Fats that Harm, Fats that Heal…… well almost

Many people have asked me about how to loose weight or what foods to avoid and I have never had a complete answer for them. From intuition , I would say, “just do everything in moderation!” and the people would go like “Huh!, what does that mean?” Well, I don’t know what it means but I do know now that I was partly right and partly wrong. “Together with smoking and physical activity, dietary habits form the foundation for the causation, prevention, and treatment of most cardiovascular and metabolic diseases, including coronary heart disease (CHD), stroke, and type 2 diabetes mellitus (DM), as well as sudden cardiac death, atrial fibrillation, heart failure, and cognitive decline.( Braunwald’s text book of Cardiology).”

Did you get that, dietary habits form the….. FOUNDATION FOR THE CAUSATION….. as in, you really are what you eat.

In developing countries, the burgeoning epidemics of obesity, Diabetes, and Cardiovascular disease (CVD) result directly from rapid social and environmental changes transmitted primarily through changes in diet and other lifestyle behaviors.^[2] Familiarity with the beneficial and harmful effects of various nutritional factors is essential to mitigate and eventually reverse the substantial disease burdens caused by suboptimal dietary habits in individuals and in populations.(Braunwald’s text book of Cardiology)

Translation….. “My people perish for lack of knowledge” which could be viewed in two ways, either people do not know or they act as if they do not know.

So, in view of the above, I will attempt to give a breakdown of what is considered a healthy diet. Most of it is common knowledge to most people but some may be new.

Foods are usually divided into carbohydrates, fats, proteins and fibres. In primary school, I was taught that carbohydrates are the energy giving foods. I still remember the teacher saying it and us, the pupils chorusing it back. I also had the distinct impression that carbohydrates are white in colour while proteins are brown foods. This skewed my thinking so much that I did not consider sugar sweetened beverages to be a form of carbohydrate until  recently, neither do most people. Did you know that 600mls of coke has the same number of calories as 2 chapatis or a good serving of ugali. So, after lunch, when you take a sugar sweetened beverage, it is like you are taking lunch all over again. By the way, alcohol is also quite high in calories and 2 bottles of beer can be equated to a meal of ugali. So, next time you are out on the rave and you want to maintain your weight, just take the beer, a few pieces of meat and an apple and that will be your supper right there, complete in all ways. By the way, when it comes to weight gain, it is not what you eat that matters, it is how much you eat. It is not where the calories are coming from, it I s how much of the calories you are taking in. Think of it this way, if you were a mule and were asked to carry a load from point A to point B, it is not what is in the load that would matter, it is how much the load weighs.

However, when it comes to cardiovascular health, it is the quality of what you eat that is most important. I wonder if there is such a thing as a “healthy fat guy?” What would happen if I eat too much of all the healthy stuff? Hmmh… food for thought!

When it comes to carbs, one should target those that have a low Glycemic index and low glycemic load. These will usually turn out to be foods that have complex carbs, not refined and contain lots of fibre (we all know that, don’t we?)

Whole grain contains bran, endosperm and germ from the natural cereal, while the refined grains have the bran and germ removed. Which reminds me, those who have been on a farm will attest to this, farmers regurlary buy “maize germ” and “maize bran” to add to the cow and pig feed. They buy this from the same millers who make our maize flour and wheat flour……………. Talk about throwing pearls to the pigs.

Bran contains fiber, B vitamins, minerals, flavonoids, and tocopherols; germ contains numerous antioxidants and phytochemicals. Intake of whole grains associates consistently with lower risk of CHD, DM, and possibly stroke. Whole-grain intake has been found to improve glucose-insulin homeostasis, endothelial function, and possibly weight loss and inflammation. Whole-grain oats reduce LDL-C.^[77] As with fruits and vegetables, it is not clear that any single micronutrient accounts for these benefits; the benefits may result from the synergistic effects of multiple constituents. (Braunwalds)

FATS

When it comes to fat intake, the science is not so straight forward. We had been made to believe that solid fats (hydrogenated vegetable oils) are bad and that the liquid ones are good. The hydrogenated vegetable oil companies therefore came up with a campaign stating that their products are “0.00% cholesterol free”. I remember seeing a bill board like that and I thought to myself, “ how can it be 0.00% cholesterol free?  What does that even mean?” I am yet to get an English teacher to explain that statement to me. In my mind, it is either “100% cholesterol free” or “contains 0.00% cholesterol”. Anyway, I believe the idea was to make us think that cholesterol is ingested in the diet ….well it is not. Dietary cholesterol is so little and of largely no consequence to your health. What matters is what the liver does with the fats that you feed it. The liver is actually the major source of body cholesterol and it generates this cholesterol from the food we eat.

Fats are divided into saturated fats, unsaturated fats and trans fats. Saturated fats play a leading part in raising blood cholesterol and factors such as Diabetes, Hypertension, Smoking and Physical inactivity act only on coronary vessels rendered susceptible by elevated cholesterol. Main source of saturated fats is animal fats and some dietary oils. Dietary fat (not dietary cholesterol) is the main contributor to blood cholesterol levels.

       

                                                                                                                        

Oils to avoid

Coconut oil and Palm oil – contain large amounts of saturated fatty acids with least amounts of unsaturated fatty acids.

Hydrogentaed vegetable oils – contain a lot of trans fatty acids. These are the worst in terms of causing cardiovascular disease.

Good oils

Olive oil, Mustard oil , sunflower oil, canola oil, safflower oil – have large amounts of unsaturated fatty acids.

                                                                                               

Oils	Poly Unsaturated Fatty Acids	Mono Unsaturated Fatty Acids	Saturated Fatty Acids	LDL cholesterol Response (mg/dl)  (bad chlosterol)
Coconut oil	2	6	92	+36
Palm Oil	10	40	50	+12
Olive Oil	11	72	17	-15
Peanut Oil	32	50	14	NA
Soyabean Oil	61	24	15	-24
Sunflower Oil	69	19	12	-30
Safflower Oil	78	13	9	-30

From the table above, good oils are in red and they will help reduce our bad cholesterol.

PUFA – polyunsaturated FA,   MUFA – monounsaturated FA, SAFA – Saturated FA

The greater the level of PUFA and MUFA, the better the oil is for your heart.

Fish oil is also an important part of dietary cardiovascular disease prevention. It has been shown to lower cholesterol as it provides omega 3 polyunsaturated fatty acids in good quantities.

Fruits and vegetables

It is recommended that we take in at least 5 servings of fruits and vegetables per day. Not only do these provide essential vitamins and anti-0xidants, they are also a great way to aid in digestion due to the presence of fibre. Higher fruit and vegetable intake is related with lower CHD incidence.  Fruit intake is also associated with lower stroke risk and dietary fiber from fruits with lower onset of Diabetes. Hey, we all know that fruits and vegetables are vital for good health, so I will not belabor the point.

Bottom line, we need to watch how many calories we take in if we want to affect our weight. We should also ensure that the calories are coming from healthy sources so as to maintain good cardiovascular health.

Medical Paramilitary

Sometimes I feel like when I signed up for medical school, I inadvertentently singed into a paramilitary force. These feelings are not helped by the fact that my boss back in Kenya would never tire of reminding me that " Medicine is like being in the military". I thought this was just a Kenyan thing until I arrived here. The 'paramilitary force' is even better defined and efficient. Now that I have close friends in the actual military, I think we can easily compare notes. In Medicine, there is a command line that is dictated by rank rather than age. The higher your medical education level, the higher your office. The Non commisioned officers are the medical students who are sometimes unruly due to being uninitiated and not knowing what to expect. They may therefore not follow orders appropriately or just simply ignore them. One can never rely on the medical student to carry out a task in the ward as they will not be held accountable for the consequences of their actions. However, gross misconduct can easily see them remain in that lowly rank for a considerable duration of time as they fail exam after exam despite reading very hard for it. The cadet is the intern. They do the bulk of the work in the paramilitary. They are expected to be responsible for everything that happens in the ward and inform the appropriate seniors as necessary. They will wake up at whatever hour to attend to whoever needs attention. They dare not complain about work load as this may see them stagnate in this position for some time. Thankfully, this stage is only for 1 year before you get promoted to a medical officer. Some people stagnate at this point and never progress. Interns come and pass them by to become consultants and come back to instruct their former teachers. Sometimes this can present quite an interesting scenario. After the medical officer comes the resident, senior resident, specialist, specialist consultant and if you are in academia will come the professor title. What, one may ask has prompted this discussion. The other day, I was invited by one of the consultants here to attend a 1 day workshop on a paediatric heart condition. The workshop is on a sarturday, it was going to take up the full day and I really did not feel like going. However, when, the consultant sent for me, I was warned to tread carefully as this particular person can be quite bad. I therefore feared to say "No" but instead committed to attend at least part of it. You see, the cardiology program here combines adult and paediatric cardiology and one is expected to be equally enthusiastic about both. This morning, the particular consultant announced in class that there would be a seminar and that the students should attend and lend a hand. This is one day notice and the next day was supposed to be a public holiday. I really felt sorry for the Residents as I saw some of them line up to give their excuses as to why they could not make it for the seminar. This brought back memories of the military where the rank is always right. When I talk to a senior ranking doctor, I call him 'Sir' and he may call me 'sir' but the difference is that I will mean it. When a senior doctor is wrong, we say he is old fashioned or I have a different opinion. In this place, this rank business goes a tard further. You should see the commotion that ensues when a senior doctor gets into the room and everyone struggles to get to their feet simultaneously. I always get caught out as I never seem to know what's happening.If a consultant is passing along the corridor and there happens to be a nursing station near the corridor, the nurses all stand up as he passes, like a standing ovation kind of thing. Never mind that he is minding his own business and may not even notice this ovation.... or maybe he does and just ignores it.... sometimes he may be gracious to motion to them to sit by a wave of the hand. If I am seated and a consultant comes and happens to pause near me, I spring up like a porcupine had just found its way into my seat. I guess thats our salute in this paramilitary, we stand up!

Of Dengu , Dengue and phantom mosquitoes

Dengue ... ever heard of it? You pronounce it almost like 'dengu'.. those seeds that some of us love to hate after having them as staple for 4 years in High School, but in actual fact the two are unrelated... well not totally unrelated if you consider similar geographical location to be a relationship but thats where the similarities end. While one is potentially deadly and not to be wished on your enemy, the other is well, just sometimes unappetizing and may induce some colon olympics. Having been in Delhi for a couple of months now, we have got used to the dengu but had no idea it had a familiar sounding cousin called dengue.

The realisation came quickly and was like a thunderbolt. One day, you wake up fine as a fiddle. Then you begin to feel a bit feverish and before you know it, your back feels like a Sumo wrestler just landed on it while carrying a tonne of bricks. Then comes a splitting headache and your eyeballs begin to pain, right inside the sockets. With each movement of the head, you are made aware of the the pain in the eye sockets. You are therefore forced to close your eyes so as to avert your gaze and this seems to help a bit. It however makes you feel wobbly and faint especially if you move too fast. On the second day of this teriffying illness that I could not put a name to, a friend comes to visit and declares, ' you know there has been an outbreak of Dengue fever in Delhi '. They make it sound like the whole of Delhi knows about it and has protected itself and we are the ones who have been caught out... like sitting ducks (I am sure that was not their intention but that was definitely my perception)  and I go like "Dengu who?" I suddenly remember some disease like that that we studied in passing because it is not found in Kenya or most parts of Africa. The fever is unrelenting. It is only relieved by paracetamol. Body and muscle aches become the order of the day. It lets you know that they don't call it 'break bone fever' for nothing. When you read the literature, you are informed that it is a viral infection that could kill you, but in the mean time, it has no cure so just continue taking paracetamol for your pain and hope for the best. I would have wished to await my fate in a nice sanitized, air conditioned hospital bed but, as fate would have it, I had neglected to take out a 3 month travell health insurance from home claiming that I would take on a proper health cover upon arrival in India. I had hypothesized that since healthcare is cheaper in India, then health insurance would follow suite. My hypothesis was right but human nature and procrastination had done me in. So, one day drags into the next and after 3 days, I am are thinking , 'I am dead and have gone to some place other than heaven.... this must be that place!' Woe unto you if you begin to vomit. That means dehydration will set in swiftly and without medical attention, death is imminent. The virus causes a form of internal dehydration where the tissues become leaky and fluid leaves the blood compartment into the tissues and may lead to shock if not recognised. Add on to this some actual vomitting and you can see how dire that  combination can be. The literature says that the fever can last upto 2 weeks, but I say I will be gone in 2 weeks. It all began when my youngest daughter developed a fever that was otherwise benign. Though my medical mind was puzzled, I was comforted that she was otherwise well, playfull and eating well. After 2 days it disappeared, only to reappear again after 5 days. My other daughter got it next, she however also remained relatively well. Little did we know that the dengue fever was saving its whole armoury for us.... the parents. My wife then complained of a fever and within no time, in a couple of hours, kaboom, she was flattened, in near tears with muscle pains. On day 3, she began to doubt my medical expertise. Despite my keeping a very close eye on the situation, I must say that Jesus was right to say a prophet is never honoured at home. She was trying really hard to believe me but I could see the doubt creeping into her eyes. When she gave me that puppy eyed look that said, "I am sorry for all the hurt I have caused you in the past" I decided enough is enough and to save face, we went in search of a second opinion. The doctor was nice but a bit scary. He seemed to pause just before writing the prescription and make gestures with his hand, as if he was praying or meditating. Only problem is we could not be sure who he was praying to. He suggested admission, we declined politely. He then wrote out more paracetamols and some blood tests which turned out negative. We went home and I think there was a spring in my step as my diagnosis and management had just been confirmed. To cut a long story short, Yahweh was merciful and in 4 days, the fever was gone. However, literature throws in another spin by proclaiming that a haemorrhagic (bleeding) rash begins to appear when the fever is coming to an end, thus giving it the famous name haemorrhagic fever. I can't stop checking myself out in the mirror and now, I am also seeing the offending mosquitoes everywhere I turn.  I see them whizzing silently by on the street (Dengue fever is transmitted by a day time biting mosquito). I feel them munching on my bum as I walk on the street, I am constantly swiping them off my back ( never mind that I am wearing a shirt). I think I must be suffering from Mosquito Induced Post traumatic Stress Disorder.

CPR..... in Hindi

Does anyone know the Hindi word for CPR (cardiopulmonary resuscitation)...... well... me neither. How about the Hindi words for "stop" and "start"...... eeehh , I am blank too. Well, that has been my life these past couple of weeks...... drawing blanks. The hospital is really good but with one major shortcoming... they speak Hindi - aaallllllll the time. Morning lectures are in English but the rest of the day is in Hindi. When they (residents and consultants) are discussing a patient, they will do it in Hindi. Never mind that you might also be in that gathering and willing to contribute. Its like you don't exist. This has caused me real turmoil these last two weeks. "Is it that I am black?", "Would it be different if I was white?" " Is it that these guys don't really want us here?" are some of the issues I have been dealing with. Then I wonder, " Why let me come if I am not welcome? Why is it that when I ask a question, I get answered very well and do not sense any negative vibe coming from them?"  What is it with all these contrasts. Its like playing a game of she likes me, she likes me not.

Then comes the light bulb moment. I am in the cath lab observing a procedure when a nurse comes to the door and says something. The operator suddenly stops, tears off his gloves and heads off in the direction of the adjoining cath lab. A patient had just collapsed on table and CPR had commenced. There is pandemonium as instructions are shouted in Hindi. Luckily, some words like Laryngoscope have no Hindi equivalent so when I heard that word, I knew they wanted to put a tube down the patients' throat to assist his breathing. I decided to assist in doing chest compressions. I get up there and begin with all gusto. I hear someone shout something in Hindi. I continue with the CPR, suddenly, everyone shouts "stop stop stop!".... so I stop. After a pause, the consultant says something in Hindi, I am still pausing, suddenly they all go "start, start start!". Had it not been a life or death situation, I would have rolled down in stitches. Imagine this, the consultant shouting the instructions is standing right next to me, he knows I have "no Hindi" yet he speaks to me in Hindi in that situation.

I have therefore come to the conclusion that this is Rome. Though learning medicine in Hindi is proving to be quite tasteless, like eating salt less food, never the less if one is hungry, even salt less food with satisfy and with time you begin to consider it a low salt diet.

Broken Heart Syndrome

Tako - Tsubo cardiomyopathy is an acute cardiomyopathy that can be provoked by a stressful or emotional situation or exposure to high doses of catecholamines (sympathomimetic drugs). This cardiomyopathy is most common among middle-aged women, appears to be related to catecholamine release, and in most cases is fully reversible with supportive care. Electrocardiographic findings of myocardial infarction in the presence of left ventricular dysfunction and absence of epicardial coronary stenoses should prompt the diagnosis. Endomyocardial biopsy is of value to exclude myocarditis, which can also mimic acute myocardial infarction, and demonstrates contraction band necrosis. Enough with the medical jargon......

What this basically means is that there is a form of heart disease that can mimick a heart attack but whose true cause may just be being over stressed leading to release of the fight or flight hormones ( adrenaline). Did you also know that research at Harvard university has shown that one of the ingredients required for one to live to 100yrs is to be optimistic about life. It also compared people who had suffered a heart attack and categorised them into optimistic guys and pessimistic guys based on a questionare they answered. The optimistic guys were doing much better 5 years down the line while a greater proportion of the pessimists had suffered a recurrent heart attack ( with all other things between the two groups held constant).

This gives me a whole new meaning to the verse " Guard your heart... proverbs 4:23)
 

The beginning - my typical day

Catheterisation  Laboratory

I wake up at around 6 am, to the rumblings of my daughter M saying ' Papa, lets go make breakfast'. She tries really hard to make it a whisper but if I do not respond the first time, it gets louder and louder. My clock is always set for 6.30am but sometimes I wonder, " whats the use?" If its not M trying to get into the covers at 6am, it will be my other gal N, yelling at 5.30am ... listening to her, you would think someone had inflicted severe pain on the one year old tot, only to discover that that is her way of saying " Goodmorning!" and  "You better come for me quick or else I will wake the other tot in the room"... its pure black mail I tell you and she has perfected the art. I will usually take breakfast at 7am but because M & N are awake, they will eat half my breakfast ... never mind that there breakfast is on the way. I walk to AIIMS which takes about 20 minutes. In the morning, from 8 - 9 am, there is a sort of lecture where the cardiology student at AIIMS presents a topic and discusses it for about 30min. Then follows questions from the consultants and sometimes these can get so heated among the consultants that the presenter is forgotten and it becomes a face off among consultants. pure nail biting adrenaline I tell you. studies are quoted and experiences expounded. 'Simple' questions are asked that have no 'simple' answer yet the person asking it wants a 'Yes' or 'No' answer but the responder says 'Yes and No'.They turn red in the face and the we (the students) are left wide eyed, reaching for the popcorn, not knowing who to believe. The presenter, meanwhile, breathes a sigh of relief. he has been forgotten for the moment. Soon, the moments will pass and we will move on to the next topic. Woe unto you, if you are the presenter and the consultants are in agreement that you are wrong and they are right.... you become cannon fodder and your presentation is torn to shreds. The minutes don't seem to end as you are called to justify slide after slide, and you begin to sweat...on the nose... then you know its bad. Thankfully, it only takes 30 minutes. Then someone else presents difficult or interesting cases encountered in the cath lab the previous day. Since the case itself will be difficult and the solution controversial, there is always debate at this point in the day. They don't make them better in Hollywood guys. The consultants rip at each others' ideas and opinions and draw blood. Its just spectacular to watch and listen... of course these things also happened when I was training at UON but not at this intensity. Here, there seems to be no fear of who ranks higher in the department, or who is a Prof and who isn't. In fact, they don't use titles, everyone is just plain old Dr. So the intensity and professionalism in the discussions is to be admired.

Coronary Angiogram

We then breakoff to cath lab or other duty stations as per different assignments. I started my rotations in cath lab. One has to dash and try get the scrubs before they run out. The scrubs themselves are old, worn out and torn and just like plain old KNH, the nurses in cath lab seem to have a stash of the good ones saved away somewhere for themselves and their friends. Very annoying this habit. Once I change into scrubs, I begin to observe the different procedures.There are four cath labs and they perform 30 - 40 procedures per day. The work ethic is excellent bearing in mind that this is a public hospital. Though the cardiology students do most of the procedures, the consultant in charge of the patient is always in the cath lab from beginning till the end of all his procedures even if this is 8pm. These guys work hard and its commendable. I have never seen consultants work this long in a public hospital, constantly  available and stepping in to make the final decision about every one of those patients undergoing the procedure before they leave the table. I have been observing for the last 1 week and already, I appreciate just how wide the topic of cardiac catheterisation can be. They usually work, sometimes non- stop untill 4 pm , but some may break for lunch for 30 minutes and resume. All cases planned for the day must be completed even if it means that they end at 8 or 9pm. I usually leave at 5pm. I go home to find S has had a rough day with M and N, the house is like an oven and the kitchen is the source of the fire (literally and allegorically). I take the kids out to the park for about 1 hr to let madam cool off and then come home. We have dinner, M is all over the place wanting to be fed and carried. We read the bible, pray and the kids are asleep by 8.30pm. I begin to fill in the knowledge gaps until sleep overtakes me.