New
Series on Health Issues from the Kandy Society of Medicine in Association
with The Sunday Times
It is well known that ge- netic factors play a ma- jor role in an individual's susceptibility or resistance to any disease. Sri Lankans like other South Asians are genetically prone to the risk of heart attacks. This risk is kept under control by our health promoting traditional life- style - where our typical villager lives a physically active life, takes a diet rich in vegetables, vitamins and fibre, is slim, has low lipid levels in blood and rarely suffers from diabetes. When such a villager migrates into an urban environment, consumption of diet rich in fat, low in vegetables and fruit, exposure to greater levels of stress and the lack of physical exercise all contribute to enhancing the likelihood of developing a heart attack.
In addition to this general ethnic susceptibility those individuals with a family history of coronary heart disease (heart disease due to blockage of blood vessels that supply the heart) or diabetes mellitus or high blood pressure are at higher risk of developing heart attacks. If in such individuals preventive efforts are started in early life the chances of successful prevention are quite high. Therefore all those with a family history of coronary heart disease or diabetes mellitus or high blood pressure in their parents, siblings or close relatives should have themselves screened for risk factors of heart disease such as high blood pressure, elevated lipids and diabetes mellitus and take all possible prevention to minimize their risk levels.
Recent research has resolved many of the uncertainties regarding the place of lipid lowering in the prevention of coronary heart disease. Both new trials and pooled analysis of older research studies show that reduction of plasma cholesterol prevents the development of coronary heart disease and reduces the risk of death in those already suffering from coronary heart disease.
Individuals at high risk of developing coronary heart disease (such as those with a family history of heart disease and those with other risk factors of coronary heart disease) should try to achieve optimal lipid levels by dietary modification and if necessary by the use of lipid lowering drugs. Unfortunately the lipid lowering effect of a low fat diet or lipid lowering drugs is temporary; blood lipid is kept low only as long as one adheres to the low fat diet or takes lipid lowering medications. A drug that permanently corrects high blood lipid levels is not available. Therefore the effort to lower blood lipids is necessarily a long-term, possibly a lifelong effort.
It is still too early to know if lowering cholesterol too much for a long period of time, particularly with medications is dangerous. Therefore widespread and indiscriminate use of lipid lowering drugs should be discouraged. It is also important to remember that like all drugs lipid lowering drugs also have certain unwanted side effects. Therefore such drugs should only be used when recommended by a competent doctor.
The optimum level of cholesterol for Asians appears to be even lower than the 200 mg/dl considered to be desirable in Western Society. The desirable cholesterol levels for an individual with coronary heart disease is around 150 mg/dl. Although total cholesterol is considered a good predictor of coronary heart disease other lipids in blood such as high density lipoproteins and triglyceride are equally important in predicting risk of developing heart disease particularly in Asians.
One of the most important measures to prevent coronary heart disease is the promotion of healthy eating habits. The intake of saturated fats in the diet should be lowered to reduce the fat levels in blood and reduce the risk of developing coronary heart disease. This is best accomplished by avoiding margarine, butter, gee, replacing full fat milk with skimmed milk and consuming less dairy fat, meat and meat products such as sausages. The liberal use of palm oil and coconut products should be discouraged especially in those whose diets are rich in other sources of saturated fat. However in those with negligible intake of meat, meat products and dairy fat (rural Sri Lankans) modest use of such oils may be preferable to no fat at all.
Plant foods (except those rich in saturated fats) have a protective effect on coronary heart disease. Plant foods are rich in fibre, antioxidant vitamins, potassium, flavonoids and plant sterols. These constituents together lower blood pressure and lipids and inhibit deposition of fat in blood vessels.
The regular consumption (biweekly use ) of fish appears to confer protection against coronary heart disease. It is not clear whether the benefit is derived solely from the fish oil since population studies suggest benefits from eating both white and fatty fish.
It is unfortunate that the public particularly our youth are often subjected to a confusing and contradictory array of information even about cigarette smoking, a habit that can be very harmful to good health. There is indisputable scientific evidence that smoking causes not only heart disease but lung disease and cancer as well. Scientifically proven evidence is threatening the profits, of cigarette manufacturers in the developed world. Tobacco companies try to compensate by ruthlessly promoting their sales among the youth in poorer countries such as ours. Expecting sponsorship from cigarette companies and promoting the cigarette smoking habit directly or indirectly (by smoking in their presence, allowing sale of cigarettes to minors and advertisement of tobacco products) tantamounts to betrayal of the younger generation of Sri Lanka.
We know that smoking is only one of the important causes of heart disease. Some who do not smoke can die of heart attacks because they have other factors that predispose them to heart disease. This does not detract from the harmful effects of tobacco smoking.
If you have high blood pressure or diabetes mellitus the coronary arteries that supply the heart muscle have a higher chance of getting clogged up and damaged. The safe limits for blood pressure is less than 140/90 mm Hg. Consuming excess salt is known to increase blood pressure, which is a potent cause of coronary heart disease. Most of us eat far more salt than we require - so cutting down extra salt is important. Salt intake should be restricted to <6 gm/day in order to prevent high blood pressure.
Perhaps the most important factor in preventing coronary heart disease is for people to be aware of factors that promote heart disease and to become motivated enough to want to control them. Some of us are too frightened to have a medical check up done for fear of being found to have high blood pressure or diabetes mellitus. It must be realized that these diseases even at a stage they do not cause any symptoms can seriously damage the arteries of your heart and brain.
Many patients are under the mistaken impression that diabetes mellitus and high blood pressure can be cured. There are no wonder drugs that will cure diabetes mellitus or high blood pressure. If you have diabetes mellitus it has to be controlled all your life by controlling the diet and if necessary taking drugs. If you have high blood pressure, blood pressure has to be controlled all your life by modification of life style factors and the use of drugs. Drugs can only control diabetes and high blood pressure. It is therefore a waste of time going from doctor to doctor looking for a cure for these two conditions.
Moderate alcohol consumption (less than three drinks a day; less than 30g of ethanol daily) has a protective effect on myocardial infarction. The protective effect of moderate alcohol consumption is related to favourable effects on high density lipoproteins which are protective to coronary heart disease. In low doses alcohol also reduces the tendency to thrombosis by reducing plasma fibrinogen and platelet aggregation.
Perhaps it is more important to stress that a lot of harm can be done to the heart and the vascular system if alcohol is consumed in excess. Alcohol intake exceeding 30 gms of ethanol a day has a lot of adverse effects. It increases the blood pressure, increases the risk of stroke, it can damage the heart muscle and cause cardiac failure and can give rise to abnormal heart rhythms.
Sri Lankans have become more and more sedentary in recent times. Lack of motivation and psychosocial barriers prevent Sri Lankans from taking regular exercise. For the majority of Sri Lankans walking appears to be the only significant form of physical activity. This is particularly true for those who are engaged in occupations that involve little physical activity. More and more such individuals prefer to travel about in motor vehicles than to walk. Most of us therefore need to engage in some form of recreational physical activity. The current recommendation is to engage in at least 30 minutes of moderate physical activity (brisk walking, gardening, jogging, cycling, swimming etc.) on 3 to 4 days of the week. Even if you cannot achieve this much, you will reduce the risk of coronary heart disease just by increasing your physical activity. Physical activity has favourable effects on blood pressure, serum lipids, obesity and tendency to develop diabetes mellitus.
It is imperative that we take steps to control overweight and increase physical activity in our population particularly children, adolescents and youth. Population wide exercise programs should be promoted particularly in higher grades in schools. Every encouragement and motivation should be given to create fitness centres and clubs all over the country.
Excess weight can increase your blood pressure and blood sugar. More over there is increasing evidence that fat deposited around the belly increases the risk of developing coronary heart disease. Women with waist to hip ratios of more than 0.85 and men with waist to hip ratios of more than 0.88 have a greater chance of developing coronary heart disease. (Waist to hip ratio is the figure you obtain by dividing your waist measurement by the girth around the broadest part of the hips). To reduce weight and get rid of excess body fat one has to reduce the quantity of food, cut down on fat and sugar in the diet and increase physical activity.
So if you really want to minimise the chances of dying of a heart attack live in the country away from stress, eat a traditional rice and curry diet rich in fibre, vegetables, fruit and low in fat, and salt, eat more fish and less meat, do not patronize fast food restaurants or smoke, watch your waist line and walk to work. It is all hard work but then who said it is easy?
The writer is attached to the Teaching Hospital and Faculty of Medicine, Peradeniya
A distinct disadvan tage of being Sri Lankan (and it matters not whether we are Buddhists, Hindus, Christians or Muslims) is that we as a nation have a much higher risk of developing heart disease than many other populations.
One of the other known risk factors for heart disease is having a high level of cholesterol in the blood-measured by a blood test known as the serum cholesterol test.
Now for those who are concerned about preventing heart attacks, there are many ways by which you can lower your serum cholesterol.
The most obvious way is to change your food habits. But for many people, changing the diet does not work - either because they are unwilling to give up the foods they enjoy or because, through inadequate knowledge, they do not make the right changes.
For example many folk still believe that lowering serum cholesterol means avoiding eggs and prawns, cutting the fat off meat, selecting margarine instead of butter and buying supermarket foods with labels saying "Cholesterol free".
It certainly is worthwhile trimming meat and taking the skin off chicken. But prawns need not be spurned (because they have almost no saturated fat)-while margarine should be, because even the 'unsaturated' ones still contain 25 to 30% saturated fat.
The basic truth about the cholesterol in our bodies is that this cholesterol is actually manufactured by our own bodies when the foods that we eat contain too much saturated fat. So it is not so much the consuming of cholesterol-containing foods that raises our serum cholesterol, but the consumption of foods rich in saturated fats.
Although the food industry pretends to help us to eat healthily by prominently labelling foods as containing no cholesterol, eating such foods does little or nothing for our own cholesterol levels unless we also reduce our saturated fat intake.
Most of us do not succeed in reducing our fat intake simply because we share the common belief that these saturated fats are only found in animal foods.
Certainly, fatty meats (like lamb) and full cream dairy products (like cheese) are rich sources of saturated fats. But so are fast foods like fried chicken and Chinese rolls, potato chips, minced meat, biscuits, cakes and unsaturated margarine.
Butter has more saturated fat than margarine, and should definitely be avoided by those with high cholesterol - but margarine is not as innocent as is made to appear. Spreading a good helping of unsaturated margarine on two slices of bread can provide as much saturated fat as eating two eggs!
For those who fail to reduce their cholesterol by dietary changes, there are prescription drugs such as the various stations which can stop the body producing too much cholesterol. These compounds work well and their efficacy has been well established by recent research.
Eating soya products can be helpful - because soya beans contain phytosterols. Some good research studies have shown that eating phytosterols prevents cholesterol eaten at the same time from being absorbed. Recent research has also shown that using soya products can reduce serum cholesterol and lipids.
Eating foods high in certain types of soluble fibre (like psyllium, pectin and guar gum) can reduce serum cholesterol, provided the diet is also low in saturated fats.
There is unfortunately no over-the-counter pill, powder or potion that has proved effective in reducing cholesterol levels. Since having consistently high cholesterol is so dangerous, all of us in Sri Lanka would be well advised to take effective steps to control it .
Overall, the best way is to reduce saturated fat intake, increase soya based foods and include foods high in soluble fibre.
If all these fail, it is worth discussing with your doctor whether you would benefit from the more expensive method of starting on a cholesterol-reducing drug.
In recent times, there has been a public out cry against the medical profession. The complaints, which regularly appear in the local press, frequently allege ill-treatment and harassment by doctors. The issue is compounded by "channelled'' private practice where medical specialists are in the dock for raking in the rupees while spending just a few minutes with the patient.
This has given rise to at least one legal battle between doctors and patients, which was decided in the patient's favour but wherein an appeal is pending. Other such cases, we understand, are in the offing.
An this context, The Sunday Times will today begin a series of articles on Medical Negligence, the crime that doctors are now accused of.
We hope to enlighten our readers not only on the legal aspects of Medical Negligence but also on the other point-of-view - that of the doctors'.
Our ultimate objective is to make both doctors and patients more aware of their obligations and responsibilities for we feel that the lesser the charges of negligence the better, both for the doctors and patients…
An English dictionary defines 'negligence' as the ''want of proper care, an act of carelessness or neglect; omission of duty, specially such care for the interests of others as the law may require.............''
This is indeed the layman's perception of medical negligence also, but legally, negligence by a doctor has more precise parameters.
The latter maybe broadly defined as a breach in the duty to care for a patient, not doing what a reasonable man would do or doing what a prudent man wouldn't do.
This encompasses four essential components: It should be established that the doctor had a duty to care for the patient, that there was a breach of that duty, that the patient suffered some damages as a result and, finally, that the damages were due to negligence by the doctor.
For a doctor to have a duty to care for a patient the doctor has to undertake treatment or care of the patient. However, there need not be contract between the doctor and the patient, to prove this. As we all know, patients do not sign contracts with doctors when they seek treatment!
Evidence, documentary or otherwise may prove a doctor had a duty to care for a patient. This may take the form of a prescription or even notes made by the doctor on the Bed-head Ticket. In the private sector, this will include the receipt issued by the doctor for payment.
We know that in Sri Lanka, state hospitals levy no fees from patients. However, the fact that the doctor charges no fees from the patient will not make him immune from charges of negligence.
In such cases the authority employing the doctor (the hospital, the Department of Health Services) and the doctor himself personally, is open to charges of negligence.
No. A doctor is only expected to provide a reasonable degree of skill, and care in diagnosis, treatment and advice. It follows then that this ''reasonable'' degree of care will depend on both the doctor's qualifications and experience and the facilities at his disposal.
The law, therefore recognizes that a junior doctor may not be as competent as a senior medical specialist in detecting or treating a rare disease. It also recognizes that the treatment available at a remote dispensary would be different form that available at an Intensive Care Unit.
Arguably, this could be an 'escape valve' for doctor charged with negligence. But, when there is a difference of opinion as to whether a doctor made the best use of his knowledge and facilities, a court would call experts to decide on the issue.
Also, there are certain procedures which any qualified doctor is expected to adhere to under any condition. Blood, for example, should be grouped and tested before being administered to a patient. A lapse of such a duty would, obviously, make the doctor liable for negligence. Not attending on a patient when requested to do so by the nursing staff is another such example.
(More next month)
Government is contemplating amending the law governing abortion in Sri Lanka.
At present all abortions except those done to save the life of the mother are considered illegal.
This has led to the widespread practice of illegal abortions, mostly by unqualified persons under dangerous conditions.
In Sri Lanka, at least sixty patients are diagnosed each year as having died of criminal abortions, but the true figure is higher.
Among the proposed changes to the law are legalizing abortions for congenital malformations of the body and for conceptions that follow rape.
The intake to Sri Lankan Medical Faculties is to be further increased.
Presently, six faculties enrol about 880 students every year. A six to seven percent increase is proposed for the 1999/2000 intake.
The Ministry of Health, meanwhile has expressed concern that it will not be able to absorb all these doctors at the conclusion of their training.
Medical graduates are produced by faculties in the Universities of Colombo, Peradeniya, Ruhuna, Jaffna, Kelaniya and Sri Jayawardenepura.
Pause a while to think about what happens when you smoke. Cigarettes contain thousands of chemicals, of which at least twenty are known to cause cancer.
* Nicotine - which is the addictive drug in the cigarette, which makes it so difficult for smokers to quit. Nicotine burdens your heart, increasing your heart rate and blood pressure.
* Carbon Monoxide - a toxic chemical that starves body tissues of oxygen.
* Tar - which clogs your lungs with chemicals many of which can lead to cancer. Remember, low-tar cigarettes aren't any better if you take deeper puffs, and hold the smoke in for a longer time.
Smoking increases your risk of having serious diseases
* three times more likely than non-smokers to have a heart attack.
* ten times more likely than non-smokers to die of chronic lung diseases, other than lung cancer.
* ten times more likely than non-smokers to die of lung cancer. (Smoking is associated in 50 per cent of cases of lung cancer).
You are also more likely to develop stomach ulcers, impotence and high blood pressure.
Babies born to mothers who smoked during pregnancy are more likely to be premature, stillborn or die shortly after birth.
But, can you quit? And is it worthwhile if you have been a heavy smoker?
Even if you have been a heavy smoker, if you stop smoking -
* Your body starts repairing itself within a day.
* You will be free from most of the Nicotine in a few days.
* After three weeks, it will be easier for you to breathe. You will be able to exert yourself more, without becoming breathless.
* After a few months, your blood flow improves as the arteries repair the damage that has been done.
* In a year, your risk of heart disease is almost half of that risk when you were smoking.
* In a few years your risk of developing lung cancer diminishes.
So, think again, before you light your next cigarette.
Continue to Plus page 6 * All that Jazz
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