ARTICLE XIII - Heart Diseases in Eve – What’s new?

“Women are immune to heart problems,” is a wrongly held belief. The biggest killer of women is neither breast cancer nor uterine problems. Most women lose their lives to heart problems and strokes. Though, they may be less common in women before menopause but afterwards the disease is not only more common in females, it is more aggressive and flows a more serious course. Most women, even in the West, are not aware of the gravity of situation. This requires urgent attention and a well coordinated prevention plan.

A landmark meeting of specialists was held in Canada called the ‘First International Conference on Women, Heart Disease and Stroke’, on May 10, 2000. This took account of the situation and made elaborate recommendations. Some of the recommendations made there were to involve women in the development, implementation and evaluation of programs and services. To remove barriers to women’s participation in leadership positions in all sectors. Most importantly, to tailor programs and services to women’s needs including primary prevention, screening, diagnosis and treatment, prevention of recurrence, rehabilitation and support programs and services

What are the major factors?
Important factors have been identified which play a substantial role in the causation of heart diseases and strokes in both men and women.

a. Poverty:
It is the biggest curse around the World. The picture becomes more obvious when one realizes that more than 1000 million people live in absolute poverty, approximately 900 million are illiterate, about 2000 million people are deprived of potable water and approximately 800 million people go hungry every day. Though it may seem incredible but the truth is that there are 150 million undernourished children under 5 years of age and 14 million children less than 5 years old die every year. Women are the worst sufferers of this appalling poverty.

b. Response to stress:
Individuals cope in a variety of ways to external stress. Health effects of stress are shaped by social and cultural factors. Western assumption is that host response mechanisms operate only at the level of individual. The cross-cultural research suggests that many other factors have important roles to play and determine the response to stress. The response to stress of women in developing countries may be different and more severe.

c. Roles of Women
The women of today and yesterday has been “E”-woman which means EVERYTHING TO EVERYONE AT EVERY TIME. Women have various roles which vary by culture and country. Women tend to have primary responsibility for maintaining a home and caring for family members – young and old. This creates double workload, looking after family and in many cases earning money. As compared to men more efforts have to be put in by women in looking after family and fulfilling all family members’ need.

d. Inequalities of society:
Though health services are inadequate for the general population but of what is available women face great inequalities due to unequal access to and use of basic resources. Major reason for that is unequal access to primary care across all strata. Health policies and programs do not address this problem objectively and positively and this leads to persistence of inadequate and inappropriate health services for women.

How to promote women’s heart health?
Considering the risk factors for heart problem and stroke, a policy was decided upon to work on some guiding principles. For the promotion of women’s heart health and prevention and management of heart diseases and stroke following goals may be considered and worked at:

· Heart healthy habits:
Women have same risk factors as men. Conglomeration of risk factors has to be appreciated. Recognition of risk factors and control of risk factors is the foremost principle. Modifiable risk factors are high blood pressure, high cholesterol, smoking, lack of exercise and obesity. Health promoting dietary habits and regular physical activity have to be promoted. Health promoting dietary habits should be conducive in reducing weight by reducing caloric intake and regular exercise. Diet has to be modulated to keep cholesterol in lower limits. Regular physical activity for all ages and both sexes should be ingrained in our priorities and emphasis should be placed on it from young age. Women in developing countries are not encouraged to exercise and participate in sports. These civil barriers have to be broken and females have to be encouraged to remain active and take regular exercise.

· Research:
There is a need to address the issues of heart disease and stroke among women, including cardiovascular health and disease among women and the impact of preventive and therapeutic intervention on women. This should include gender sensitive research, education, training and supportive environments for women researchers. There is dire need, especially in Pakistan for involvement of women directly in the identification of women’s research issues, methods, analyses and interpretation of results.

· Dissemination of information:
There is urgent need to develop an “info-structure” to effectively disseminate the latest research pertinent to women. Recommendations on latest guidelines issued by various bodies have to be made public. Burning issues in women’s health need media attention and any conclusion drawn need to reach the end users. Ongoing programs need surveillance and monitoring of their findings and to be made available to general public on print and electronic media.
In conclusion, we have to recognize that heart diseases and stroke are the leading causes of death among women in the developed world and are fast approaching the same status in the developing world. Gender inequity, poverty, illiteracy, unemployment, and lack of access to health services influence women’s health, and we have to take appropriate actions to address these and other underlying determinants of health, and promote a healthy lifestyle that would help prevent heart diseases and stroke in women.

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Ref: Heal Thy Heart written by Prof: Dr. Muhammad Hafizullah

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ARTICLE - XII - How to treat heart failure? (Part-II)

Treatment depends on the cause of heart failure, the type and severity of symptoms and how well the body is able to compensate. Early testing is important because early treatment can sometimes prevent heart failure from worsening or even reverse its progress. Lifestyle changes and medication can improve the quality and length of life.

Life style modifications:

Regardless of cause of failure and severity of symptoms, there are certain rules to follow for every one. Diet and lifestyle modifications are important in managing the symptoms.

Limit Fluid intake. Excessive fluid puts extra load on heart and can make it harder for the already weakened heart to pump. Monitoring fluid intake can reduce complications and hospitalization. All foods that melt such as ice cream, gelatin, or frozen ice treats and foods that contain a lot of liquid such as soup are considered liquids. To relieve thirst without taking extra water, chewing gum or rinsing mouth with water and spitting it out can be tried.

Limit sodium intake: When a patient has heart failure, one need to eat less sodium, a component of salt, Excessive sodium leads to retention of water that makes it harder for the weakened heart to pump and leads to worsening of heart failure. Fluid may build up in the lungs – making it harder to breath. It may accumulate in feet, ankles, legs, and abdomen. Sodium intake should be limited to less than 2 g (2000 mg) per day and keeping track of sodium intake is the surest way of evaluating diet. Processed and restaurant food are high in sodium. Remember, food can be tasty and still be low in sodium.

Exercise: Exercise is very important for people with heart failure. If the patient is not already active, he should be encouraged to start an exercise program. Prescribed exercise is often part of a cardiac rehabilitation program.

Weight: Heart is entrusted with the responsibility of supplying nutrition in the form of blood to all parts of body. Losing weight can favourable lessen the load on heart. Over weight patients should be very strongly urged to lose weight.

Smoking: Smoking increases the risk of heart disease and makes it more difficult to exercise.

High blood pressure: Exercising, limiting salt intake, and controlling stress can help keep blood pressure in a healthy range.

2. Drugs: We are lucky that we have a host of drugs available, to not only control the complaints associated with heart failure but also favourably effect the eventual outcome. Added medications may be used depending on how well the patient tolerates the prescribed medications:

· Diuretics: Water tablets form the corner stone of heart failure treatment. The body is over loaded with extra fluid and the only way to get ride of this is through increased urine output. The drug has to be used very carefully because excessive use can lead to loss of salts and water leading to dehydration. Supplements of potassium are required on a regular basis to compensate for the loss. Some diuretics have special Potassium retaining effect and the combination of a loop diuretic and potassium sparing diuretic makes a logical choice. Renal function may dictate the type of diuretic to be used.
· ACE inhibitors: ACE inhibitors have been a wonderful addition in the armamentarium of anti-failure drugs. They have been proven to reduce death rate and improve symptoms in patients with mild, moderate or severe heart failure. Their efficacy has been established in patients with poor heart function but no obvious evidence of heart failure. This medication reduces the heart’s workload, lowers blood pressure, and optimizes heart function. Every patient with heart failure should benefit from ACE inhibitors. Some patients develop intractable cough with ACE inhibitors, they can benefit from the new class of drugs called Angiotensin receptor inhibitors.
· Beta Blockers: Beta blockers have revolutionized the management of heart failure patients. The research one the use of Beta blockers in heart failure, has shown that Beta blockers prevent worsening heart failure and in some cases improve heart function. However, some patients are not able to take them because of their side effects.
· Additional medications for coronary artery disease (CAD), high blood pressure, diabetes, infection or inflammation of the heart muscle (such as myocarditis), thyroid problems, heart valve problems, and abnormal heart rhythms (arrhythmias) may be required.

3. Definitive treatment:
In some cases, heart failure can be reversed when the underlying problem can be corrected, such as heart valve replacement surgery and treatment for hyperthyroidism. Sometimes heart failure develops shortly after a heart attack; heart failure can sometimes be reversed in these cases when treatments such as coronary artery bypass surgery or angioplasty, medication, and cardiac rehabilitation improve blood flow.

4. New treatment options:
Recent research has focused on developing devices that can help cardiac failure.

· Cardiac resynchronization therapy: Biventricular pacemakers can synchronize the rhythm of the heart’s chambers (cardiac resynchronization). Cardiac resynchronization is typically used for people with heart failure who also have certain problems with their heart’s electrical system. A recent study suggests that cardiac resynchronization may offer improvements in heart function, exercise capacity, and quality of life beyond that seen with medications alone in these people.
· In some cases when standard medical treatment does not help worsening symptoms of heart failure, other measures are considered. These include heart transplant, artificial hearts, and left ventricular assist devices (LVADs) – mechanical pumping devices that are implanted into the chest. However, these options are only for a very small number of people.

Heart failure is a life long malady and it demands understanding and commitment by the patient. Patient’s attitude and level of participation in the treatment can strongly effect the treatment outcome. Making the required changes in life style and complying with dietary restrictions can have a positive impact on the eventual prognosis. Taking the medications as directed, controlling the diet, and getting regular exercise are key lifestyle changes to control heart failure symptoms and preventing worsening of heart failure.

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Ref: Heal Thy Heart written by Prof: Dr. Muhammad Hafizullah

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Article VI - Quitting Smoking – Make it Possible

“Smoking is the easiest thing to give up, I have given it up a hundred times,” commented Kareem, while puffing. The missing link was why did he restart ninety nine times? On the other extreme, a very accomplished doctor after undergoing bypass surgery and angioplasty told his wife in unambiguous terms, “I can leave you, but I cannot quit smoking.” Yet, there are many people who have given up smoking and feel very happy about it. They cannot stand the smell of cigarette and refused to inhale nicotine actively or passively. Having learnt their lesson, they openly question the wisdom behind smoking. They find it difficult to rationalize their previous ‘smoking status’. There has been an unending war against smoking and more than 60 million people around the world have quit smoking. You can, too! If you have never tried to quit smoking and failed, you are not alone. Many people try to quit smoking several times before they succeed.

This article will off you inspiration, reasons and ways to quit smoking. Every one knows and appreciates that smoking cigarettes is bad for health. Smoking causes more than a half million premature deaths worldwide each year. A smoker has a two to four time greater risk of sudden cardiac death than a nonsmoker. If a person has any other risk factors for heart disease, smoking synergistically increases overall risk of heart attack. Smoking predisposes to cancers of lung, upper respiratory airway, upper and one lower ends of food pipe and mouth. Smoking also predisposes a person to progressive narrowing of vessels involving brain and legs. Smoking worsens the health of the smoker and the people around the smoker. Infants and children exposed to passive smoking develop more respiratory problems like bronchitis, pneumonia, ear infections, coughing, wheezing, and worsen asthma. Passive smoke can cause heart disease and lung diseases in nonsmokers. Children of smokers are much more likely to smoke than children of nonsmokers. Pregnant women who smoke put their babies at risk for low birth weight, developmental problems, and even death of babies.

Can quitting smoking be beneficial?
The first question every smoker asks is, “ I have been painting my lungs black with smoking and depositing atheroma in my vessels and accumulating all types of carcinogens in my body, will it do any good if I stop smoking now?” Fortunately the answer is a BIG affirmative and various studies have documented the benefits of quitting smoking. When one stops smoking, the body starts repairing itself most immediately. The risk of heart attack, stroke, and cancer starts dropping immediately. Risk of a heart attack drops quickly within days as soon as one stops smoking. Stopping smoking reduces the risk of smoking-related cardiovascular disease by approximately 50% within one year, and to normal levels equivalent to people who never smoked within five years. The cough becomes less and less severe. Food starts to taste better. One’s sense of smell gets sharper and clothes start smelling laundry-fresh. The nicotine stains on hands or face start to disappear. Quitting smoking prolongs life and reduces the risk of disease including heart disease, heart attack, high blood pressure, lung cancer, throat cancer, emphysema, ulcers, gum disease and other conditions. One feels healthier and can endure prolonged activity by increasing stamina.

Can doctor’s intervention be effective?
All doctors have unwavering faith in the known hazards of smoking and the amply demonstrated benefits of cessation. But even now the literature continues to document the failure of doctors and other healthcare professionals to intervene with all of their patients who smoke. Even in the west, only half of current smokers report having been encouraged to quit and even fewer receiving specific counseling. Doctors have their own problems and report the following barriers to providing smoking interventions: a belief that they are not effective, poor intervention skills, a belief that patients do not want their doctors to intervene, and little time to fit intervention into their practice.

There is no doubt that healthcare settings like hospitals or clinics provide an important teachable moment for smoking cessation intervention specially after an acute illness like a heart attack, episode of angina or a procedure like angiography, angioplasty or bypass surgery. On average seventy-five percent of the adult population visit a physician at least once a year. In the doctor’s office, patients are often conscious of their health and most receptive to risk factor intervention. This provides an important opportunity for change. Many studies have documented that doctor-delivered counseling for smoking cessation can be effective. However, these studies have also shown that two factors are especially important: the doctor should receive skill-building training in counseling methods, and an office system that facilitates delivery of such counseling and enhances its effect, must be in place. We, in Pakistan lack both of them, but resources can be recruited for both as long as we appreciate and identify our goals. With such training and support, more intensive interventions produce a greater effect. In general, doctor-based primary-care interventions have yielded cessation rates of 10% to 20%, a threefold to fivefold increase over the 1-year maintained cessation rate of 4% seen in the general population.

What if smokers do not give up smoking, is it a wasted effort?
Even if patients do not give up smoking, smokers clearly value and appreciate their doctor’s advice and counsel. They believe that it is helpful in their efforts to quit smoking. Furthermore, they see the provision of such counsel as an indicator of caring on the part of the provider, and they appreciate it even if they do not intend to quit. Advice alone, taking no more than a few minutes, is of value. It helps to goad them on the path of ‘quit smoking’. For the healthcare professional interested and willing to do more, a patient-centered approach in which the patient is an equal partner is optimal. Such an approach helps smokers gain confidence in their ability to quit. Such an intervention process can be adapted to any time frame but optimally takes 5 to 10 minutes.

Multi-prolonged attack – any advantage?
The person who smokes often has one or more additional risk factors. There is substantial evidence for risk factor clustering, and the smoker is more likely than the nonsmoker to have elevated cholesterol and hypertension. Thus, smoking is often only one of several risk factors that must be addressed simultaneously. Important aspect of this is to recognize the importance of approaching all modifiable risk factors with equal zeal and vigor. Of all the risk factors smoking cessation is most cost effective and useful in more than one way. Patient-centered counseling methodology is as applicable to counseling for diet change or exercise as it is to smoking.

Specific multi-component programs entail treatment of patients who have already experienced a heart attack or an episode of unstable angina. One such developed by Debusk and colleagues demonstrated favorable effects on smoking, cholesterol, and exercise in patients who had suffered a heart attack, with an increase in 1-year smoking cessation rates from 53% to 70%. In this program trained nurse case managers follow computer-generated treatment program. We may not have access to such luxuries like computer generated programs and trained nurses but within our limited resources we can develop our own system and program and train our own staff.

Can drugs be helpful to quit smoking?
Most patients may not require any drugs but in certain smokers who consume more than fifteen cigarettes daily, craving for nicotine is strong enough to be substituted by other preparations of nicotine. Although various drugs have been used in the past to help smokers, nicotine replacement therapy has been shown to be more effective and should be an important constituent in all smoking cessation programs. Nicotine delivered through skin by special patches called transdermal nicotine, has been shown to be safe and effective. Its safety is amply documented in patients with known heart diseases. These are applied to skin and can be applied anywhere on the body. Nicotine-containing gum and the transdermal nicotine patch are equally efficacious an safe, but in general the patch is preferably for routine clinical use, although gum may be preferable in certain clinical situations like some persons prefer the oral stimulation that the gum provides. In addition, a nicotine nasal spray is now available in the west, and a nicotine inhaler is likely to be available soon.

There is little evidence available on the value of nicotine replacement therapy in light smokers less than fifteen cigarettes per day; in these patients, assessment of nicotine dependency should include time of starting smoking and number of cigarettes – whether increasing or decreasing. A new drug called ‘Chantix’ has been shown, in various studies to be effective in ‘motivated’ persons to quit smoking. The effects are apparent after a fortnight and the drug has to be continued for three months.

How you may feel after quitting?
There is a lot of mystery surrounding this topic. The world does not end after quitting smoking rather a new world unfolds – a world of reason, health and aroma of ‘good smell’. Most smokers who have quit smoking would not like to sit next to a smoker. Most of the quitters never want to restart smoking. Many of them regard smoking as absolute stupidity where a person is actually paying for his ill health and cancer. For sure this is one habit where one ‘invests’ in cancer and deadly diseases. Most people have no problems as all except for slight ‘off mood’ for a couple of days. So you should be mentally prepared for it. You may crave cigarettes, be irritable, feel very hungry, cough often, get headaches or have difficulty in concentrating. These symptoms of withdrawal occur because your body is used to nicotine, the active addicting agent within cigarettes.

When withdrawal symptoms occur within the first two weeks after quitting, stay in control. Think about your reasons for quitting. Remind yourself that these are signs that your body is healing and getting used to being without cigarettes. The withdrawal symptoms are only temporary. They are strongest when you first quit but will go away within 10 to 14 days. Your major inspiration should be to remember that withdrawal symptoms are easier to treat than the major diseases that smoking can cause. You may still have the desire to smoke, since there are many strong associations with smoking. People may associate smoking with specific situations, with a variety of emotions or with certain people in their lives. The best way to overcome these associations is to experience them without smoking.

A relapse is not a reason to lose hope. If you smoke again (called a relapse) do not lose hope. Seventy-five percent of those who quit relapse and most smokers quit three times before they are successful. If you relapse, don’t give up! Review the reasons why you wanted to become a nonsmoker. Plan ahead and think about the reasons for not smoking.

Steps You Must Take Today:
There are certain tricks which work very well for those who find quitting very difficult. If you have not decided to quit, try smoking one cigarette for two cigarettes so you can reduce by half. Smoke only half and throw away the other half. Smoke one less cigarette today and smoke two less tomorrow. Smoke in only one place and make it an inconvenient place. Keep your cigarettes, lighter, and ashtray in that one place and do not give yourself license to smoke anywhere else. Smoke with your opposite hand, the trick here is to break up your smoking routine. Allow yourself to run out of cigarettes before you buy another pack. Buy only one pack at a time and avoid buying cartons. Decide on a date to quit for good and write it down on your calendar and then stick to it.

To conclude, there is overwhelming evidence demonstrating both the cardiovascular hazards of smoking and the prompt benefits that occur with smoking cessation. The provision of advice alone significantly increases the smoking cessation rate, and even minimal counseling yields further benefits. Intervention with patients who have already suffered a cardiac event yields particularly significant benefits. The smoking status of all patients should be assessed and appropriate intervention offered to those who smoke. Doctors should be trained in counseling techniques and the use of nicotine replacement therapy. The universal application of these modalities will contribute to the continued decline of smoking and subsequently heart diseases and cancers.

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Ref: Heal Thy Heart written by Prof: Dr. Muhammad Hafizullah

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Article V - Ways to Relax

“Doctor, I am working six days a week from seven am to seven pm but now I am losing concentration and have lost my energy!” discloses Ahmed a young thirty year old industrialist. He had been successful to increase his family fortunes from one sick unit to a conglomerate of profitable industries. He has worked very hard but he is finding it difficult to carry on. “What I could do in an hour? Now it takes me a day to do!” confessed a forty year old banker. He got his MBA from LUMS and had a very bright start. He is set for a very promising career. He put his hear and soul in his job and won laurels for his bank. But, for the last four months, had been noting a decrease in concentration and his output. Jamil a bureaucrat by profession started to feel pain in his chest and right arm, mostly at the end of day. He had a very difficult job and was under tremendous stress. He was a perfectionist and that made the matters worse. He would be sitting late in his office and would take a bundle of files home almost daily. He had a thorough medical checkup but was declared physically fit.

All these patients had two things in common – over wok and stress. They had all been working very hard and were still not past their middle age but ‘burnt out’. These are manifestations of tension and over wok. These are markers of lack of any relaxation strategies. All out lives we have been urged to work very hard – to give more than hundred percent. We heard similar lectures from our school and college teachers and later from our bosses. It was repetition of same story that we heard from our mother and father. So naturally we have learnt how to work hard, but no body at any stage, even casually mentioned that after all the hard work one needs to unwind and relax. Every ascent is followed by a descent and after hard work the body and mind has to be rewarded by some rest.

In the west they know the importance of relaxation. They have learnt how many hours a body can work hard and how much relaxation is required. They work hard forty hours a week and then for two days they are like kings. It takes at least forty eight hours to unwind and relax to be able to put a hard work the next week. Other than the weekends every one has also devised a way to relax after work. Some people walk, others hit gold balls in gold course, some splash water in swimming pool, other go to pub and some go riding and skiing.

Working abroad, you no longer have to ‘beg to state that I have an urgent piece of work’ or kill an aunt or grand mother to request leave. In our country leave is not considered a right, rather is a luxury and at the discretion of the boss. Abroad, holidays mean ‘holidays’ – any job that you join, first of all you declare that you will be off at such and such time. Holidays are neither to attend Janaza and nor to participate in Mehndi and Shaadi. Holidays are meant to relax, take your family away and just relax. Perhaps its more of recharging of batteries. Holidays are your right and no body can deny you that. A hospital has to find locum but your holidays cannot be cancelled.

In our stressful daily routine how can we relax? Surely taking tranquilizers cannot be the answer to our daily problems. We have to find ways to relax. Just as every one has his own way of working, every one has to devise his own way of relaxing. And this is as important and as cost effective as working hard. The relationship between hard work and relaxation has to be appreciated. In all daily time tables there should be clearly demarcated time for relaxation.

What are different ways to relax that can be adopted and practiced in our society? Exercise and walking are two very effective and time tested ways of relaxation. Many people use it for analysis and planning; others detract their mind and offer ‘tasbeehat’ during walk. Playing games and specially games like golf, tennis and squash can be rewarding. During a game one’s mind is detracted from all worldly problems and it revolves around one ball! One can learn relaxation exercises and practice them with great results. These offer very effective relief in a short time. Many people practice these in their offices without leaving their chairs.

But perhaps the best and most effective way is to offer prayers with utmost concentration. Nothing can be better than that! On the one hand five times a day one detracts one’s mind from worldly strife to the ‘real’, and on the other hand one gets a lot of inspiration from it. One feels closer to God and is reassured that He is the One who takes care of everything. One also realizes how humble a human being is! One can only work hard but the result is decided by Him. What could be better than to supplicate Him and have faith in Him. Most successful people find prayers as an ultimate form of relaxation and after every prayer they find themselves charged up for the next assignment.

There is no single remedy for this problem. One may select any method of relaxation but it has to be done ‘as soon as possible’. Once its defined, one has to follow it religiously and incorporate it in daily routine. By this body can be rewarded regularly and it will have a positive impact on productivity. One has to choose between ‘longer hours’ and ‘long years’. To chose for long productive years one has to work hard and even harder to relax!

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Ref: Heal Thy Heart written by Prof: Dr. Muhammad Hafizullah

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Article IV - How to lose Weight?

Ameena was in tears, “but honestly I try very hard, I go without food for days and have been trying to exercise.” I felt very sorry for the young medical student who had been struggling without overweight for the last few years. “What do you avoid?” I asked her. “I swear I do not eat anything, I starve myself but some times I have to eat something…” and purposely she did not elaborate on ‘something’. All along I believed in her and appreciated her determination and efforts but it is that ‘something’ which makes the difference and determines the eventual outcome.

“Bibi, for years, you have been slipping ‘prohibitive’ amounts of ‘proscribed’ food through this ‘silt’ (pointing to mouth) to please only a small part of your tongue. Do you realize that taste buds are only confined to the front one third of tongue? You have held the whole body hostage to the demands of a small part of tongue. All the illnesses you are inviting are the consequences of this imbalance of food and priorities of life,” I deliver an impromptu sermon. Many people have their mouth and eyes wide open as they grapple with the new ‘revelations’. “So, from now onwards, look after the rest of your body and deny the ‘extraordinary luxuries’ you are bestowing upon the ‘twittering tongue’,” I advise while concluding my oration.

The concept of bank account works well with some people. Weight is like an account, the more you put in and the lesser you take out, the amount increases. The sum will naturally decrease, if less money is put in and more is siphoned out. When one is consuming food, one is in fact putting more money in and when one is exercising that is like spending money. The interest rate may be different in different type of accounts but the basic philosophy remains the same. This is how I can explain, the much argued, different rates of metabolism in different people.

Different types of food are like different types of currency. Where as fats are like pounds, carbohydrates are like dollars and proteins are equivalent to the local currency. So if people consume fats, they are putting in more pounds and the account will increase proportionally. Similarly excessive consumption of sweets and carbohydrates contributes to the account (weight). Spending patterns mimic same analogy. Strenuous aerobic exercise like running, swimming, climbing stairs, playing competitive games – squash, football or hockey are like spending in pounds. Moderate aerobic exercises like brisk walking and playing indoor games, will be like spending in dollars. Leisure walking, playing golf and cycling are like spending money in local currency. As long as some money is being spent, the account cannot stay static and is bound to go down. Therefore some type of exercise has to be encouraged as it is bound to reflect in reducing the account/weight.

This concept of storing and spending works well with most people. Saving and spending in different currencies clicks with a little more enlightened person. The resolve to avoid ‘pound foods’ at all costs, refuse ‘dollar foods’ most of the time and prefer ‘local currency food’ has to be inculcated forcefully. The concept may take some time to be swallowed but it is worth the effort. Similarly, classifying spending as pounds, dollar and rupees generates interest in intelligent persons. The emphasis on ‘pound exercises’ pays dividend and many patients refer to it in a light vein on their next visit.

“If you continue like this, I will be obliged to order a new tougher and bigger chair and a larger door for your next visit; on the contrary, you might surprise me by losing a lot of weight with a slim figure and an enviable waist line,” are the final words before the patient leaves the clinic. It contains both messages – admonition and encouragement. The approach has to be based on ‘carrot and stick’ theory. Many patients shuffle restlessly to get their weight checked on subsequent visits to register their success.

What are the goals? Goals have to be realistic and achievable. For moderately obese person an ideal target will be to lose 10% of weight in six months. So, if someone is weighing 100 kg, the aim will be to lose 10 kg over six months. This translates roughly to 2 kg every month. Of paramount importance is to emphasize that perseverance is the key to success. Initial enthusiasm can die very quickly. Encouragement from the family is most important. And comments like, “Oh, you look very smart,” or “you look a lot slimmer and healthier,” can go a long way.

What to eat and what not eat, is the crux of all bickering. Every fat man recognizes the fact, that the extra folds of fat are consequences of his overindulgence in food. But what to avoid and what to consume remains the most important question. What types of foods doctors ban, holds the key to compliance. This is more like introduction of ‘emergency’ where the person is instructed to avoid a few ‘calorie bombs’ and reduce ‘calorie missiles’. Talking in vague terms of ‘percentage of reduction’ in carbohydrate, fats and proteins is difficult to comprehend and implement by a majority of semi literate and even otherwise literate persons. The emphasis should not be on offering a ‘short course’ on nutrition and calories rather a list of ‘dos and don’ts’ while explaining the rationale in simple and comprehensible terms.

I have made the ‘lesson on food’ very easy to understand in theory, how ever it needs determination and conviction for ‘gluttons’ to put it to practice. I employ Urdu alphabet ‘chai’ to elaborate my theory. My single one liner message is to avoid edibles starting with ‘chai’ to lead a ‘happy, smart and enviable life’. Most of the food items bubbling with calories contain – cheeney, chawal and chiknai – all start with ‘chey’.

Cheeney (sugar) implies all sweet things including ‘sugar and gur’ in any form and combination; be it hot drinks – like tea, coffee, qehwa, lemon tea or cold drinks like fizzy drinks and sweetened drinks like sweet juices. Many women will fervently deny taking sugar in any form, just to concede a little later, of using tea prepared for the family containing sugar, using ‘gur’ in tea or adding honey to yogurt. Bakery items are loaded with calories as they contain sugar and fats. All exotics like alluring cakes, tempting pastries, appealing rolls and other must be avoided all together. Finger licking and ‘calories dipping’ sweets of the ‘halwai’ – like khoya, barfai, gulab jaman, rubric, laddu, balushahi have to be kept away from at all cost. Desserts – the better half of a meal – are usually encumbered with calories and may contain more ‘ingredients for obesity’ than the main course itself. Many of us find ice cream and local version – ‘Kulfi’ very alluring and hard to resist, but then, so are most of the sins. The luring combination of scoops of ice cream topped with cream may be very appealing but as they contain not one but at least two ‘cheys’ – sweet and fats they have to be from a weight reducing diet. Beware of these tempting snares of ‘tummy busters’, they come in different tantalizing forms and hues but the eventual effect on health and waist line is the same!

Chawal – rice has to be totally avoided as it is difficult to ascertain the quantity. A platful may mean different things to different people. Many of the accompaniments of ‘rice’ have a tremendous fattening effect. Chiknai – fats have to be avoided and extra effort has to be put in to avoid getting ‘pounds’ in account. Fats include gheeand oil besides butter, cheese and cream. Many overweight people will flatly refuse consuming fats believing that they do not drink oil and eat ghee. Most of our patients feverishly deny taking fats, only to realize that their last meal was cooked in fat and this is how most of the people consume fat. Many assume that oil is better than ghee; that may be true from cholesterol point of view but as far as they weight and calories are concerned, both are equally bad. The advice to take boiled, broiled, baked without fat, grilled or barbecued food is not swallowed very well. The traditional concept of gravy and rot (roties here) is a major impediment.

Another ‘chey’ – chapati needs special mention, though one would like to ban it all together yet a midway will be to reduce it by half. Here again many people will enter into argument regarding the number of ‘roties’ being consumed. The simple answer to this is the advice to reduce the number by half, regardless of what the person is consuming.

Exercise is like a medicine, the dose and frequency has to be prescribed by the doctor. By and large, fit persons should exercise for twenty to thirty minutes five times a week. Any aerobic exercise will serve the purpose, for example aerobic exercise, walking, jogging, swimming, competitive games or structured exercises. Walking, perhaps is an excellent form of exercise as it employs most of the muscles of the body and does not entail heavy expenses. It can be performed anywhere and does not require any special dress code or membership. Walking briskly five days a week will satisfy most of the demands of body. Walk has to be taken seriously like prayers.

Before undertaking walk, one has to determine how much to walk and for what length of time, more like ‘Niat’ of prayers. And after asking for Divine help, one should embark upon walking on a pre-specified route without resorting to engage in talking. “Tasbeehat’ enhance the utility of walk and confer sanctity to it. One has to concentrate to maintain the desired speed and achieve the goal in pre-specified time.

Every woman thinks that performing daily chores in the house is the most rigorous form of exercise and to ask for more will be against the norms of decency and natural justice. Men are convinced tht duties they perform in the office should be classified as exercise. And to expect them to exercise before or after working hours is asking for too much. Many of them will refuse point blank, and say, “I am so busy that I cannot afford to have time off.” “Oh, I am sorry, am I conversing with the president of Pakistan?” I ask, while purposely keeping my eyes down and add, “If a person as busy as him can find time for exercise, why can’t you?” Another trick up in our sleeves is to ask, “Do you offer your prayers regularly?” If reply is in affirmative then I add, “Isha prayers normally take 20 to 30 minutes; you have to be convinced that exercise is important for you, then you will have no problem finding similar time for exercise as well.”

After initial hesitation many would agree and some will try as well. But, not all will persist for a long time, as we all believe in quick results. They weigh themselves after every walk and if weight does not drop drastically, they are disappointed and give up walking and restrictions. At this time they have learnt all the theory, but they need active encouragement from their family and friends to persist to achieve the goals. Good habits have to be positively reinforced, like appreciating their determination, encouraging exercise and understanding difficulties in following restrictions.

What shall be the next step if dieting and exercising are not enough? Are there any drugs to help to reduce weight? Drugs can be helpful to decrease weight but dietary restrictions have to be followed and exercises have to be performed. There are drugs that work on satiety centre in the brain and suppress appetite and others that work on decreasing absorption of food. Previously, drugs used to reduce weight have been associated with serious side effects and have been withdrawn from the market. Recently introduced drugs are supposed to be safe and effective but none of them are supposed to perform wonders. Drugs like Orlistat have been used to reduce absorption hence it is administered with food. The experience has been rewarding and many persons have been able to reduce their weight significantly. Drugs that suppress the appetite have resulted in appreciable loss of weight in many patients At one time all these drugs were beyond the reach of common man but now they are available at reasonable price.

Surgery is an option in a limited number of persons who are grossly obese, cannot diet and find it difficult to exercise and are at high risk for obesity related diseases and death. It is reserved for patients in whom all other efforts have failed. The best option in such persons is wiring of jaws where they are denied food and fed through a tube via nose. Second form of surgery is gastro intestinal surgery with stomach restriction or stomach by pass.

The concept of a bank account has to be reinforced again and again. Food going in has to be regulated versus energy spent to lose weight. A balance has to be struck and a person has to be conscious of ‘income’ and ‘expenditure’ all the time. This calculator has to be followed in letter and spirit and excuses like ‘one meal will not make a difference, today is my birthday and why ‘perhaiz’ on Eid and Ramazan’ should not be entertained.

In the fight against obesity, the plan has to be well conceived and executed meticulously. It is not a one time affair, it needs life long commitment and hard work. But the benefits and joys are unlimited and perhaps not quantifiable. It is all worth it!

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Ref: Heal Thy Heart written by Prof: Dr. Muhammad Hafizullah

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Article I - Fitness, Changing Lifestyle can prevent Heart Problems

Fitness is a great problem especially for the persons who are over weight. Although the fat is essential part of the body but to some extent, normally 12-15% for women and 3-6% for men. Many people are experiencing a life-long battle due to their weight. Despite their much struggle little people succeed in getting smart. While defining healthy person the WHO said health is a complete physical, mental and social well being and not merely absence of disease or infirmity.

The major aim is to raise fitness without tension. Jogging is a "high-impact" exercise that places stress on the body, especially the joints of the knee. This is in fact one of the vital reasons for doing the exercise, as the impact drives growth processes in the areas of the body strained by that impact. Some person leave jogging in order to take up alternate ways of exercises such as climbing stairs, swimming or cycling. Time and again Jogging is used by running as a source of active recovery during interval training.

Now a days like other health related problems blood pressure and heart diseases are common. The main object of all these exercises is to keep the man fit and prevent diseases like blood pressure, heart etc.

Merely eloquent about heart and its ailments does not solve the problem; action is required to avoid heart problems. Those afflicted with the bug of heart problems can become more eloquent and eager partners in the treatment, if they know the strategies being adopted by their clinician. The result will certainly be healthier with more convinced and enlightened patients in this prolonged war against the enemies of heart, which is being fought at many fronts.

In this article and subsequent other articles we will dwell on taming villains, changing lifestyles and giving the latest information on drugs and operations of the heat and more importantly interventional procedures like angioplasty, stenting involving wires, balloons and springs.

This is preface and in the next articles we will discuss non drug treatments which play a major role in recovery and prevention of heart diseases. Topics like how to stop smoking, how to exercise and how to relax are dealt comprehensively and in a practical format. Special emphasis has been placed on treatment of the newest and commonest malady of the world – obesity.

In Article II we will discuss how to prevent a heart attack? In article II we will mention exercise – when, why and how? In article III how to lose weight? In article IV we will learn way to relax? While in article V discusses about quitting smoking – make it possible!

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