends on the stability of the atherosclerotic plaque. The plaques in some patients are vulnerable because of their high lipid (cholesterol) content and have a high chance of rupture leading to heart attack. Plaques with low cholesterol content are more stable and unlikely to give heart attack, even though the patient has atherosclerosis.

Types of cholesterol

The terms, lipids and cholesterol are not the same; cholesterol is only one of the many types of lipids in the blood. In humans, the fat content in the blood is cholesterol and I have used these two words synonymously, for the ease of discussion. There are four types of cholesterols (lipids). Total cholesterol, low-density lipoprotein (LDL) often called bad cholesterol, high-density lipoprotein (HDL) often known as good cholesterol and triglycerides (VLDL and chylomicrons). Their actions are shown in Table 2.

76 Table 2. Different types of cholesterol and their actions

Type of cholesterol Low-density lipoproteins (LDL) High-density lipoproteins (HDL) Triglycerides Chylomicrons Very low-density lipoproteins (VLDL) What do they do?

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Lead to a buildup of cholesterol in the walls of your arteries Prevent harmful buildup of cholesterol in your arteries by cleaning Lead to high cholesterol; increase the ability of blood to clot Lead to excess triglyceride Contribute to buildup of cholesterol in your arteries

There are four types of abnormality of cholesterol (lipids). (1) Elevation of the total cholesterol; (2) increase in "bad" cholesterol or lowdensity lipoprotein (LDL); (3) increase in triglycerides; (4) decrease in the "good" cholesterol or high-density lipoprotein (HDL).

What causes high cholesterol?

High cholesterol can be genetic (hereditary) or due to poor lifestyle. Lifestyle or environmental factors consist of an unhealthy diet, lack of exercise, stress, etc. However, high cholesterol is rarely purely genetic or attributed to poor lifestyle alone. In most cases, high cholesterol results from an interaction between genes and the environment. Most people with high cholesterol are those who are genetically susceptible individuals leading an unhealthy lifestyle. An example of a purely genetic form of high cholesterol is familial hypercholesterolemia. This condition results from a genetic defect of the LDL receptors. LDL is removed from the blood by these receptors, which are controlled by LDL genes. Individuals with defective LDL gene (from one or two parents) eliminate LDL cholesterol at a slower rate than normal and so have very high LDL cholesterol levels. If not diagnosed and treated in childhood, they often develop atherosclerosis which may lead to heart attack at younger age.

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In some patients, the high cholesterol may result from an underlying disease. This is a secondary form of dyslipidemia and may occur in people with diabetes mellitus, thyroid disorders, kidney or liver diseases, and with certain drugs, including steroids, birth control pills in some women, drugs used for high blood pressure such as beta-blockers and diuretics.

When to check your cholesterol?

The National Cholesterol Education Program Guidelines (USA) recommend that all individuals over 20 years of age should have their cholesterol measured every five years. The Canadian recommendation is to check cholesterol in all men over the age of 40 and women over 50 years of age. As heart disease affects South Asian people including Indians at an early age, I would recommend that all adults over 20 years of age should have their total cholesterol and HDL cholesterol measured every five years. Cholesterol levels should be checked even before 20 years of age if there is a family history of early heart disease or death (could be familial hypercholesterolemia ­ see above).

My cholesterol is high, what is normal?

The desired level of cholesterol depends on the presence of heart disease and the coexistence of its risk factors and diabetes mellitus. Normal lipid levels are given below. The cornerstone of treatment is to achieve target LDL levels. A general guideline is shown in Table 3.

Normal lipid levels

· · · · Total cholesterol LDL cholesterol levels HDL cholesterol Triglyceride levels <5.2 mmol/L (200 mg) <4.0 mmol/L (160 mg) >1.02 mmol/L (40 mg) <2.0 mmol/L (175 mg)

78 Table 3. Desirable cholesterol levels

Condition <2 Risk factors 2 Risk factors Diabetes mellitus Triglyceride HDL

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LDL

<175 mg (2.0 mmol) >40 mg (1.02 mmol) <160 mg (4 mmol) <175 mg (2.0 mmol) >40 mg (1.02 mmol) <130 mg (3.5 mmol) <100 mg (2.6 mmol) <100 mg (2.6 mmol) <150 mg (1.7 mmol) Higher - Better

Coronary heart disease <150 mg (1.7 mmol) Higher - Better

How do I control my cholesterol levels?

For patients at low risk (without any risk factors or heart disease), the initial step is to promote specific healthy lifestyle changes (see Healthy diet article). If target lipid levels are not reached after 6 months, drug treatment is desirable. For those at moderate risk (those with other risk factors, but no heart disease), promote specific healthy lifestyle changes for 3 months. If target cholesterol levels are not achieved after 3 months, drug therapy is advisable. In those patients at very high risk (those with heart disease or diabetes) or with alarmingly high levels of cholesterol, start drug treatment immediately. Even among these patients, specific healthy lifestyle changes should be made along with drug treatment.

How can I increase my good cholesterol?

HDL is the good cholesterol that helps to clean the arteries and is low in the majority of people of Asian origin. Low HDL is an independent and very important risk factor for the development of heart disease. Total cholesterol, LDL and triglyceride levels can be adequately controlled by drug treatment. But, achieving target levels of HDL is difficult, especially among Indians. Regular exercise, consumption of monosaturated fat in the form of certain nuts like almonds and hazel nuts (not fried), soya products, moderate consumption of grape juice or red wine are helpful. If the above fail to increase the levels, your doctor may consider drugs such as satins, fibrates or nicotinic acid.

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Preventing heart disease: a missed opportunity

Medicine has advanced so much that there is effective treatment for almost all forms heart disease and its risk factors. However, recent studies in many parts of the world have shown that the majority of patients at very high risk for coronary heart disease do not achieve target cholesterol levels. This failure is not accounted for by lack of drugs or doctors. It is mainly because of insufficient drug therapy and lack of lifestyle modification. This form of heart disease is rapidly increasing in countries like India and unless we identify and efficiently treat the risk factors that lead to CHD, the disease can have catastrophic impact on the health of the individuals and the health and development of the nation as a whole. Drug treatment is not a substitute for lifestyle modification, especially in the holistic management of the individual patient. Medicines can only reduce cholesterol or blood pressure. Healthy diet and increased physical activity lead to decreased triglycerides and increased HDL cholesterol levels. Other benefits of exercise and diet include reduction and prevention of diabetes, blood pressure, arthritis, cancer, etc. Exercise elevates the mood, reduces depression and lowers stress. Adopting a healthy lifestyle not only helps you to control heart disease and other forms of diseases but more importantly you "walk" away from these diseases altogether.

Hypertension

Thomas Koshy Georgea

Blood pressure is a measurement of the pressure or force inside your arteries with each heartbeat. Blood pressure is measured using a stethoscope and a special meter. It is recorded by two numbers. The first is systolic blood pressure which is the amount of pressure against the artery walls each time the heart contracts or squeezes blood out of your heart. Optimal is less than 120 mmHg. The second is diastolic blood pressure, the amount of pressure inside your arteries when your heart is at rest, in between heartbeats. Optimal is less than 80 mmHg. High blood pressure is called hypertension (more than 120/80 mmHg). Hypertension is a major risk factor for heart and blood vessel disease. If untreated, it can lead to a stroke, heart attack, heart enlargement, heart failure, peripheral vascular disease such as lack of blood circulation in the legs, kidney disease and bleeding into the blood vessels in the eyes. Blood pressure is classified as shown in Table 1. In 90­95% of cases no cause is found for high blood pressure. In the rest there may be secondary causes of hypertension; your physician will decide if further investigations are needed. If one or both your parents have got hypertension you are at increased risk. Your lifestyle also plays a very important role in hypertension. So lifestyle changes can help to prevent hypertension in genetically susceptible people. We have not yet learned to select our genes, but it is possible to manipulate our environment. It is up to you to take control! Here are some strategies to control blood pressure.

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Dr Thomas Koshy George is a Cardiologist at Chest Hospital, Kuwait, formerly Assistant Professor at P.S.G. Medical College, Coimbatore, India. Email: [email protected]

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Health Guide Table 1. Blood pressure classifications

Classification Normal blood pressure Pre-hypertension Hypertension Stage 1 Stage 2

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Range (mm/Hg) <120/80 120­139/80­89 140­159/90­99 160/100

Therapy Encourage healthy lifestyle Modify lifestyle Modify lifestyle and medication Modify lifestyle and medication

Patients with chronic renal disease or diabetes should be treated to <130/80 mmHg. While,

120/80 is optimal blood pressure, if you have been diagnosed with high blood pressure, the goal is to lower your blood pressure to less than 140/80. JNC VII, National Heart, Lung, and Blood Institute: http://www.nhlbi.nih.gov/index.htm, 2003.

1. Achieve and maintain your ideal body weight. Being overweight is closely connected to hypertension, especially if your body mass index (weight in kilograms divided by your height in meters squared) is 27 or more. Excess upper body fat (waist measurement of 34 inches or greater in women or 39 inches or more in men) is also related to high blood pressure, diabetes, increased cholesterol and heart disease. Take a look at your current eating habits, learn how to read food labels, decrease the fat in your diet, watch your portion sizes, choose healthy low-calorie snacks, add exercise to your daily routine, set realistic goals. Weight loss should be gradual (no more than one or two pounds per week). For more information go to http://www.aacvpr. org/ or http://www.americanheart.org/. 2. Limit your intake of salt (sodium). Lessening the amount of salt in your diet can lower blood pressure. Sodium should be limited to 2400 mg/day (one teaspoonful of salt) with a goal of lowering it to 1500 mg/day. Sodium is found in table salt and many of the foods we eat: e,g, preserved foods, canned foods, luncheon meats, pickles, pappad, cheeses and snacks. The following tips will help you to reduce your intake of sodium: read food labels and medication labels for sodium content, do not use a salt shaker at the table, use herbs and spices instead of salt to flavor foods, avoid processed foods

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such as canned and frozen foods, luncheon meats and cheeses, choose snack foods wisely. 3. Include foods rich in potassium in your diet. Including potassium-rich food in your diet may protect against hypertension and help to control blood pressure that is too high. Also, if your blood potassium is too low, it may increase blood pressure. Foods that contain potassium include: bananas, dried fruits, skim milk and potatoes. Useful link: http://www.eatright.org/public/. 4. Follow the DASH diet. The Dietary Approaches to Stop Hypertension (DASH) study looked at the impacts of foods on high blood pressure. They found that this diet lowered systolic blood pressure (the top number) by 5.5 mmHg and diastolic pressure (the bottom number) by 3 mmHg. If you have hypertension it decreases the systolic value by 11.4 and the diastolic values by 5.5 mmHg. The benefit occurred within 2 weeks of starting the DASH plan. The diet includes: increase calcium intake to more than 1200 mg/day; eat low-fat or fat-free dairy products; lower fats to less than 26% of calories; eat two or less of 3 ounce portions of meat, chicken or fish each day, increase fiber, potassium and magnesium, increase your daily intake of fruits and vegetables. A dietician can help you with this diet or go to http://www.nhlbi.nih.gov/health/public/ heart/hbp/dash/. 5. Follow a regular exercise program. Regular exercise helps to prevent and control hypertension. Exercise must be: regular (three to five times per week for 30­45 minutes); aerobic (activities such as walking, cycling, or water aerobics); safe (before you begin an exercise program ask your physician what type and amount of exercise is right for you). 6. If you smoke, QUIT! Each time you smoke a cigarette, your blood pressure rises. Cigarette smoking is a very strong risk factor for cardiovascular disease. Quit smoking tips: make a list of all the reasons you want to quit; read over

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the list every day, before and after you quit; pick a date for quitting and stick to it; note the situations when you smoke and break those links; get a "buddy" to help you quit; keep trying if you slip; try medicines like nicotine patches or chewing gum. I know it is easier said than done, and to stop smoking is one of the most challenging tasks, but its your health? Useful sites: http://www. nhlbi.nih.gov/health/pubs/pub_gen.htm, http://www.lungusa.org/. 7. Limit alcohol intake. In Kuwait, alcohol is prohibited, but for those who can manage to circumvent the law, either stop doing this totally or else if you cannot be without it, limit daily intake to no more than 2 drinks per day for men and one drink for women. One drink equals 40 mL of whiskey, vodka or gin, 150 mL of wine or 350 mL of beer. 8. Control stress and anger. During periods of stress and anger, blood pressure rises. If the stress and anger persists, high blood pressure can occur over time and can also lead to heart disease. Tips to control stress and anger: manage your time and set realistic goals of what you can accomplish each day; take time each day to relax. To learn more go to http://nccam.nih.gov/. 9. Get support from a friend or family member. It is very important for friends and family members to play a big role. They have to instill a positive attitude and motivate the person to do all these lifestyle changes. Remember, you are both on the same team. You cannot make your loved one well on your own, but you can offer your love, understanding and hope. There is often a fine line between helpful reminders and "nagging". Remember your loved one may feel bad if he or she is having trouble making healthy lifestyle changes. The more constructive your suggestions are the better. Do more than talk the talk. Many of the lifestyle changes written here can also make you healthier. So instead of telling your wife she needs more exercise, be a good partner and lace up your walking shoes, too. If you are the primary cook in your household, learn how to cook with reduced fat and low-salt recipes. You will all be healthier for the change.

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10. Take medications to control high blood pressure, as prescribed. Depending on your blood pressure readings and other risk factors, your doctor will decide if you need medication which, along with lifestyle changes, will decrease the risk of cardiovascular disease and death. Tips to treat high blood pressure with medication: follow your doctor's orders on taking medicines; do not stop taking your medicines without talking to your doctor; have frequent visits until your blood pressure is under control (every 1­4 weeks); have regular follow up visits (your doctor will schedule your visits). It is up to you. High blood pressure affects millions of people. Over time hypertension can cause damage to your blood vessels and major organs (heart, kidney, brain). Through lifestyle changes, medication and working with your health care team, you can control your blood pressure and prevent future problems.

Coronary artery disease

Christus Singh Thomasa

What are coronary arteries (CAR)?

Arteries supply pure blood to the organs of the body. Each organ requires a certain amount of oxygen to carry on its normal function. The heart is the central pump in the body; it keeps beating tirelessly. The constant activity of the heart muscle means that it requires more oxygen than normal body tissues. This requirement can increase dramatically during increased physical activity. The coronary arteries (CAR) have the important function of carrying oxygen containing pure blood to the heart muscles.

What is coronary artery disease (CAD)?

As the body ages, the CAR also start aging. The smooth lining of the CAR become thickened and irregular. There is deposition of fatty material (atheroma) in the wall of the CAR making it unhealthy. Atherosclerosis is the general term used to describe this aging process in arteries. In response to the fatty deposition, defense mechanisms in the body are activated. Different types of white blood cells are attracted to the site of disease resulting in inflammation (akin to the redness, warmth, swelling and pain noticed at the site of any wound). This makes the inner lining of the CAR more vulnerable to

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Dr Christus is a senior Consultant Cardiologist working in the Chest Diseases Hospital. He is an interventional Cardiologist with expertise in the management of CAD as well as other cardiac disorders. Email: [email protected]

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tearing and bleeding. Platelets are small cells circulating in the blood. When they are activated at the site of disease, they could form unhealthy clumps leading to plugging of the arteries. Similarly the clotting system in the blood can also become more active (abnormally) leading to clot formation and blockage of the artery at the site of disease.

How does CAD manifest?

This depends on the degree of blockage in the CAR, the type of narrowing and the rapidity with which it occurs. Depending on all these factors, a patient with CAD may have exertional chest discomfort (angina) or chest discomfort at rest (heart attack). Sudden death without any forewarning is another dangerous manifestation. Alternatively, a patient with CAD may be totally asymptomatic (silent CAD). Sudden blockage in the lumen of CAR results in heart attack. This is associated with damage to the heart muscle and depression in the contracting ability of the heart. Significant damage to the heart muscle leads to heart failure. Angina, if significant, incapacitates a person from his normal abilities. Similarly irregularities in heart beat (arrhythmia) secondary to CAD could be troublesome or even dangerous.

What are the risk factors?

The presence of risk factors makes a person more vulnerable to CAD. The more severe the risk factor and the higher the number of risk factors, the higher is the risk of developing CAD. Risk factors may be of two types: modifiable and non-modifiable. Important modifiable risk factors are lifestyle related and include:

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Tobacco smoking Diabetes mellitus High blood pressure Abnormal lipids (high cholesterol/LDL cholesterol, high triglycerides and low LDL cholesterol) · Overweight · Physical inactivity · Stress/unhealthy emotions As the name implies, these are factors that can be modified favorably by taking suitable measures. Non-modifiable factors are: Increasing age Male sex Post-menopausal state Positive family history of early CAD (CAD occurring in a first degree relative at an early age) · Race · · · ·

· · · ·

Lifestyle modification and CAD

Lifestyle includes habits related to diet, activity and exercise, relaxation, stress, addictions, attitude and motivation. Lifestyle modification (LSM) attempts to bring about changes in these areas to improve health. The overall aim of lifestyle alteration is to change modifiable risk factors to the maximum extent possible. The ultimate goal is to live a full healthy life. Adopting a healthy lifestyle can modify, delay or prevent CAD. Even in those with established CAD, LSM leads to a better outcome. Aggressive LSM is even powerful enough to bring about regression of CAD. The earlier we start the better but it is never too late. By the age of 20 years everyone should be actively involved in lifestyle modification.

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Healthy eating

What you eat and drink can affect CAD in several ways. Too much saturated fat from red meat, biscuits, cakes, chips and dairy products can clog up the CAR and put a strain on your heart. However, eating fish, poultry and vegetables is good. 1. Fruits and vegetables. There is good evidence that eating a diet that is rich in a range of vegetables and fruits lowers the risk of heart disease. Eating at least five servings of fruit and vegetables a day will reduce the risk of CAD, by helping to prevent atheroma build-up within the walls of the CAR. 2. Fats and cholesterol. It is wise to limit eggs to not more than three a week. It is important to reduce the total amount of fat and change the types of fat that you eat. On average, reducing cholesterol by 1% can lower the risk of CAD by 2%. 3. Fish and fish oils. Eating oily fish regularly can help to reduce the risk of CAD and improve the chances of survival after a heart attack. The particular oil in fish that has these good effects is known as "omega-3 fatty acid". It is found mainly in oily fish such as mackerel, pilchards, sardines, herring, kippers, salmon, fresh tuna, trout and anchovies. Try to eat oily fish about twice a week. 4. Salt. Reducing the amount of salt you eat will help keep your blood pressure down. 5. Alcohol. Too much alcohol can damage the heart muscle, increase blood pressure and also lead to weight gain. It can also contribute to high triglycerides, and produce irregular heartbeats. Binge drinking will increase your risk of having another heart attack.

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Regular exercise

Half an hour a day on at least 5 days a week makes all the difference and this can be included in your daily routine. Start off gently and build up gradually. Walking, swimming and dancing are good forms of exercise. Develop a routine exercise regimen. Short, frequent sessions of exercise are preferable to a complete sedentary lifestyle. Walking instead of driving, taking the stairs instead of the elevator, and parking far from building entrances are all measures that you can incorporate into your busy routines. Regular exercise reduces your chances of getting heart disease. If you are known to have heart disease, consult your doctor and follow his/her advice.

Maintaining an ideal body weight

Meet your doctor and find out your ideal body weight. Set a realistic goal to achieve it through diet and exercise. By eating a balanced diet, and increasing your levels of physical activity, you can maintain a healthy body and heart. You can also avoid many diseases associated with overweight.

Being smoke free

From the moment you stop smoking, the risk of heart attack starts to reduce and is halved within one year. Aim for a smoke-free environment at home and at work.

Other areas

See your health care provider regularly and following the advice of your physician. · Strict control of diabetes · Keeping blood pressure under control · Management of stress

Stroke

Shekhar Lamdhadea

Cerebrovascular disease, commonly known as stroke or paralysis, is a devastating condition. It is a major cause of permanent disability and death. Changes in lifestyle patterns secondary to industrialization and demands of work (globalization) have increased the risk for many diseases such as diabetes, hypertension, lung cancer, heart attacks and colon diseases. These are primarily attributed to smoking, alcohol, lack of exercise and "fast foods" or dietary habits and stress. Evidence has shown that control of these factors is beneficial to individuals and communities.

Warning signs of stroke

The waarning signs of stroke are: sudden weakness, numbness or paralysis of the face, arms, legs, especially on one side of the body; loss of speech or trouble in talking or understanding language; sudden loss of vision, especially in one eye; sudden severe headache without any cause; sudden unexplained dizziness or loss of balance.

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Dr Shekhar is a Neurologist at the Ibn Sina Hospital, Kuwait. Email: [email protected]

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Lifestyle management: revival of healthy living patterns

A simple Google search on the internet with the key words: "stroke, lifestyle management" retrieves almost 139,000 sites, underscoring the immediate importance of this topic. The crude prevalence of stroke in India is 200 cases per 100,000 population. The percentage is higher in young adults than the western figures. Stroke is a condition caused by occlusion of blood vessels supplying the brain, commonly by deposition of cholesterol. Rarely, it can be caused by rupture of a blood vessel due to uncontrolled hypertension. Conditions such as diabetes, hypertension, obesity, heart attacks are interlinked, in addition to smoking, alcohol and poor dietary habits. The net or cumulative effect of these factors leads to a condition called atherosclerosis or cholesterol deposition in blood vessels causing narrowing or obstruction.

Things to consider in lifestyle management

1. Smoking. Studies confirm that smokers have a higher risk of stroke regardless of age, blood pressure or heart disease. The risk is double or triple that in non-smokers. The risk decreases within a few years of stopping smoking. 2. Obesity or overweight. Higher weight is linked to high blood pressure and puts strain on the heart and blood vessels and also predisposes to diabetes, thus increasing the risk of stroke. 3. Exercise. A sedentary lifestyle leads to accumulation of fat. Regular exercise helps to keep this accumulation to a minimum. Experts recommend at least 20­30 minutes of aerobic exercises 3­4 times a week to achieve and maintain an improved level of fitness.

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4. Stress. Stress increases blood pressure; it is indirectly linked to stroke. Stress management includes: relaxation techniques, use of biofeedback, exercises, counseling, and meditation (yoga and prayers) to reduce blood pressure. 5. Diabetes. There is a clear and direct relation between stroke and circulatory problems (micro- and macro-angiopathy) in diabetics. Good control of diabetes helps to reduce vascular complications. 6. Oral contraceptives. Use of oral contraptives to regulate pregnancy, especially those with a high estrogen content, appears to increase the risk of clot formation (1/1000 cases), specially in women over 30 years. This risk increases in women who smoke. It is advisable to consult a physician before taking oral contraceptive drugs. 7. Post-menopausal estrogen. Contrary to earlier beliefs about the benefits of hormone replacement therapy, it is now clear that there is a small increase in the risk of stroke. 8. Alcohol. Individuals who take more than 2­3 alcoholic beverages a day are at high risk of developing a stroke. 9. Diet. Let me explain a bit more about diet. Under normal dietary recommendations, 30% of the calories in the diet come from fats. Eating a lot of saturated palm oil, butter (bad fat) leads to cholesterol deposition in arteries. Dietary fat can be reduced by limiting fat or oil used in cooking, removing fat and skin from meat and poultry. Broiling and baking foods rather than frying. More than three eggs/week are not recommended. If cholesterol levels remain high, then medication (statins) is necessary. There are many refined oils available on the market, however safflower

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(Indian) and olive oil (Mediterranean) are considered safe. Increased fiber in the diet (vegetables) helps in proper conditioning of the stomach and digestive system and also helps in reducing cholesterol. Avoid excessive sodium. Excessive sodium is linked to hypertension. Most processed and canned foods contain "hidden salt", e.g. sodium phosphate, monosodium glutamate, sodium nitrate. Try to eat as much fresh food as possible. For proper and detailed understanding of diet and various biochemical processes browse the internet or read one of the many books on diet. Diet management should be given a chance for 6 months before starting any medication. The George Institute in New Zealand have studied the New Zealand population over 20 years and have found that the risk of stroke can be reducted by 11% by simple lifestyle management (Craig Anderson). The following chart highlights the links: strongest evidence at Level I to lowest evidence at Level IV):

Factor Obesity Low salt Smoking Physical activity Heavy alcohol Low cholesterol + + Level I Level II + + + Level III Level IV

High blood pressure + Oral contraceptives) +

Goals to achieve

Lifestyle management is a tool to remain healthy with the help of known simple modifications in our day to day life. The process starts in healthy minds. Though it looks simple many people find it difficult to continue and fail beyond 2­3 years. It is advisable to show, teach and practice "good" habits to children before they catch up with the bad ones. Great things begin at home!

Lung disease

P.C. Naira

All living things adapt to their environment; so also with human beings. The changes in lifestyle in the modern world has led to many medical problems such as obesity/overweight, multiple system disorders, smoking, substance abuse, etc. Obesity and its complications are well known from the age of Charles Dickens. The Pickwickian syndrome characterized by obesity, excessive sleepiness and increased appetite is derived from the description of Charles Dickens' character, Joe, the fat boy, in Pickwick Papers. Plincy the younger, an ancient Roman described the eruption of Vesuvius in 79 AD and related the death of his uncle in a letter well known to classicists. Pliancy describes snoring, sleepiness and obesity. These are case reports from the past, but now obesity and overweight have reached epidemic proportions throughout the world. There are now more fat people in the world than hungry people; according to WHO figures, there are more than a billion overweight people compared to 800 million who are under nourished. Here, we discuss the lung manifestations of modern lifestyles, mainly obstructive sleep apnea (OSA), chronic obstructive pulmonary disease (COPD) and asthma.

Obstructive sleep apnea (OSA/OSHAS)

OSA was first identified only 40 years ago and its clinical importance is increasingly recognized. It is a major public health problem in the

Dr P.C. Nair is a Consultant Pulmonologist at the Chest Hospital, Kuwait. Email: [email protected]

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world. In the US alone it affects 2­4% of middle-aged Americans and 1­2% of middle-aged women; the majority of affected individuals remain undiagnosed. The prevalence of OSA is likely to increase in parallel with the epidemic of obesity currently occurring in many countries.

How do they present?

The common presenting complaints are excessive sleepiness during the day and loud snoring, partner prompting or during the management of comorbidities, witnessed apneas, choking and/or gasping during sleep.

Who are at higher risk?

People who are hypertensive, obese, have a neck circumference of 17 inches or more, or a laterally narrowed oropharynx are at higher risk.

What is upper airway resistance syndrome?

This term describes patients who do not meet the criteria for OSA. They usually present to psychiatrists with somatic functional syndromes.

Do all snorers have OSA?

Snoring is very common in the adult population, but all snorers need not have OSA. OSA patients not only have oxygen desaturation but are also prone to cardiac arrhythmias and sudden death.

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What are the complications of OSA?

OSA not only causes sleep disturbances, but is also associated with numerous cardiovascular sequelae including systemic and pulmonary hypertension, sudden death cardiac arrhythmias and strokes, and cognitive morbidities.

What is the mechanism of OSA?

OSA is characterized by repeated collapse of the upper airway as a result of the loss of neuromuscular drive on wakening as the brain changes from wakefulness to sleep. This produces a state-dependent decrease in muscle tone which with other predisposing factors produces the spectrum of sleep-disordered breathing. The recurrent hypoxic episodes lead to cardiovascular and systemic morbidities.

Can children be affected?

OSA can definitely affect children. The major treatment modality for children is tonsillectomy, adenoidectomy with or without radio frequency treatment of nasal turbinate, and rarely continuous positive airway pressure (CPAP).

How to diagnose OSA

The gold standard for diagnosis of OSA is by sleep study or polysomnography. This facility is available only in big referral centers but nocturnal/split oxymetry studies can help to diagnose sleep disorders.

What is the treatment for OSA

The mainstay of treatment is by positive airway pressure (PAP): continuous PAP (cPAP), bi-level PAP (BiPAP) or auto PAP. Adjunctive treatment modalities include:

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· Lifestyle modification: reducing weight · Surgical measures: uvalopalatoplasty · Behavior/pharmacologic measures All people with a high index of suspicion of sleep disorder should be investigated and managed, as it is potentially treatable and sudden mishaps can be avoided. A good quality of life is possible.

Asthma and lifestyle changes

Asthma and obesity are prevalent disorders, each with a significant public health impact. The systemic inflammatory milieu in obesity leads to metabolic and cardiovascular complications, but whether this environment alters asthma risk is not known. Age-adjusted data from the 1992­2002 National Health and Nutritional Survey indicate that approximately 65% of US adults 20 years or older are either overweight or obese. Furthermore, 31% of children aged 6­19 years are either overweight or at risk of being overweight. Although obesity is not of public health impact in India at present, the risk cannot be ignored. Asthma affects more than 7% of the population of industrialized countries. Asthma is a disease of the airways characterized by short term episodes of broncho constriction. The important component of asthma is the spasm of the smooth muscles of the lung. The flow of gases along the airways is significantly reduced leading to difficulty in breathing. In most patients with asthma the range of triggers include specific allergens, other non-specific substances, exercise and drugs. Breathing requires work to be done mainly to overcome airway resistance and to stretch the lungs and chest wall. Work is defined in physical sciences as the product of a force × the distance moved from the point of application. This system is quiet efficient in the human body at minimizing the expenditure of energy by the respiratory muscles. In obesity, the airway resistance and the elastic properties of the lung may

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be compromised; the extra work done by the muscles to provide oxygen to the rest of the body, demands more oxygen than it provides which of course is an untenable situation. The patient will be easily tired and exhausted by minimum exertion. Obesity causes a reduction in respiratory system compliance, lung volume and peripheral airway diameter, altered pulmonary blood flow and ventilation perfusion mismatch. Data from animal and human studies suggest that enhancement of normal adipose tissue function in obesity leads to a systemic proinflammatory state. Fat tissue from an obese individual releases a number of pro-inflammatory molecules such as leptin, tumor necrosis factor, IL-6 and C-reactive proteins, etc. There appears to be a significant overlap between the immune function of fat tissue and the inflammatory body response. This pro-inflammatory state in obesity has been implicated in a number of metabolic and systemic complications. The exact mechanism of asthma in obesity is not known but an altered immune response, altered airway smooth muscle function and increased airway hyper-responsiveness has been postulated. Medical weight loss studies in individuals with asthma have demonstrated, however, that weight loss can lead to improvements in both clinical and physiologic parameters. In conclusion much work remains to be done to elucidate the relationship of obesity and asthma. Longitudinal epidemiologic studies on adults suggest that there is an association between obesity and asthma; the overall impact of obesity on asthma incidence and prevalence appears to be modest and modified by factors such as age and sex.

Lifestyle and COPD

Chronic obstructive pulmonary disease (COPD) is currently the fifth leading cause of global mortality and a major public health problem in both developed and developing countries. By the year 2020, COPD is expected to become the third most common cause of death in the world and the fifth leading cause of disease burden.

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Smoking is of the health hazards associated with today's lifestyle. Although the prevalence of smoking has started to decline among adults in developed nations, it is showing an increased trend in developing countries. Chronic obstructive pulmonary disease (COPD) is nearly always the result of long-term smoking. It results in changes throughout the respiratory system from the large airways to the alveoli as a result of prolonged irritation by smoke. In the large airways, inflammation of the airway mucosa increases the thickness of the airway wall and the mucus secreting glands. Smaller airways are also inflamed and may be significantly narrowed or obstructed by secretions. This narrowing and obstruction of the smaller airways results in the characteristic increase in airway resistance that is a feature of COPD. There is also generalized loss of lung tissue with destruction of alveoli and pulmonary capillaries as well as loss of supporting connective tissue. This loss of alveoli and capillaries results in a very significant impairment of gas exchange as a result of mismatch of ventilation and perfusion. COPD used to be known as "chronic bronchitis" and "emphysema", a name related to the airway inflammation and loss of alveolar tissue (emphysema). The separation of these two different entities is difficult clinically and hence a single terminology, COPD, is used. The disease is characterized by recurrent cough, progressive breathing difficulties, shortness of breath during rest and wheezing. COPD is a preventable disease, thereby reducing the mortality and morbidity associated with it. It will continue to be the leading cause of mortality and morbidity until lifestyle modifications are made. The only effective treatment to combat this dreadful disease is to stop smoking and other management measures.

Conclusion

The contribution of surplus body weight to mortality and morbidity continues to be widely published. Obesity causes hundreds of thousands of deaths and billions of dollars in excess medical expenditure

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each year. It has been described as a growing health threat on a par with smoking and is currently the focus of many policy initiatives. Several authors have reported that weight gain is actually associated with increased mortality. In an interesting corollary, Greg et al. reported that attempting to lose weight is beneficial for health whether or not it is actually lost. Such results beg the question of when and how weight loss is relevant to one's health. Current evidence strongly supports the beneficial effects of diet and exercise. The modern lifestyle has critically influenced the health and wellbeing of society at large; lifestyle modification is the only way to maintain healthy lung function.

Gastrointestinal and liver disorders

Mohamed Nausheda

The most common symptoms pertaining to the gastrointestinal system are excessive flatulence, bloating, heartburn, dyspepsia, constipation, diarrhea and obesity. A symptom is a complaint reported by the patient to a doctor. It is the subjective perception of a gut sensation. Personal awareness of one's own gut sensation is part of life. Most gut symptoms are not associated with pathology and fail to fit into disease entities. Most symptoms reported to doctors have no structural explanation. Physicians group such patterns of symptoms into syndromes, such as irritable bowel syndrome, dyspepsia, functional constipation, etc. Symptoms without the pathologist's stamp usually lack specific treatment. Most gut symptoms have no known pathological explanation and are said to be functional. Many people escape the experience of some of these symptoms. Psychologists agree that such symptoms are part of life's trauma.

Intestinal gas and bloating

Excessive flatulence, abdominal distension and bloating are very common complaints for which medical attention is sought. Whether excessive accumulation of gas is the actual cause of bloating is doubtful. There is poor correlation between the volume of abdominal gas and the severity of the

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Dr Mohamed Naushed MD, DM. is a Gastroenterologist at the Al-Amiri Hospital. Email: [email protected]

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symptoms. Many people relate abdominal distension to a volume of intestinal content that could be well tolerated by most normal people. The frequent claim that various foods create gas may represent the ability of the food to stimulate abnormal motility, which is perceived as bloating. Such people are unusually sensitive to normal levels of intestinal distension. Because of the poor correlation between the volume of gas and symptoms of bloating, dietary therapy to reduce gas production may not be successful. Localized collections of gas could serve as a painful stimulus in appropriately reactive guts. Most intestinal air is exogenous air and is swallowed by normal eating and drinking. About 2000­3000 ml of air may be swallowed passively and this is continuously expelled by belching and regurgitation, a process that occurs without much perception. The ability to empty swallowed air is highly variable from person to person. Failure to expel results in excessive accumulation of gas in the intestines which can be painful. Bloating is felt after eating and clothing becomes very tight. Although excessive intestinal gas in itself is of little or no clinical significance, many tend to believe that it is due to serious diseases. Intestinal gas consists of nitrogen, hydrogen, carbon dioxide and oxygen. Hydrogen and carbon dioxide are produced by bacterial fermentation of undigested carbohydrates which escape digestion in the intestine due to the absence of specific enzymes. The volume of air swallowed and trapped in the intestine is highly variable and so is the sensitivity of an individual to respond to this via abdominal pain. Gulping food results in inadvertent swallowing of air into the stomach. Drinking through a straw ingests twice the volume of air. Gas trapped in the stomach passes down through the intestine by peristaltic activity. Downward passage of trapped gas may induce spasmodic contractions in the intestine resulting in abdominal pain and bloating. Gas moves slowly in the large intestine and passes through the anus as flatus. Excessive passage of flatus through the anus is embaressing and may have social implications. Passage of 10­20 flatus per day is considered normal for a healthy person. Less than 20% of intestinal gas is produced from non-digestable starches or resistant starches present in wheat, corn, potato, etc. due to the absence of specific enzymes in

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the human intestine. These starches are consumed by large intestinal bacteria as food for growth and multiplication, producing gases such as carbon dioxide and hydrogen by the process of fermentation. The volume of these gases depends on the type of colonic bacteria inherent to the colon and the type of food we consume. As we get older, our ability to digest lactose diminishes and undigested milk and milk products are released into the colon where they are consumed by lactase fermenting bacteria to produce hydrogen. Beans and legumes contain complex starches which are converted to carbon dioxide, hydrogen and methane. Onions, cabbage, many other fruits and vegetables, and fructose and sorbitol present in soft drinks are important sources of gas production in the large intestine, again via colonic bacteria. Malodorous gases (e.g. hydrogen sulfide) are produced in the large intestine from sulfur containing foods (e.g. cauliflower, broccoli, cabbage). Not everyone produces intestinal gas from indigestible starches; this depends on the bacterial population peculiar to that person. For many, intestinal gas, bloating and flatulence are more of a nuisance than a serious medical problem.

How to control excessive intestinal gas

· · · · · · · · · · · · · Eat slowly Try to limit air swallowing Keep active; increase physical activities Drink directly from the bottle and avoid using a straw Avoid smoking and chewing tobacco Don't talk while eating Avoid using chewing gums Avoid carbonated beverages Avoid milk and milk products Avoid foods/drinks containing sorbitol, fructose Pre-soak beans before cooking Avoid onions, cabbage, and legumes Take a high fiber diet

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Heart burn and reflux symptoms

Heartburn and acid regurgitation are very common symptoms. Thirty percent of the normal population experience reflux symptoms at least once a month. It occurs in 50­80% of pregnant women. The majority of sufferers do not seek medical attention and the symptoms are relieved by drinking fluids or alkalis or by taking non-prescription medication. But for a significant proportion of the population reflux symptoms are serious enough to affect their quality of life. Heartburn and acid regurgitation result in a burning sensation behind the sternum that arises from the upper abdomen, radiating toward the neck; it is often misinterpreted as a heart attack and a sizable number of patients undergo detailed evaluation to rule out possible cardiac problems and are finally diagnosed with non-cardiac chest pain. Regurgitation is the effortless return of the gastric contents into the oropharynx without nausea or retching. Bending, belching or moving in a manner that increases intra-abdominal pressure can provoke regurgitation. Reflux is due to the failure or inability of the lower esophageal sphincter to prevent gastric content from regurgitating into the esophagus. The mucus membrane of the esophagus is delicate and not meant to withstand the corrosive action of the digestive juices and acid from the stomach. The presence of a hiatus hernia (upward herniation of the upper portion of the stomach into the thorax) is often associated with exaggeration of reflux symptoms. Acid reflux may irritate the upper airways precipitating asthmatic attacks or causing a chronic cough.

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Lifestyle modifications to control reflux symptoms

· · · · · · · · · Take frequent small meals at regular intervals Avoid fatty, heavy meals Avoid smoking and alcohol consumption Avoid tight fitting garments Avoid lying down for 2 hours after meals Dinner should be taken at least 3 hours before going to bed Reduce your body weight Keep the head end of the bed elevated Check the medicines you are using for other medical problems. Certain medicines used for control of asthma, high blood pressure, nitrates, analgesics, etc. can aggravate reflux

Alcohol abuse and liver disease

Alcohol is a direct liver toxin. The relative risks of developing alcoholic liver disease begin to rise in individuals who consume more than 30 grams of alcohol per day. Not all people who drink alcohol develop alcoholic liver disease. The risk of developing liver disease is genitically determined. Patterns of drinking behavior and its metabolism are heritable. Even among those who consume large amounts of alcohol, only 1 in 10 develop liver damage. The rate of alcohol elimination varies as much as threefold among individuals due to genetic pleomorphism or variations of inherited enzymes. The quantity and duration of alcohol consumption are the most important determinants of liver damage. Women are more vulnerable to liver damage with half the dose and duration of intake. Alcohol increases the minimum daily requirement of certain essential amino acids, folic acid and several other nutrients. Apart from liver damage, alcohol induces several multi-system dysfunctions such as acute and chronic pancreatic damage, damage to the skeletal muscles and muscles of the heart, peripheral nerve damage, gall bladder stones, etc.

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Constipation

Constipation refers to difficult defecation and is associated with straining or infrequent stool passage. Normally there is a wide variation in toilet frequency. Many people believe that daily bowel movement is essential for health and they worry if bowel movements are less frequent and irregular. Infrequent bowel movements and other defecatory symptoms are common in the healthy population and need not be harmful to health. A person is deemed to have functional constipation after initial clinical evaluation by a physician to exclude constipation as a consequence of potentially correctable medical or surgical problems. Constipation may be the initial manifestation of serious diseases like hypothyroidism, diabetes, parkinsonism, depressive illness or the result of medications used in the treatment of psychiatric disorders, high blood pressure, iron or calcium supplementation, etc. Constipation may be the result of slow colonic transit due to delay in the passage of stools through the colon because of colonic inertia or obstructive defecation caused by dysfunction of the pelvic floor muscles which expel the stools from the rectum. It can be worsened by emotional disturbance or stress.

Lifestyle modifications to ease constipation

· Increased physical activity: regular exercise, such as brisk walking and jogging may stimulate colonic motility and enhance bowel movements · Increased fluid intake: more water may be delivered to the colon; many elderly people consume small amounts fluids and are dehydrated · Increase dietary fiber

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· Bulk laxatives (wheat bran, ispaghula methyl cellulose) increase stool bulk and smoothness for evacuation; bulk laxatives have a role in the long term management of constipation In case of severe constipation, neither a high fiber diet nor bulk laxatives relieve constipation. The need to set aside an unhurried and if possible regular time for defecation is important. Always respond to a defecatory urge. If you experience difficulty in expulsion of the stool place a support approximately 15 cm in height under the feet when sitting on a toilet seat so that the hips are flexed towards a squatting position. For the same reason Indian type toilets are more helpful.

Chronic kidney disease

Ram Kumar Guptaa

An unregulated lifestyle and uncontrolled diet are the mother of many dreadful kidney diseases: e.g. kidney stones, obesity-related focal segmental glomerulonephritis, smoking-related urinary system cancers and complicating hyperlipidemia, hypertension and diabetes. A controlled lifestyle and diet are mandatory not only for primary but also secondary and tertiary prevention.

Kidney stones

How they are formed

The kidneys filter the blood to remove excess mineral salts and other soluble wastes. The kidneys also have the capacity to dissolve these wastes and excrete them in the urine. The undissolved portions of the minerals form crystals which clump together and grow into hard stones in the kidneys or anywhere in the urinary tract. These stones are composed of uric acid, calcium, phosphorus, oxalates and other minerals. If left untreated these stone increase in size, blocking the urinary passage and

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Dr R. K. Gupta is a Nephrologist with the Mubarak Al Kabeer Teaching Hospital, Kuwait. Email: [email protected]

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causing irreversible kidney damage. This serious problem can be prevented simply by healthier dietary habits.

Dietary factors and healthier lifestyle for prevention of kidney stones

1. Fluid intake. Of all the preventive recommendations, drinking enough fluid is the most important guideline for people with all types of kidneys stones. Increasing urine flow rates lowers urine supersaturation. The 24-hour urine volume should be 2.5­3 liters. A prospective randomized trial of high fluid intake and increased urine excretion has shown almost 60­ 65% reduction of stone recurrence over 5 years [1,2]. A simple rule of thumb is the color of urine; it should be like water and not dark and yellow. 2. Restriction of protein, calcium, oxalates, potassium and sodium Depending on the major constituent of the stone, your nephrologist and dietician should be of great help in modifying your diet. In general, the simple dietary rules to prevent stone formation are as follows: animal protein around 60­70 g, calcium around 700 mg, salt around 6 g/day. Persons with a stone containing oxalate should restrict peanuts, chocolate, black tea, coffee, berries and dark leafy green vegetables.

Diabetes and kidney disease

Insulin resistance syndrome and obesity in Indians

Indians, irrespective of their geographic location and mostly due to an underlying genetic predisposition, have a very high prevalence of insulin resistance syndrome: truncal obesity, hypertension, premature coronary atherosclerosis, diabetes and hyperlipidemia [3]. As an Indian national, one need to take precautions to

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lead an extra healthy lifestyle to overcome this genetically predisposed insulin resistance syndrome.

What does diabetes do to the kidneys?

With diabetes the small blood vessels in the body, including the kidneys, are injured, so the blood cannot be cleaned properly. Hence more salt and water are retained causing high blood pressure, weight gain and ankle swelling. Nerve damage by diabetes will cause difficulty in emptying your bladder resulting in back pressure and infection in your kidneys. The build-up of waste material will cause increase in serum creatinine and protein excretion in urine.

Effective treatment

The American and Indian Diabetic Associations emphasize lifestyle changes by which everyone beyond doubt improves insulin sensitivity. The standard recommendation is at least 30 minutes daily of moderate intensity physical activity such as brisk walking. The ultimate goal is to maintain body mass index at less than 25 2 kg/m . A diet low in protein and salt and high in natural sources of fiber (whole grain and leafy green vegetables) helps combat insulin resistance. In conclusion effective management has to be under direct supervision of a dietician and a nephrologist.

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Hypertension and kidney damage

How does high blood pressure hurt your kidneys?

High blood pressure makes your heart work harder. This will damage your blood vessels through out your body, including the kidneys. When the blood vessels in your kidneys are damaged they will stop removing waste and extra fluid from your body. This extra fluid in your blood vessels will then increase your blood pressure even more. It is a dangerous cycle. Continuing damage will cause end-stage renal failure. High blood pressure causes more than 25,000 new cases of kidney failure in the United States [4].

How will you know whether you have kidney damage?

Like hypertension, kidney damage can also remain unnoticed and will be detected only through medical tests. Your doctor can have your serum creatinine levels checked. An increased level is a sign of kidney damage. Another sign is protein in the urine. Your doctor will order estimation of 24-hour urine protein excretion. Certain kidney imaging tests will also be carried out.

How one can prevent blood pressure from damaging one's kidneys?

If you already have established kidney damage, the first task is to keep your blood pressure around 120/80 mmHg by different drug therapies. The National Institute of Health (NIH) recommends a healthier lifestyle and diet control along with drug therapy under a dietician and nephrologist [5].

What should you do to control blood pressure with kidney damage?

You must take all medications exactly as prescribed by your nephrologist. You must maintain your body weight as close as possible to normal range. A healthier lifestyle includes regular exercise, restricting

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protein intake to around 0.8 g/kg per day, and salt intake should be around 5­6 g/day. Excess alcohol and caffeine must be avoided.

Obesity and kidney disease

Massive obesity is known to cause protein in urine secondary to a kidney disease known as focal glomerulosclerosis [6]. Pathologically obese people have markedly increased glomerular hypertension with expansion of Bowman's capsule. These people have swelling in the legs, high blood pressure, increased urinary protein excretion and increased serum creatinine. Both weight loss and the administration of an ACE inhibitor can dramatically reduce protein excretion (up to 80­85%) in these patients [6].

Kidney and urinary bladder cancer related to smoking

It has been proven beyond doubt that smoking poses serious health hazards worldwide. Researchers have found that smokers are three times more likely to get renal and bladder cancer [7]. Similarly passive smokers are 40% more likely to develop renal and bladder cancer. This disease is the fourth most common preventable cancer among men and approximately 55,000 new cases are diagnosed each year in the United States. Carcinogens present in tobacco smoke are absorbed in the blood and then filtered by the kidneys and concentrated in the urine. These chemicals damage the urothelial cells and produce cancerous growths. Unfortunately there are currently no effective screening procedures for detecting this cancer early before symptoms are present. Hence in heavy smokers even the presence of asymptomatic painless microscopic hematuria warrants thorough investigations for genitourinary cancer. Stopping smoking at any stage is beneficial. Fortunately researchers have shown that stopping smoking, even after many years, will reduce the risk of renal and bladder cancer significantly [7].

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Conclusion

· Prevention is better than cure · Adopt a healthier lifestyle to prevent not only primary but secondary and tertiary chronic kidney diseases · Take adequate amounta of liquid and restrict protein and salt intake · Follow the advice of dieticians and nephrologists.

References

1. 2. US Preventive Services Task Force Guide to Clinical Prevention Services. 2nd ed. Baltimore, MD: Williams and Wilkins; 1996, p. 20­25. Borghi L, Meschi T, Amato F, Briganti A, Novarini A, Giannini A. Urine volume, water and recurrences in idiopathic calcium nephrolithiasis: a 5-year randomized, prospective study. J Urol 1996;155:839­843. Misra A, Vikram NK. Insulin resistance syndrome (metabolic syndrome) and obesity in Asian Indians: evidence and implications. Nutrition 2004;20:482­491. Perry HM, Miller P, Fornoff JR, Baty JD, Sambhi MP, Rutan A, et al. Early predictors of 15-year end-stage renal disease in hypertensive patients. Hypertension 1995;25:587­ 594. Cowley Jr AW, Roman RJ. The role of the kidney in hypertension. JAMA 1996;275: 1581­1589. Kambham N, Markowitz GS, Valeri AM, Lin J, D'Agati VD. Obesity related glomerulopathy: an emerging epidemic. Kidney Int 2001;59:1498. Jemal A, Siegel R, Ward E, Murray T, Xu J, Smigal C, Thun MJ. Cancer statistics, 2006. CA Cancer J Clin 2006;56:106­108.

3. 4.

5. 6. 7.

The hospital care of accident victims

V. K. Grovera

Editors' note: This article serves to outline to the public the process involved in the management of emergencies once a patient reaches the hospital.

Trauma is the most common cause of death in people under the age of 40. The economic effects are enormous .It has been estimated that cars have killed more people since their invention than all wars in the same period. Casualty rates vary widely from country to country. Finland and the United Kingdom have the lowest rates and Slovak Republic has the highest rates. The speedy assessment and resuscitation of trauma patients should be coupled with readiness to transfer multiple injury patients quickly and efficiently to a hospital with special expertise. The ultimate outcome in the seriously injured depends on many people and agencies working together towards the same goal.

Pre-hospital care

The objective of pre-hospital care is to prevent further injury, initiate resuscitation and transport the patient safely and rapidly to the most appropriate hospital. It is provided by the ambulance service and paramedical staff who are in constant communication with the hospital. Paramedics can provide techniques such as tracheal intubation, periDr Vinod K. Grover, MS, FRCS, is a Consultant Surgeon with Jahra hospital, Kuwait. Email: [email protected]

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pheral intravenous (IV) access and administration of IV fluids and drugs. Such procedures may increase pre-hospital time, delaying definitive treatment. Where available the seriously injured patient is transferred to hospital by helicopter.

Reception, resuscitation and assessment

The initial evaluation of a critically injured person is a challenging task, and every minute can make the difference between life and death. Mortality can be grouped into immediate (occurring at the site of injury) caused by fatal disruption of great vessels, heart, lung or major disruption of body cavities; early (from 15 minutes to 16 hours after the injury) occurring because of cardiovascular and/or pulmonary collapse or massive central nervous system injury; late trauma mortality peaks from days to weeks after injury and is due primarily to sepsis and multiple organ failure. Surgeons recognition of these patterns led to the development of advance trauma life support (ATLS), a system built around a standardized protocol for patient evaluation. The initial evaluation follows a protocol of primary survey, resuscitation, secondary survey and either definitive treatment or transfer to an appropriate trauma centre for definitive care and rehabilitation. Regardless of the clinical setting, a team of doctors and nurses is available to receive the injured as soon as the ambulance personnel inform the emergency department.

Primary survey and resuscitation

The steps of a primary survey are encapsulated by the mnemonic ABCDE: airway, breathing, circulation/hemorrhage, disability, and exposure/environment. 1. Airway with cervical spine control. Assess the airway by determining the ability of air to pass unobstructed into the lungs. From the outset the neck should be kept in a neutral po-

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sition. The application of a rigid collar and the use of sandbags and tape will prevent inadvertent spinal injury. If the patient is talking naturally and there is no respiratory distress, the airway is clear. Critical findings include obstruction of airway due to direct injury, edema, a foreign body and the inability to protect the airway because of depressed level of consciousness. Treatment may be simply control with suctioning, oropharyngeal airway or may require endotracheal intubation or placement of a surgical airway (e.g. cricothyroidotomy, tracheostomy). 2. Breathing. Next, evaluate the breathing, looking for the absence of spontaneous ventilation, absent or asymmetric breath sounds (consistent with either pneumothorax or endotracheal tube malposition), dyspnea, hyperresonance or dullness on chest percussion (suggesting tension pneumothorax or hemothorax), and gross chest wall instability or defects that compromise ventilation (e.g. flail chest, sucking chest wound). Treat pneumothorax, hemothorax, tension pneumothorax, and sucking chest wounds with a tube thoracostomy. Initial treatment for a flail chest is mechanical ventilation, which is frequently required for other injuries. 3. Circulation. Evaluate the circulation by identifying hypovolemia (an injured patient who is cold, clammy, sweating, restless, and anxious is in hypovolemic shock until proven otherwise and has lost about 30% blood volume), cardiac tamponade, and external sources of hemorrhage. External hemorrhage is identified and controlled. Invariably this can be controlled by simple direct pressure. Hemostasis from the sometimes profuse bleeding of a scalp wound is best achieved by sutures. Careful splinting of long bone fractures reduces the blood loss from the fracture sites by up to 50%, makes the patient more comfortable, and reduces analgesic requirement. In contrast, blood loss into the peritoneal cavity, thorax or pelvis is usually concealed, can be life-threatening in magnitude, and cannot be controlled. Inspect the neck veins for distension or collapse, determine whether the heart sounds are auscultated. Initiate treatment of hypovolemia by intravenous fluids. Patients with multiple trauma

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may require several liters of fluids over 24 hours to restore intravascular volume, tissue and vital organ perfusion, and ensure adequate urine output. If ongoing blood loss is not controlled surgery may be required to attain hemostasis. Treat cardiac tamponade by pericardiocentesis, followed immediately by surgery to explore and repair the source of bleeding. Control any external hemorrhage with direct pressure or surgery. 4. Disability. Disability is determined by examining the patient's response to commands or to painful stimuli. Examination of the pupils of the eys is also important. An abnormal finding may indicate a head injury. According to specific findings, treatment may vary from close monitoring and observation to surgical intervention. 5. Exposure. The final step in the primary survey includes patient exposure and control of the immediate environment. Completely remove the patient's clothes for a thorough physical examination.

Monitoring and investigations

Several monitoring adjuncts such as ECG, ventilatory monitoring leads, and pulse oximetry are needed. Some situations require gastric intubation to decompress the stomach. The important laboratory studies are type and crossmatch to ascertain the patient's blood group just in case transfusion is required. Urine and serum evaluation are necessary to screen for drug abuse including alcohol.

Secondary survey

At this stage a thorough history is taken and a physical examination is performed. Essential history points are: allergy, medication, previous illness, last meal, event related to the injury, the so-called AMPLE mnemonic.

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A thorough clinical examination should include inspection, palpation and auscultation of the head, neck, chest, abdomen, pelvis and extremities, looking for abnormalities. Adjunct radiological investigations include plain x-rays of the cervical spine, chest and pelvis. Ultrasonagraphic examination of the abdomen and computed tomography of the head, spine, chest and abdomen are performed, according to the findings from the history and clinical examination.

Definitive care

Both the primary and secondary surveys will segregate patients into those who can go home with or without a period of observation, those who require an ICU or ward admission, or those who require immediate surgical intervention. The definitive care might involve more than one surgical team, so close coordination and collaboration is an important aspect in trauma care.

Abdominal injuries

Abdominal injuries require a laparatomy if they are significant; e.g. continuous internal bleeding from the spleen or other abdominal viscera. Repair of bleeding or a lacerated organ is treated in the most conservative way by a simple repair; resection of the affected organ is only done in cases of non-salvagable injury. Some injuries are managed without the need for laparatomy, e.g. most liver injuries.

Chest injuries

The treatment of chest injuries can vary from simple analgesia as in rib fractures, to insertion of a thoracostomy tube (ICT) to drain trapped air and moderate bleeding. Opening of the chest (thoracotomy) is only done for life-threatening injuries, such as massive blood draining from the ICT indicating continual bleeding.

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Fractures

Long bone fractures are treated by fixation either with internal devices, or when accompanied by significant dirty wounds, the device is fixed externally. Most pelvic fractures are managed conservatively.

Collision prevention

State regulations for speed-limits · Compulsory training and licensing · Restrictions on driving while drunk or impaired by drugs · · · · · · · · · · Seat belts for all passengers Restriction on mobile phone use while driving Compulsory safety testing of vehicles over a certain age Restriction on commercial vehicle driver hours Avoid rubbernecking, where drivers slow down to look at recent collisions Avoid backup accidents, i.e. when a driver reverses his car into an object, person or another car Segregated facilities such as cycle lanes, underpasses and over bridges Limited pedestrian access to highways Compulsory helmet for cyclists Traffic awareness campaign ·

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