World Heart Day:

Prevention of ischaemic heart disease

By Dr. Ruwan Ekanayake

Ischaemic heart disease (IHD) is the leading cause of death in many countries including Sri Lanka. However, a curious discrepancy is observed when considering the epidemiology of IHD in the developed western countries and developing countries such as Sri Lanka, India and Thailand. In the USA, the incidence of IHD shows a definite downward trend. This beneficial effect began to show up in the latter part of the 20th century but statistics indicate that during the past 10 years or so this downward trend has continued. This drop in the incidence is seen in the UK, Australia and Norway too.

We must remember that this reduction in IHD is seen in spite of the rise in the incidence of diabetes mellitus, which is a major risk factor leading to atherosclerosis and subsequent heart disease.

What is the explanation for this marked reduction of IHD in the western world? Epidemiologists and community medicine experts attribute the major credit to health education, in that the population is better aware of risk factors for IHD and the necessity of life style change. On the other hand, countries such as Sri Lanka show a constant upward trend in the incidence of IHD which is true also for all developing countries. In fact, it is in the third world countries that IHD is now reaching epidemic proportions.

Many reasons can be recruited to explain this explosion of disease in the third world scenario. Unhealthy life style is the prominent factor which is incriminated. The stresses and strains of living affects all strata of society in the 3rd world where the basic necessities for civilised living have to be obtained by long hours of poorly paid work.

The mental stress which ensues is compounded by indiscipline in society and lack of social security. This stressful background is fertile soil for the seeds of chronic non communicable disease to germinate. As a result, the 3rd world is showing a marked increase in IHD which, even there, is most seen in the lower socioeconomic levels of society.

Controlled

The lesson we learn from the developed countries is that IHD can be curtailed. This is became the risk factors can be controlled. The traditional risk factors for causation of IHD are, smoking, high blood pressure, diabetes mellitus, obesity, high blood lipids, lack of exercise, mental stress, male sex and genetic predisposition. Consider these nine factors.

Except for the last two (male sex & genetic predisposition) all others are within an individual’s control. Hence they are subject to restriction by motivated persons. This is where educating the public becomes so vital. Only a well informed public can bring about a reduction in the burden of non communicable disease.

Legislation and other controls will be of secondary importance. The risk factors mentioned before are called ‘modifiable’ risk factors for obvious reasons. New risk factors are being currently discussed which are largely non modifiable. These generally need costly investigation and continuous medication for control but will be applicable primarily in the high risk group of patients, as there is little or no evidence that mass scale action well lead to appreciable reduction in the incidence of IHD as the numbers involved are too few to make a statistical impact on epidemiological parameters.

Cigarette smoke is important as many young people still consider it as a status symbol. The deleterious effect of passive smoking on the health of female family mrmbers and born and unborn children need reiteration.

Good control of high blood pressure and blood sugar levels give marked benefits in terms of reduction of strokes, kidney disease and heart attacks. Unfortunately a misconception is perpetuated within society that drugs given for these diseases lead to irreversible kidney damage and liver failure. This is wholly untrue. The current drugs are safe when used under the guidance of competent medical care.

Physical exercise has come to the forefront of many life style behavior modifying programs, as it rightly should. Exercise not only reduces atherosclerosis plaque formation but also contributes towards the formation of new blood vessels to the heart which is called neo-vascularisation. Thus it has a marked effect in reducing the incidence of IHD and ischaemia related deaths.

High blood lipids have an established place in the prevention of all vascular diseases. The term “Cholesterol” has entered the vocabulary of the least educated individuals who equate cholesterol and heart attacks as one and the same. The problem with cholesterol is as to how much is too much?. The normal values for cholesterol recommended by official organisations show such wide disparity that even health care providers are at times wondering whether to treat a given level or not.

The confusion is mainly due to the fact that we now work on two ideal values, one for those who have had no heart disease and another for those who have already become heart patients. It is wrong to label all patients with high cholesterol as heart patients. The appropriate value for a given individual must be decided by the treating physician.

The group of drugs called “Statins” used commonly for the control of blood lipids are generally extremely safe except for muscle damage (manifesting as muscle aches and pains) and liver effects (manifesting as a rise in certain liver tests). These drugs can be used continuously. No irreversible organ damage has been reported if used under proper physician guidance. Large doses are now used which also cause much anxiety to patients but the benefits are thought to be significant.

A basically vegetarian diet, supplemented by fish or chicken as desired seems to be the best diet that can be recommended. It is however now known that purely being vegetarian is not of much help if the calorie load is high. Thus a vegetarian who consumes a large quantity of food will suffer from obesity and thus have a higher risk of IHD and diabetes mellitus.

If the excess fat is stored in the centre ( as in the abdomen ) the risk seems to be greater. On the other hand even a meat rich diet which does not lead to weight gain may not be as deleterious as over eating vegetarian food. Hence the recommendation is to be aware of both the quality and quality of the food consumed.

As is well known, fatty food must be restricted. It is, however, true that fat confers much desired tastiness to food. This must be kept in mind.

Hence fat is not totally taboo but may be used in restricted amounts. Generally speaking, two to three teaspoons of a fat (solid or non solid) is appropriate amount of intake, specially if the poly unsaturated or mono un-saturated fats are used.Trans fats have recently been highlighted although their deleterious effects have been known for several decades. Always look at the label on the carton as western countries now require by law that the transfat content be displayed in processed foods.

The trans fat component in natural foods is almost negligible. Only on processing food that trans fat form, which are atherogenic as well as carcinogenic. For this same reason, the poly unsaturated foods must not be repeatedly reheated as they transform into “trans” form in the process.

Finally a word on mental stress would appropriate. Even genetically identical twins seem to show different tendencies to develop IHD if the mental stress component is different. The twin living in a less stressed environment did better on IHD scores then his/her twin living in mentally stressful situations. Thus, lifestyle modifications must necessarily involve relaxation techniques which must be multifaceted to be universally beneficial.

The writer is Consultant Cardiologist, National Hospital of Sri Lanka.

Choline may influence gene expression

Just as women are advised to get plenty of folic acid around the time of conception and throughout early pregnancy, new research suggests another very similar nutrient may one day deserve a spot on the obstetrician's list of recommendations.Consuming greater amounts of choline - a nutrient found in eggs and meat = during pregnancy may lower an infant's vulnerability to stress-related illnesses, such as mental health disturbances, and chronic conditions, like hypertension, later in life.

In an early study in The FASEB Journal, nutrition scientists and obstetricians found that higher-than-normal amounts of choline in the diet during pregnancy changed epigenetic markers - modifications on our DNA that tell our genes to switch on or off, to go gangbusters or keep a low profile - in the foetus. While epigenetic markers don't change our genes, they make a permanent imprint by dictating their fate: If a gene is not expressed - turned on - it's as if it didn't exist.

The finding became particularly exciting when researchers discovered that the affected markers were those that regulated the hypothalamic-pituitary-adrenal or HPA axis, which controls virtually all hormone activity in the body, including the production of the hormone cortisol that reflects our response to stress and regulates our metabolism, among other things.

More choline in the mother's diet led to a more stable HPA axis and consequently less cortisol in the foetus.

As with many aspects of our health, stability is a very good thing: Past research has shown that early exposure to high levels of cortisol, often a result of a mother's anxiety or depression, can increase a baby's lifelong risk of stress-related and metabolic disorders.

- MNT

Why women are into ‘self-harming'

By Harshani A. Pinnawala

In general, ‘self-harming’ is the result of an inability to cope with problems in healthy ways. A person might have a hard time in regulating, expressing or understanding her/his emotions.

‘Self-harming’ or ‘Deliberate self-harming’ is also known as ‘self-injury’ which is a term given to those who deliberately harm themselves. The most frequent form of self-injury is skin-cutting. Normally, the cuttings are not too deep. In addition, it includes burning, overdose, scalding, punching, banging, or bruising their body in some way. Some pull out their skin and pick their skin.

Self-harming might bring a momentary sense of calm and a release of tension, yet, it follows the feelings of guilt and shame and the painful emotions might return after the particular incident.

Causes of self-harming

There is no definite cause for a person to act like this. It is more or less like a symptom of other mental disorders. According to DSM-IV-TR Diagnostic and Statistical Manual of Mental Disorders), ‘self-harming’ categorised as a symptom of Borderline personality disorder which is a subtype of Personality Disorders. It can also be due to physical abuse, sexual abuse or eating disorders, low self esteem and perfectionism.

Often the person does not feel pain or distress during the act, but, often feelings of relief and satisfaction have been described as soon as the act has accomplished the desired effect. Someone who cuts themselves habitually might say that they feel overwhelming feelings before the event, feels no pain during the cutting. But, they get a great relief once blood has been drawn. The person does not mean to do themselves serious injury. However, in certain occasions, the damage can end up being life threatening if overdose is severe or blood loss is great.Reasons given for self-harming have included feeling useless and desperate, having feelings of guilt or being ashamed, great sadness, a loss of reality or simply feeling numb towards life in general. Whatever the reasons given, most individuals have their own unique experience, motivation, emotional backgrounds for wanting to harm themselves.

Reason

For most individuals there will be some sort of underlying reason for this problem. This may be that they have suffered some sort of abuse in the past, be in an abusive relationship, and have got extremely low self-esteem for some reason or that they feel deep guilt caused by their previous behaviour or actions.

‘Self-harming’ is widespread than most people think. It is a subject that is mostly connected to females. The reason might be the different techniques that both men and women apply to cope up their matters. For example, the way of men expressing the strong feelings such as anger, irritation, and annoyance are different from the way of women expressing themselves. Most often men act violently and talk harshly, while women remain in silent and calm. Evidence has found that women are up to four times more likely than men to self-harm. Several myths are there with regard to ‘self-harming'. One might think that it is a failed suicide attempt. This is not exactly true since it is one way of carrying on with life, not of dying. Furthermore, it is not that the person is seeking only attention from others, but, their expected final outcome is to release the tension and pain that they are unable to cope. ‘Self-harming’ is also not a sign of madness, yet, it is a sign of distress and a sign of a person who is trying to cope with her or his life as best she or he can. These patients do not harm others as many think. Therefore, the fear which most of us have is irrelevant.

Self-harming is a complicated problem that affects many women in Europe than in Asia. This does not mean that it is a rare disorder in Asia. Experts estimate that about 1 percent of the population has self-harmed.

Treatment

First, it is very important to know that if a person starts self-harming, it is very difficult to stop it since it is an addictive behaviour. Therefore, the patients need to seek professional help and treatment initially, it is important to treat the injury whether this be controlling severe bleeding, treating infection or undertaking an overdose. Once the immediate medical problems have been dealt with, the underlying, psychological problems must be addressed. To treat the person properly, he or she should be able to admit that he/she has a problem and want to discover the source and address the problem in a different way.

The use of behavioural therapies, group therapies, counselling or other proven method of addressing psychological problems could be used. These will have a greater success rate if they are addressed using professional guidance from those who are specially trained in this area. Cognitive-behavioural therapy might help a person to realise the reason of doing it. It also helps to cope up with their problems without hurting themselves physically. Eye Movement desensitisation and Reprocessing therapy (EMDR) which is a form of psychotherapy used to help with post-traumatic disorder.It may be beneficial to the persons to gain confidence in their own abilities and also by ensuring they have a supportive network around them. This can be done through their friends and family or the person who is helping them overcome the problem. Communication plays an important role while addressing the problem and the person should not be embarrassed or ashamed of confiding their deepest feelings with others whom they cannot trust. Drugs might also be helpful up to a certain limit. Some drugs might be very addictive. However, it is important to know that the type of treatment which is most effective is different from person to person.

- The writer holds an MSc in Psychology

Large donors force WHO to reform

The current practice of large donors is forcing the World Health Organisation (WHO) and the World Bank to reflect on how to reform to remain more appealing to the wider set of stakeholders and interests at play, according to Devi Sridhar from the University of Oxford writing in this week's PLOS Medicine.

Sridhar argues that since the priorities of funding bodies largely dictate what health issues and diseases are studied, a major challenge in the governance of global health research funding is agenda-setting, which in turn is a consequence of a larger phenomenon - “multi-bi financing.”

This term refers to the practice of donors choosing to route funding - earmarked for specific sectors, themes, countries, or regions - through multilateral agencies such as the World Health Organisation and the World Bank and to the emergence of new multistakeholder initiatives such as the Global Fund to Fight AIDS, Tuberculosis and Malaria and the GAVI Alliance.

Sridhar says: “These new multistakeholder initiatives have five distinct characteristics: a wider set of stakeholders that include non-state institutions, narrower problem-based mandates, financing based on voluntary contributions, no country presence, and legitimacy based on effectiveness, not process.”

Sridhar argues that the risk of multi-bi financing is that difficult choices about priority-setting in health will be made in the marketplace of global initiatives, rather than in the community that will have to live with those choices.She says: “The shift to multi-bi financing likely reflects a desire by participating governments, and others, to control international agencies more tightly.”However, Sridhar adds: “one major impact of multi-bi financing has been to shine a clear light on how and where multilateral institutions, such as the World Bank and the World Health Organisation, might do better.”

MNT

Scientists hope gene breakthrough could help men with breast cancer

Scientists have found a gene which can increase the risk of male breast cancer by 50 percent, after the world's largest study into the disease.

Screening of the genetic codes of more than 800 male breast cancer patients, mainly from the UK, has revealed that mutations in one particular gene play a role in the disease, and could herald the development of new treatments specifically for men. Very little is known about the causes of male breast cancer, which is diagnosed in 350 men in the UK every year, compared with 48,000 women.

Previously researchers uncovered that faulty BRCA2 genes are involved in around 10 per cent of male breast cancer cases but they have now established that faulty RAD51B genes, which have also been found to increase the risk of breast cancer in women, also play a role in the disease in men.

Dr Nick Orr, a group leader at the Breakthrough Breast Cancer Research Centre at The Institute of Cancer Research, London, and one of the study's authors, said, “This study represents a leap forward in our understanding of male breast cancer.”

The research published today in Nature Genetics will help doctors predict whether men are more at risk of developing breast cancer. “

For a general man in the population this latest news isn't that significant because the risk of breast cancer in males is already so

low,” Dr Orr said. “But for people who are already at high risk of breast cancer, for example men who have mutations in the BRCA2 gene, having this extra information could really help our ability to predict whether they are going to get the disease or not.”Scientists from the Breakthrough Breast Cancer Research Centre were part of an international research team involved in the Genome-Wide Association Study (GWAS), which investigated 447,000 alterations in the DNA of participants as part of a wider four-year-long study.Scientists now hope to build on the success of the GWAS’ findings to identify further causes of both male and female breast cancer.

- The Independent