The Tribune, Chandigarh, India

How life goes up in smoke
By Dr G.D. Thapar

Smoking cigarettes is probably the most important single factor in the causation of ischaemic heart disease. Smoking is of course capable of causing many more diseases, which are no less serious such as the cancer of the lung, chronic bronchitis and emphysema. It is estimated that every cigarette smoked reduces the life-span of the smoker by five minutes. Women have a special risk for their heart. Their risk of a heart attack and a stroke, which is normally low, is increased 10-fold if they smoke while taking contraceptive pills.Physical performance is an important determinant of longevity and is determined mainly by the combined function of the heart and lungs. By accelerating the decline of both lung and heart functions, smoking cuts the life short.

Constituents of tobacco smoke: About 500 different compounds have been identified in the tobacco smoke. The chief among them are: nicotine, tars, carbon monoxide, ammonia and unburnt carbon particles — all contributing to the ill-effects of smoke. Even paper of the cigarette adds its own harmful effect to the smoke.

Effects on the heart: Broadly, nicotine is involved mainly in cardio-vascular effects, tars in cancer, and ammonia and unburnt carbon in chronic bronchitis and emphysema.

Nicotine has a direct constricting effect on the coronary arteries, significantly reducing their ability to transmit blood. Thus a single cigarette smoked by a patient of a heart attack can substantially increase the damage to his heart by further compromising the already-obstructed blood supply to the heart.

For the non-smoker, even lower doses have the same effect so that a cigarette smoked near a non-smoker heart-attack patient can dramatically increase the damage to his heart and put his life in jeopardy. Studies have consistently shown an increased risk of death from heart disease and cancer for non-smokers married to smokers.

Nicotine increases the levels of fatty acids and cholesterol in the blood and reduces the level of good cholesterol (HDL-C). These alterations in the lipid (fat) profile facilitate the formation of fatty deposits (atheroma) in the coronary and other major arteries in the heart, brain, legs, etc., causing obstruction to the flow of blood. Worse, nicotine makes the blood more prone to coagulating within the arteries, increasing the chances of thrombosis. These changes are responsible for the increased incidence of angina, heart attacks, strokes and gangrene of the leg.

In addition to these long-term changes, nicotine causes irregular action of the heart by producing extra beats. It also elevates the blood pressure. In this way, it increases the workload of the heart. At the same time, carbon monoxide of the smoke combines with haemoglobin, the oxygen carrier of the blood, to form inert carboxyhaemoglobin, which is incapable of carrying oxygen. The body, the heart in particular, is starved of oxygen in the face of increased requirements consequent on increased workload. This produces (or aggravates) angina or a heart attack.

The chronic lung disease and emphysema that unburnt carbon particles and ammonia give rise to interfere with oxygenation of blood. The chronic deficiency of oxygen thus produced exerts its own deleterious effect on the functioning of the heart and in case of a heart attack, contributes to the damage to the heart muscle.

Results from the world's longest running study of smoking over a period of 40 years show that in Britain about half of all regular smokers are eventually killed by their habit. Unless current smoking patterns change, cigarettes will kill 10 million people a year worldwide by the year 2025.

Currently, smoking is responsible for three million deaths yearly. All this increase is expected to occur in the developing countries where multinational tobacco companies, which are under great pressure in their home countries to stop production, have aggressively stepped up their marketing activities by promotional advertising, money power and political pressure.

De-addiction: Tobacco is a serious but preventable and modifiable risk factor for the heart. There is no doubt that it has a large habit-forming potential. That is why the Food and Drug Administration of the USA is seriously planning to declare cigarettes as a drug to enable the government to have a measure of control over their consumption.

The strong addiction to smoking does need equally strong motivation and determination to get rid of the habit, but it is not as difficult as it may seem; in Britain and the USA a very large percentage of the health-care professionals who were confirmed smokers have successfully stopped smoking.

Like any other addiction, the best thing is not to start the habit in the first instance. Teenagers are at the greatest risk of starting it. Parents and teachers, therefore, need to concentrate their efforts on this segment of the population if we have to save the younger generations from this scourge.

For those who have already started it, there is no option but to quit the habit, the earlier the better, if they wish to prevent heart and lung problems and save themselves from the hassles and expense of bypass surgery or angioplasty.

If you are a smoker, you will do well to make up your mind to quit smoking; make it 100 per cent, as anything less would not do. It must be understood that it is far easier for a confirmed smoker not to smoke a single cigarette than to struggle with a reduced number. Therefore, aim at quitting completely. There is no such thing as "reduction" for you. The rewards of quitting are enormous as the extra risk of a heart attack that you are carrying will immediately start receding and will disappear in two years.

The plan: To help you stop smoking, it is necessary that your general health should improve as much as possible, especially the smoker's cough, sinusitis and headaches, because these symptoms weaken you and may interfere with your resolve to quit smoking. Get them treated with suitable antibiotics, steam inhalations etc. with the help of your doctor. This will help you to remain steadfast in your resolve.

If you can now throw away your last packet for good, there is nothing like it. Do it. However, if you find difficulty in suddenly stopping it, do it in two or three stages, but with a clear resolve and understanding with yourself that the goal is total abstinence and under no circumstances will the interim stage be allowed to become the goal.

The principle: It is a fact that one cigarette leads to another, because it not only satisfies the craving for nicotine but also produces craving for more. You would have noticed that if you have been confined to bed because of some illness and have not smoked for a few days, the craving appreciably diminishes.

Similarly, when you wake up in the morning after the night's rest and abstinence from cigarette for 10 hours or so, the craving for tobacco is at its minimum. After you have smoked the first cigarette, the craving increases. It becomes more and more difficult to resist as you smoke more and more cigarettes. It is, therefore, important to recognise the fact that the easiest cigarette to resist is the first cigarette of the day.

So, if you delay smoking the easiest to-resist-cigarette, i.e, the first cigarette of the day, you will reduce the number of cigarettes smoked. If you delay smoking that first cigarette till you sleep at night, you will win the battle.

The method: First, you reduce the number of cigarettes to exactly half, of course with a clear understanding to yourself that the reduction is strictly temporary and is merely the first step in your battle against tobacco. Continue this reduced number of cigarettes for one month. You will notice that craving for tobacco has considerably decreased, and is now easier to manage. Now proceed to the second stage.

In the second stage, you reduce the cigarettes to four or five per day, and continue for another month. You will then find that the craving has become so little that it is not difficult to stop smoking. Proceed to the third and the final stage.

In the third stage, take the final plunge and say goodbye to smoking for ever. Do not keep any cigarettes in the house. Stack away all ash trays, cigarette lighters or anything that reminds you of smoking. Make your house a real non-smoker's house. In the first few days or weeks, you may need some substitutes like pan, chewing gum or cardamom. Make use of them as needed but do not smoke. As time passes, the need for these substitute items will gradually diminish and finally disappear altogether.

The ex-smoker status: A little piece of warning is in order. It needs to be understood that nicotine addiction is like any other drug addiction and can wake up again if you smoke even one cigarette. The ex-smoker status is somewhat unstable. You might argue with yourself that you will smoke only four cigarettes a day. But it does not work this way. It has worked with no one and it would not work with you also. The four cigarettes will soon become 40. It is easy, in fact very easy, for you not to smoke at all but difficult to restrict yourself to four cigarettes. It will be a hard struggle, in which a confirmed ex-smoker is bound to lose.

Once you have stopped smoking, it should be total and complete abstinence for ever.

Dealing with heartburn
By Dr Suresh Rana

Heartburn is the feeling of a burning sensation in the upper abdomen or the chest behind the breastbone that moves up towards the neck and the throat. Some experience the bitter or sour taste of acid at the back of the throat. This burning sensation can last for several hours and often worsen after eating.Heartburn is a condition in which stomach contents flow backwards up into the food pipe (oesophagus). Stomach contents consist of acid and digestive enzymes. The prolonged contact of acidic stomach contents with the food-pipe lining injures the food pipe and it becomes inflamed, painful and produces a burning sensation.

Heartburn is very common. Every person experiences it occasionally. there are more chances to have heartburn in situations like eating large meals near bed time, being a smoker, being over weight, wearing tight clothing around the waist and during pregnancy.

Causes of heartburn: Normally, a muscular valve (lower oesophageal sphincter) at the junction of the food pipe and the stomach, keeps the stomach contents in the stomach and does not allow them to go into the food pipe. In heartburn this valve relaxes too frequently, which allows the stomach contents to flow backwards into the food pipe. Since the food pipe lining is sensitive to stomach contents, persistent and prolonged exposure to these contents may cause changes such as inflammation, ulcers and scarring in the lower portion of the food pipe. The persistence of heartburn symptoms may represent a disease known as Gastro-oesophageal reflux disease (GERD).

Guidelines: In order to decrease the amount of the stomach contents which may reach the food pipe, certain simple guidelines can be followed:

Stop smoking: Tobacco inhibits saliva which is the body's major buffer. Tobacco also stimulated the stomach acid production and relaxes the muscular valve between the food pipe and the stomach.

Weight: Avoid becoming overweight. If you are too heavy, reduce weight.

Diet: Particular foods can make the symptoms worse. Avoid foods and beverages which contribute to heartburn. These may include citrus fruits and juices; drinks which are too hot; excessive tea or coffee; fried fatty foods and spicy meals.

Eating and sleeping habits: It is better to eat little and often fill but do not overfill the stomach. Avoid lying down for two hours after eating. Do not eat atleast two hours before bed time. This will decrease the amount of the stomach acid available to reflux into the food pipe. Heartburn may be made worse by poor eating habits.

Clothing: Avoid tight belts and underclothes as they increase the pressure on the stomach.

When to contact your doctor: Many persons who suffer from occasional heartburn may take antacids either in tablet or liquid form and get relief. In persons with mild heartburn simple life-style modifications may improve the symptoms.

When symptoms of heartburn are not controlled with modifications in the life-style, or the symptom remain unresolved by taking antacids, or if a person is getting more frequent episodes of heartburn, a doctor should be consulted.

The value of rest

The value of rest after strenuous physical exercise or work is well recognised. Its need in acute illness is also well known. But what is not recognised is the need for rest under certain circumstances to prevent heart problems from developing or becoming worse.Physical activity under normal conditions is healthy for the heart.

The activity should be such that it produces a pleasant feeling of tiredness which, after a bit of rest, disappears. If the feeling of exhaustion is more intense than this, particularly in middle age and beyond, it calls for extra rest, and may need to be investigated by your physician.

If during the physical activity or exercise there are untoward symptoms such as pain in the front of the chest or laboured breathing suggestive of a heart problem or such indefinite symptoms as palpitation or undue weakness, it will be foolhardy to continue with the activity.

It will be saner to back off, take rest and consult your physician. Such symptoms may be the beginning of a heart attack. At such a critical time, you may be able to save the situation from becoming really bad by a bit of extra rest and timely consultation with your physician. At any rate, this precaution is not going to do you any harm.

As age advances, your body will need rest at more regular intervals than you had been taking during the younger years. This statement should not be construed to mean that you have to become more and more inactive physically with advancement in age. In fact, you should aim at continuing to be physically active to the maximum of your capacity till the end, but ensure regular periods of rest and avoid prolonged periods of hectic activity at a stretch. A regulated active life is what you will then need.

Physical exercise is good; so is rest. But too much of even good things is bad. What you need is a healthy combination of rest and activity in the right proportion commensurate with your age. Moderation is the keyword. Let your own body guide you when enough is enough and you need rest. — G.D.T.

Obesity & (f)utility of drugs
By Dr K.C. Kanwar

Obesity is on the increase worldwide. It is no longer restricted to the affluent and the elite. It has spread to even the less privileged strata of society. The percentage of obese Americans is well over 35. In East Europe, the obesity scene is even more scaring where amongst women it has already crossed 50 per cent.

A study conducted by the Nutrition Foundation of India, Delhi, has found that more than half of the urban female population and nearly one third of the Indian males are obese.

According to a report published in Lancet on global fat, obesity is a "potential medical calamity" since it signals accelerated ageing and poses risks of many human ailments like varied cardiovascular disorders, diabetes and stroke to name a few.

There has been a flurry of activity in the scientific community to formulate strategies for containing and curing the ever-increasing obesity problem -- the most obvious outcome of our lazy life-style. While it is easy to gain weight, it is really hard to lose those extra pounds. Even if an obese person loses some weight by resorting to exercise and strict dietary control, it is hard for him to sustain it.

A study based on 200 obese dieters who lost an average of 48 pounds each by being on a formula and preportioned diet has yielded interesting observations. Three years later, only one in eight of these "obese dieters" had kept off 75 per cent of the lost weight. Two out of five of these dieters during this time, in fact, gained more than they had lost. In view of this the researchers are frantically trying, so far in vain, to evolve the "elusive slimming pill" which would suck out fat from the body without toiling for it.

Obesity ranges between mild to moderate and morbid. Most of us suffer from mild or moderate obesity which is a result of over-eating combined with low energy expenditure implying a lethargic life-style. Morbid obesity may also involve hypothalamic (brain centre controlling appetite and satiety) disturbance and metabolic malfunctioning which need to be attended to if obesity is to be managed.

Usually, obese persons are or pretend to be either too busy, too tired or too lazy to exercise to shed weight. On the other hand, the obese, by and large, are those who live well, eat well and want to maintain themselves fit and slim with minimal effort. Drug houses have taken advantage of this human weakness to get rid of body fat effortlessly irrespective of the cost involved.

Drugs available in the market for the management of obesity are bizarre. The simplest and safest of these are those encapsulating fibre with no caloric value. These help control weight by inducing a feeling of abdominal fullness which reduces the desire to eat. To achieve this effect, the bulk use of salads and vegetables rich in indigestible cellulose and the much needed vitamins and minerals should be preferred. Various crash or miracle diet regimens advertised for weight loss are highly unbalanced and physiologically disturbing.

Amphetamines and their derivatives are the other category of compounds used in the slimming pills. These work by inhibiting the hypothalamus — the region of the brain controlling appetite. But such drugs cut appetite only temporarily and have potential for drug abuse. These may cause dependency and could, in fact, be hazardous if one is suffering from high blood pressure, heart diseases, diabetes, glaucoma, thyroid disease or kidney problems. Besides these drugs are known to over-excite the central nervous system and make one jittery and irritable.

“As of today there is not a single drug which can cure obesity totally”, says Dr Amrapurkar, a Bombay gastroenterologist. The weight loss achieved by such medicines is only short-term, followed by a rebound weight gain once the medicines are stopped. Further, the appetite suppressants, if used for long, may cause the deficiency of essential vitamins and minerals which can even be more hazardous than obesity.

Barring a few pharmaceutical companies, many such pills do not have the list of ingredients mentioned. Health clinics (slimming centres) advertise slimming potions whereby the subjects (obese persons under treatment) require no diet control, no exercise and which have no side-effects. Such claims are catchy but do not withstand scrutiny.

Many slimming potions are said to be safer than others because of being “herbal and Ayurvedic in origin”. Let these gimmicks not fool anybody. “Nowhere in the ancient texts it is claimed that all the Ayurvedic preparations are totally harmless”, says Dr Sharadini Dahanukar, Head of the Ayurved Research Centre, KEM Hospital, Mumbai. After all, even plants do produce potent toxins. Ayurvedic slimming potions available in the market do not have adequate clinical data on their efficacy. And they do not list clearly the ingredients.

Simply and scientifically speaking, the management of obesity demands strict and regular dietary and exercisal discipline. Either of these is grossly inadequate to reduce weight significantly. In addition, determination and motivation are necessary. The dieter should be able to withstand voluntarily pangs of hunger at times. The clinician’s help is only advisory. He can select food items low in calories, and supplement these with vitamins and minerals. Exercise alone is not enough to get rid of obesity. Remember, one pound of body weight is equivalent to 3,500 kcal and to shed this much body weight, one needs to walk approximately 50 miles or 80 km — a difficult job indeed! To simplify it further, to be able to burn up 150 kcal contained in an extra slice of bread pasted with jam and butter, the body needs a workload equivalent to a three-mile run or strenuous exercise for half an hour. How many of us are able to do this ? By far, the only way of shedding excessive weight

(fat) is to eat fewer calories — fewer than those expended. Losing weight should be a gradual and long-term process. There is no miraculous crash diet which would take off large amount of weight within a few days without toiling hard. Complete fasting for a week is difficult and physiologically inadvisable but even if it is accomplished it would take away not more than five pounds of body fat. The best way to fight obesity is to consume a properly balanced, medically approved and low-caloric diet, to be followed by exercisal bouts.

Slimming pills of questionable efficacy, even though available over the counter, are not cheap. These are priced approximately at Rs 5 per tablet, of which four to six have to be consumed daily for at least three months. Moreover, once you are on them, you cannot discontinue to avoid a rebound. Other electronic devices advertised by various slimming centres are of questionable or limited efficacy and even if they “work wonders”, as claimed, they maximally can be an adjunct to be had along with dietary and exercisal modes. Such slimming parlours charge exorbitantly for the service they render.

Lastly, a word about certain medicines which are prescribed routinely for various ailments and which tend to make one fat or at least look fat. Some of these make the body retain water, some increase the appetite and some act on the way the body burns fat. A few, perhaps, accomplish all the three. The American Society of Bariatric Physicians (doctors who specialise in weight problems ) caution that prolonged oral steroid administration prescribed for many chronic afflictions end up in weight gain; these increase both appetite and fluid retention. Similarly, many antidepressants increase one’s appetite. Some antihistamines increase the craving for sweets and thus facilitate weight gain. Certain other drugs like oral contraceptives or even some antihypertensive drugs or those preparations prescribed for HRT do (or may) trigger weight gain. In case one feels that medicines which have been prescribed for long use make one fat, one should consult the doctor who may suggest appropriate substitutes or ask one to be disciplined in one’s food intake to avoid obesity.