ARTICLE XVIII - Should everyone take statins?

“Statins, especially in combination with a good diet and regular exercise, have been proven to decrease the risk of heart attack and stroke, lessen the need for heart surgery and angioplasty, and reduce the risk of death significantly. An overview of prevention trials using both drugs and diet to lower cholesterol demonstrated an approximate 25% reduction in nonfatal and 14% in fatal (deadly) heart attacks,” explained my cardiologist after diagnosing my illness and reviewing the investigations. This stimulated me to learn more about the subject of high cholesterol and specially about this new class of drugs. The conclusion of my ‘google search’ was, “Statins are the new class of drugs, introduced in the current decade. These have been shown to have a major impact on heart disease progress. They have been studied extensively and have proven to be a safe and effective way to help patients lower their cholesterol levels,”

As a literate patient I wanted to update my self on current information and intend to share it with you. My first priority was to understand, what is primary and secondary prevention? Primary prevention is for people without any evidence of heart problem and secondary prevention is for patients who already have evidence of cardiac problems. My second aim was to look at the basic data and try to learn about the landmark studies which revolutionized the way the patients of coronary artery disease are treated. My aim was to learn the actual figures beyond non specific terms like mild, moderate and severe. Many small and large studies have been conducted with statin in the scenario of primary and secondary prevention and it is not possible to go over all of them, therefore we will confine our discussion to some important trials. My third aim was to look at safety data for personal reassurance.

The importance of high cholesterol as an important risk factors had always been appreciated by doctors and lay people. Many studies done in the past, employing large populations and different cholesterol lowering strategies failed to show any significant reduction in death rate. Statins used in this setting for the first time have shown very reliable data, that shows reduction of death rate in persons without any evidence of coronary artery disease. The data is not only convincing for people with high cholesterol but also very encouraging in patients with not so high cholesterol.

For the first time, the world of medicine received the news of statins’s efficacy in a population with no existing heart problem, by a study done in Scotland. This evaluated the role of statin in primary prevention in a relatively high risk population. After a 5-year period treatment a significant reduction of 31 percent was achieved in the defined primary endpoint. Total death rate was reduced with no increase in noncardiac death rates. When taking into account suspected coronary events, deaths from coronary artery disease decreased by 33 percent. It reported marked reduction in requirement of coronary angiography and revascularization procedures. The trial established the benefit of statin therapy in a high-risk group. The statin (Pravastatin) demonstrated a significant reduction in death and nonfatal heart attacks.

What does it mean to us as patients? Pravastatin therapy in male subjects with similar patient characteristics to the trial would prevent one event in 31 subjects who take statin therapy over a 5-year period. A conservative estimate of the feasibility of treating patients like those was determined to be well within the range of interventions that are considered to be cost effective approximately $ 13,000 US per year of life saved.

After evaluating the effects of lowering cholesterol in high risk patients, I searched for effects of cholesterol lowering in medium or low risk groups. I found a study that examined the potential impact of statin therapy in subjects including both middle-aged men and women whose total cholesterol approximated the average cholesterol. Lovastatin therapy resulted in a statistically significant 37 percent reduction in the incidence of primary endpoint event. Lovastatin therapy resulted in consistent reductions in event rates in the secondary endpoints: a moderate riask reduction in evascularizations, unstable angina, and nonfatal or fatal heart attack. Among patient subgroups in the group (e.g., women, smokers, and hypertensives), the benefit of lovastatin treatment was comparable with the benefit in the overall cohort. This was the first major clinical trial of a statin to demonstrate reductions in first coronary events in a low-risk subgroup whose profile approximates the general population.

Secondary prevention studies are conducted in patients with established coronary artery disease, offering new insights and directions in the management of coronary artery disease. For the first time we have very convincing data that shows mortality benefit by altering cholesterol levels favourably in patients with high and not so high cholesterol and established coronary artery disease.

A new piece of information that set new trends in heart diseases management came from a study called 4S. This landmark trial demonstrated clearly that statin therapy could reduce total mortality in a secondary prevention situation. The most significant impact on mortality was due to the reduction in heart events. A number of substudies were also performed and demonstrated that Simvastatin therapy was effective in women and older patients - age more than 60 years. Cerebrovascular events (strokes) and new carotid bruits were also significantly reduced by the therapy. This was a large-scale trial that evaluated the effect of Simvastatin therapy in patients with high cholesterol who were either heart attack survivors, patients with angina, or both in a 5.4 year trial.
Very interesting and exciting data was provided by an extremely large secondary prevention trial that evaluated statin (Pravastatin) in patients over a period of 6.1 years. Overall death rate was 22 percent less in the group randomized to statin, which was highly statistically significant. The relative risk reduction by statin in deaths from heart diseases was reduced by 24 percent as compared to placebo. A number of secondary endpoints, including the incidence of heart attacks, revascularization procedures like angioplasty and bypass, hospitalization for unstable angina, stroke and hospital days, were significantly reduced by Statin therapy.

This trial provided extremely strong evidence because of its large and diverse population. It showed that treatment with statin (pravastatin) in secondary prevention is of clinical benefit across a broad range of baseline cholesterol values and is associated with a reduction in total and cardiac mortality without an increase in noncardiac deaths. It became easy, to understand the magnitude of benefit, when I learnt that for every 1000 patients assigned to treatment with statin (pravastatin) over a period of 6 years, a total of 30 deaths, 28 nonfatal heart attacks, and nine nonfatal strokes could be avoided.

New trends were set by a remarkable trial called Heart Protection Study (HPS) that involved 20,000 volunteers, who were at high risk of coronary heart disease. Cholesterol lowering with statin treatment, reduced the risk of heart attacks and strokes by at least one-third. It reduced the need for bypass surgery, angioplasty and amputations by one third. Reductions of at least one-third in these ‘major vascular’ events were found in a very wide range of high risk patients for whom, there had previously been uncertainty about using cholesterol lowering therapy: women as well as men, people aged over 70 as well as younger people, people with blood levels of total cholesterol below 200 mg/dl or of ‘bad’ LDL cholesterol below 120 mg/dl, as well as those considered to have ‘high’ levels.

It was easy for me to understand that about 5 years of statin treatment typically prevents heart attacks, strokes or other major vascular events in: 100 of every 1000 people who previously had a heart attack, 80 of every 1000 people with angina or some other evidence of heart disease, 70 of every 1000 patients who previously had a stroke, 70 of every 1000 people with occlusive disease in leg or other arteries, 70 of every 1000 people with diabetes. I appreciated that in addition, cholesterol lowering reduces the risk of being hospitalized because of worsening angina typically, about 30 fewer admissions per 1000 treated for 5 years. The interesting aspect was that the benefits increased throughout the study treatment period (so more prolonged therapy might be expected to produce even bigger benefits), and are additional to those of other treatments used to prevent heart attacks and strokes.
My third aim was to study the side effects profile. Main side effects pertaining to statins are the effects on muscles and liver. The muscles can be effected by statins ranging from asymptomatic rise in a blood test called creatine kinase and muscle pain to frank rhabdomylosis-destruction of muscles. The evidence that statin drugs may also be associated with development of rhabdomyolysis (destruction of muscles) and kidney failure is understandably of concern. But we have to be careful to understand the extent of problem and not to throw the baby out with the bath water. Whether different statin-fibrate combinations have different risks for rhabdomyolysis (destruction of muscles) is not yet known. In fact, several recent studies have shown other statins and combinations to be effective without evidence of abnormal biochemical test. Results confirm that in large patient data base employing different statins, rhabdomyolysis (destructions of muscles) was extremely rare. Rise in CPK, indicating muscle involvement is comparable with placebo. However this side effect should be kept in mind and drugs which increase the likehood of muscle disese – myopathy should be avoided. Patients on statins presenting with muscle pain and aches should have their CPK checked. The drug should be discontinued if myopathy is suspected, if CPK levels rise markedly, or if the patient has risk factors for rhabdomyolysis (destruction of muscles).

Liver can be effected by statins. Effects can be asymptomatic mild to marked rise of blood test of liver called serum transaminase or frank jaundice. In majority of cases the rise of enzyme is transitory and almost always reversible on discontinuation of therapy. Mild increase in transaminsase (2-4 upper limit of normal), does not warrant cessation of therapy. Close monitoring and reduction of dose is usually sufficient. If the rise is more than 4 times then the drugs should be stopped. A different statin at a lower dose may be initiated and the dose built up slowly. Liver function should be monitored, before treatment is started and periodically checked thereafter like twice a year, for the first year of treatment or until 1 year after the last elevation in dose. Patients titrated to high dosage should receive an additional liver function test at 3 months.

To conclude, it has been proven that an average reduction of cholesterol by 40 mg/dl for about 5 years will result in reduction in non fatal and fatal heart attack by about one fourth. Similar effects are seen in people with no evidence of coronary artery disease and having high or not so high cholesterol. The data is quite encouraging for patients with evidence of coronary artery disease and having high or normal levels of cholesterol. Similar benefits await persons with average or high cholesterol with no heart problem.

The side effects may sound alarming but are very rare and do not require very close monitoring in majority of patients: these side effects should not prevent the more wide spread application of this “new aspirin”.
American College of Cardiology and Amerian Heart Association reassured patients about statin effectiveness and safety and the President of ACC Douglas P Zipes declared.

“While statins like all other drugs have side effects the benefits of using statins to manage patients cholesterol far outweighs the risk of serious side effects from their use. We want to reassure patients that statins have proven to be safe and very effective drugs and we urge patients who are taking statins and have no side effects to continue taking the drug.”

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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 VII - How to Control the Monster of Cholesterol?

“I have been fasting for nearly a month but my cholesterol wouldn’t budge!” complained forty year old Naseem who was diagnosed with high cholesterol a month ago. “What have you been eating?” I asked him. “Honest to God nothing – just nothing. Only two boiled eggs in the morning, butter and two toasts with nothing else in the evening and a glass of milk with a little piece of cheese at night!” confessed Naseem. “With your dietary regimen you are bound to push cholesterol up than bring it down. You have to alter the quality of diet and not the quantity of diet,” I said in a matter of fact way.

How can one reduce cholesterol? There are three cardinal features around which this philosophy revolves. Dieting, exercise and drugs. All of the are equally important. One always starts with diet and exercise. It has to be emphasized in crisis or recovery, before and after an intervention, with drugs and without drugs.

1) DIET: Diet involves:
a) reduction of calories essentially to reduce weight
b) reduction of total fat intake
c) reduction of saturated fat and cholesterol
Obese people are more at risk for atherosclerosis that those at desirable weight. Obese people are more likely to have other risk factors like sugar (diabetes) and high blood pressure (hypertension) etc. First step towards reduction of cholesterol is to reduce intake of food rich in calories. All foods items containing sugar like cold drinks, hot drinks, ice creams, bakery items and desserts etc. should either be avoided or have to be reduced drastically. Fats are a very rich source of calories. Oil has an equal content of calories as compared to ghee, so for reduction of weight both have to be avoided. Many people change over to oil from ghee and think that this should suffice. In the fight against obesity ghee and oil both have to be discarded from diet.

More stress should be laid on fresh fruits and vegetables. Boiled vegetables and pulses (without the tarka) are good sources of nutrition without a high caloric count. An ideal will be to have a couple of glasses of water before attacking the food, take a bowl full of fresh salad followed by a bowl full of boiled pulses like beans, gram (with adequate spice to make it tasty) followed by another two glasses of cold water. Fresh fruit may be eaten after it. The beauty of this is no ghee or oil, no sugar or high caloric stuff and enough variety to choose from.

Fat is present in four main forms in the food we eat, saturated fatty acid, mono saturated fatty acids, poly unsaturated fatty acid and cholesterol. It is advisable to restrict intake of fat to less than 30% of total calories for a day with less than 10% from saturated fatty acid and the rest from unsaturated acids.

1) Saturated fatty acids are mainly responsible for increase in cholesterol. Main animal sources are butter, cream, cheese, fat in beef, lamb and poultry. Coconut oil, palm oil and kernel oil are the main sources of saturated fat from plants. Every effort should be made to avoid this class of food as it is the main source of cholesterol.
2) Mono unsaturated fatty acids are found in olive oil, canola oil, rapeseed oil, peanut oil and sunflower oil. These oils do not contribute towards increase in cholesterol. In fact these help to lower cholesterol. These oils may be used rather liberally but with care because increase in content may increase caloric intake, which may in turn increase weight.
3) Poly unsaturated fatty acids are derived from animal and plant source. These fatty acids reduce total and LDL cholesterol in body. Vegetable oils like sunflower, soybean and corn contain omega-6 fatty acids. Certain fish like trout, sardine, coho and ping salmon and atlantics halibut are rich sources of omega-3 fatty acids. These fatty acids offer protection against atherosclerosis by retarding the process. Intake of omega oils is encouraged to the extent of taking fish two to three times a week (not cooked in ghee). Fish oil capsules containing large quantity of omega oils have not been shown to have any definitive effect on hear problems.
4) Cholesterol is only derived from animal sources like egg yolk, internal organs, milk, butter, cheese etc. Total cholesterol intake should be less than 300 mg per day. It should be reduced further in people with high cholesterol. Every one should be wary of high cholesterol contents of certain food stuff and should make a determined effort to avoid it.

What to avoid:
a) Whole milk: A cup of whole milk contains 5.1 mg saturated fatty acids, 33 gms of cholesterol and 150 calories. Where as skimmed milk contains 0.3 mg saturated fat, 4 mg of cholesterol and 86 calories. Skimmed milk should be substituted for whole milk to reduce cholesterol and caloric intake.
b) Butter and creams: One teaspoon of butter contains 36 calories, 11 mg of cholesterol and 2.5 mg of saturated fat. Avoid butter and cream specially used in bakery items, desserts and ice cream.
c) Eggs: One egg yolk contains 213 mg of cholesterol. Egg while is a rich source of protein and does not contain cholesterol. Egg yolk must be avoided with high cholesterol and the use should be reduced in those with borderline or normal cholesterol.
d) Cheese: Cheddar cheese has high cholesterol and should be avoided. Cottage cheese has 5 mg cholesterol in half a cup so it can be taken.
e) Meats and fish: Contrary to widely held belief, beef and lamb have equal amount of cholesterol that is 22 mg per three ounces. All visible fat should be removed. Poultry should be cooked without skin which is a rich source of cholesterol. Internal organs like brain, liver and kidney etc. are very rich in cholesterol and MUST be avoided. Fish has low cholesterol but shrimps and lobster have high cholesterol.
f) Horrible Combinations: We know ghee has large amount of saturated fatty acids so it has to be avoided. This follows a simple dictum that everything cooked in ghee is high in cholesterol and should be avoided. If an egg is fried in ghee or butter, the cholesterol content goes up – it simply multiplies. Internal organs are the richest source of cholesterol, if cooked in ghee or butter the content increases, add some eggs to it and make it worse and top it up with some bone marrow and make it the ‘deadliest’ of recipe. ‘Kat-a-Kat’ is perhaps what you should be offering to your enemies. ‘Karahi Ghosht’ is lamb cooked in its own fat, special attempts are made to use the fatty portions and extra fat is added to make it really high in cholesterol. Nehari savoured by a lot us is very high in cholesterol; meat with internal organs cooked in ghee with added bone marrow with plenty of spices – ‘finger licking’ but sticking stuff for arteries. What is ‘Chappali Kabab’? Minced meat with lots of unwanted fat cooked in highly saturated fat and topped with eggs and at times bone marrow. It may be tasty but very high in cholesterol. Unfortunately most of our exotic food is very rich in cholesterol.

We know full cream milk has high cholesterol, so does full cream ‘lassi’. What do you think of full cream ‘Khoya’ dissolved in Lassi or milk – is it fit for human consumption? Desset made with full cream milk, eggs and cream tastes sweet but has exorbitantly high cholesterol. So beware of ‘Kheer’, custards and trifles. Though cheese is not used liberally in our foods but pizzas have cheese which has a very high cholesterol content. Cottage cheese, however, is nutritious and does not have high cholesterol content.

‘Halwa’ is not bad except when it is cooked in ghee and has the wrong additives. It is rich in calories because of sugar, ghee/oil and ‘maida’ though cholesterol content varies according to the additives and oil used. Most of bakery items are made in ghee, have eggs in it and are topped by cream. So beware of those attractive colourful ‘snares of cholesterol’ called cakes and pastries. Finger licking ‘mithais’ with tall claims of being cooked in ‘desi ghee’ are rich source of calories rather bursting with calories. Most of ‘mithais’ use eggs and are cooked in ghee hence increasing cholesterol content. I am sure you will agree that the best desset is either fresh fruit or after dinner jokes!

It is quite obvious that to reduce cholesterol one has to use low fat, low cholesterol diet while avoiding dairy products – whole milk, cheese, bakery items, eggs and meat containing fat. Fruits, vegetables and whole grain should be encouraged.

When dieting is not enough – Exercise:
Exercise is a vital companion to any dieting program. It serves the threefold purpose of burning calories, fighting flab and improving efficiency of cardiovascular system. Studies show that individuals who exercise have a high amount of HDL ‘good’ cholesterol which protects against cardiac problems.

Domestic work burns 180 calories (cal), walking 2.5 miles per hour (mph) burns 210 cal, gold burns 250 cal. Walking 3.5 mph burns 300 cal and running 10 mph burns 900 cal per hour. The most accessible, easiest and least expensive means of aerobic exercise is fast walking. Start exercising after consultation with doctor if you have crossed forty. Start with fifteen minutes thrice a week and slowly build it up to 30 minutes four to five times a week.

Drugs – When dieting and exercise are not sufficient:
If dieting and exercise fail to deliver the goods the next step is drugs. Besides fibrates available for a long time a new group of drugs called statins have captured the market. These statins – simvastatin, fluvastatin, lovastatin, atorvastatin and pravastatin are very effective agents to lower cholesterol with quite a safe profit. These have been used in many trials and have been shown to be effective in reducing cholesterol, deaths associated with heart, investigational procedures needed in cardiology and the need for angioplasty and bypass surgery. These drugs should be taken according to the advice of doctors. The drug therapy needs regular monitoring and reduction (and not cessation!) of dosage when targets and achieved.

With sound knowledge and enough zeal, the problem of cholesterol can be conquered. In this war, we need patience and persistence as it is a life long war. The dosage may decrease though careful life long monitoring is required.

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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 II - Fitness, How to avoid heart attack?

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Every body wishes to avoid heart attack very few people try to prevent it. The most important thing is how may people know how to prevent such a disastrous disease? Before we start to discuss how to prevent a heart attack, we have to consider the circumstances and estimate the risk profile.

We have to stare all the risk factors – modifiable and non modifiable and then start from there. The gravity of situation or otherwise determines the future plan. One has to be objective and practical. First of all, look at the non modifiable risk factors which determine one’s likelihood of developing a problem, but one cannot do anything about them. It is aggressive one has to be in modifying other modifiable risk factors. Important to know them because this will determine how aggressive one has to be in modifying other modifiable risk factors. Important factors are age, sex, and family history. The older the person, the higher the risk of heart attack. The risk of developing a heart ailment below the age of thirty is very slim in males and rather rare in female. The chances of developing a problem are very high as one enters in seventh decade of life. The risk is almost similar for both sexes, a little more for females. In between there is a gradual increase in risk for both sexes, whereas the risk rises sharply for women as they become post menopausal. Those with a positive family history are more at risk. There is a lot of confusion that surrounds family history. Family history is important when a parent or a sibling suffers a heart attack at a younger age – around forty. If someone’s mother dies of a heart attack at the age of eighty that does not come under a strong risk factory.

So if its a male, in his early forties and has a strong family history such as one of the parents succumbing to a heart attack at age thirty five, he should have a different plan. He has a very high risk profile and has to be aggressive in getting his baseline blood checked up and be more particular in his regular check ups. He should have a different threshold for treatment for his risk factors and should have different targets to achieve. As against that a sixty year old male with no positive family history has a rather benign profile, he should get his tests done annually and keep his eyes on laboratory values. A lady at fifty with positive family history of heart attack in a sibling or parent is at very high risk. She has to be aggressive in looking for all the risk factors and their reduction wherever required. She needs more frequent cardiac checkups and a strict eye on all the risk factors.

What are the modifiable risk factors? These are the risk factors which can be altered and have an important effect on eventual outcome. The list is very long and new factors are being added to it as the research continues. Most important among these are the presence of diabetes, high blood pressure, high level of total cholesterol and specially high LDL and low HDL cholesterol, and smoking. Obesity and lack of physical activity contribute directly and indirectly towards heart attack. Novel risk factors are newly identified risk factors and their role and the effects on reduction have not been thoroughly studied in large trials. Their cause effect has to be established and the cost effectiveness of their reduction has yet to be proved. These are important risk factors and assume more importance when the traditional risk factors are absent in a young person with heart attack.

The most important of modifiable risk factors is diabetes. There has been a growing awareness about diabetes and there is a large data base to establish the effects of diabetes on heart and vessels – tubes carrying blood to all parts of body. Diabetes mellitus is a scourge which is now assuming the status of an epidemic. Whereas other epidemics follow a certain course and wither away, unfortunately it has come here to stay for good! The real danger of diabetes is accelerated process of hardening of vessels called atherosclerosis with high mortality and higher morbidity. The worst effects are through involvement of small and medium sized vessels effecting almost all systems of body. Main targets are heart, brain, eyes and peripheries. Involvement of vessels in diabetics is more severe and diffuse.

Though effects on all target organs are profound and diffuse, let us focus on heart for the time being. More diabetics succumb to heart attacks as against non diabetics. Diabetics afflicted with heart attack have more complications and higher death rate. Lesser number of diabetics are amenable to procedures like by pass surgery and angioplasty as compared to non diabetics due to diffuse involvement of vessels. Diabetics undergoing these procedures are more likely to have complications during the procedure. The changes of recurrence of symptoms and disease are higher in diabetics. It is due to incomplete revascularization and the aggressive course of disease that follows.

Diabetes for all practical purposes is one of the strongest risk factors. According to new guidelines for treatment of high cholesterol, it is being considered as equivalent to established cardiac disease. Diabetes has accumulative effects in combination with other risk factors like high blood pressure, high levels of total cholesterol and especially high LDL and low HDL cholesterol, and smoking. The effect is synergistic and new goals for treatment have to be defined.

How can diabetics help themselves? Should there by a different strategy for diabetics? Should they wait for complications to occur and only then take action? Do diabetics get a fair deal and optimal therapy in our setup? The answers to all these questions are neither simple nor straight forward. Diabetic should have good working knowledge of diabetes and its complication. They should understand the importance of looking for other risk factors, effects on target organs and treating them aggressively. Over and above they should believe in aggressive treatment and the merits of such treatment right from the start. Recent studies have documented the importance of tight control with reduction in many end points because unless the patient is convinced he cannot demand better treatment from his doctor.

The strategy for diabetics has to be different. The criteria and goals of treatment for associated risk factors like high blood pressure and high cholesterol are different. For example diabetics should have lower blood pressure and the threshold of treating high blood pressure is lower and the aim is to bring it down to systolic 130 mmHg and diastolic 85 mmHg. Similarly cholesterol especially LDL has to be lower around 130 mg/dl to start therapy and the aim should be less than 100 mg/dl. The threshold of starting therapy and the necessity of lower goals has to be appreciated by the patient himself and only then it can be put in practice.

The importance of meticulous diabetic control has to be ingrained in the minds of diabetics and especially those at higher risk of developing heart attack. This can be done by strictly adhering to treatment regimen and observing all dietary restrictions and regular exercise and control of other risk factors. All diabetics should have the background to look for and monitor different complications. Though diabetics should not treat themselves like ‘people form Mars’ yet they need to have strong belief that meticulous control will mitigate their sufferings and keep them safe from heart attacks and many other complications.

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

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