Monday, September 27, 2010

The good, the bad, the ugly: facts about cholesterol

I. Sathyamurthy


It is often said that the tongue knows not what cholesterol can do to the heart. The high rates of death from heart attack testify to this.

Lipid (fat) measurement is important to predict and help prevent heart attacks. Blood lipids are classified according to their density as high, intermediate and low density lipids. Most of the blood cholesterol is carried as low density particles. These lipids have a protein coating called lipoproteins that carry them. Basically, low density cholesterol (LDLc) is ugly cholesterol and triglycerides (TGL) are bad cholesterol and they are harmful (atherogenic). High density cholesterol (HDLc) is protective and is called good cholesterol. Atherogenic cholesterols have a protein layer coating called ApoB, while good cholesterol contains Apo A1.

LDL cholesterol can further be divided into large, dense and small dense particles. Small, dense particles are highly atherogenic and can penetrate the inner wall of blood vessels readily. There is a type of LDL cholesterol called Lp(a), and in some studies it was shown to be highly atherogenic if its level is more than 30mg/dl. Many studies have shown that ApoB concentrations and the ratio of ApoB to ApoA1 are important predictors of heart attacks. But some older studies showed that a simple ratio of total cholesterol to HDL of more than 5, predicted a high risk of heart disease.

Many modern-day diagnostic laboratories display a menu that features tests for total cholesterol (TC); high density cholesterol (HDLc); triglycerides (TGL); low density cholesterol (LDLc); ApoA1; ApoB;.very low density cholesterol (VLDL) and Lp (a). What one basically should know is that TC levels should be less than 200 mg per cent, TGL levels less than 150 mg per cent and LDLc levels should be less than 130 mg per cent if there is no history of heart disease. In someone who has already had a cardiac event, LDL should be less than 100 mg per cent. For very high-risk individuals, LDL should be less than 70mg per cent. For those who have had a cardiac event (and whose concern should be secondary prevention) the lower the LDL, the better. HDL cholesterol should be greater than 40 mg per cent in men and greater than 50 mg per cent in women.

Twelve-hour fasting is essential for TGL measurement, LDLc. To measure TC and HDL cholesterol, fasting is not essential. For population studies the measurement of these components is enough. If you subtract HDLc (good) cholesterol from total cholesterol you will get the total amount of atherogenic (harmful) lipids. HDLc is antiatherogenic. If bad cholesterol levels are normal, HDL levels are of no concern even if they are low. In Indians it is often reported that HDL levels are usually low and do not increase despite regular exercises, reduction in alcohol intake, cessation of smoking and dietary discipline. In such cases, statins alone are not enough.

Lipid levels can be raised due to a high fat-diet: what are referred to as exogenous lipids. Those who do not have a high-fat diet can still have high blood lipid levels owing to abnormal endogenous lipoprotein metabolism in the liver. A thin-looking individual can have high lipid levels. On the contrary, an obese individual can have a normal lipid level. It all depends on body metabolism.

Footprints of premature atherosclerosis begin in childhood. The progression and the rapidity of progression depend on lipid levels and other risk factors such as high blood pressure, diabetes, effects of smoking and dietary indiscipline. Familial hypercholesterolemia is one of the commonest causes of increased blood lipids in childhood, and usually there is a family history of premature heart disease and sudden death. People with a family history of premature heart attacks (that occur below 40 years), a family history of sudden death, childhood obesity, and with familial hypercholesterolemia and diabetics with high lipid levels, should be strict about their diet in containing exogenous fat intake.

Statins are drugs given to lower lipid levels. They also have anti-inflammatory properties, improve endothelial function (inner layer of blood vessels), stabilise plaques (fatty deposits in the vessel wall) and have antioxidant properties. The side-effects are muscle weakness, elevation of liver enzymes, impaired cognitive function and depression. Recently, after the publication of an article in the media there were apprehensions among patients about depression relating to statin use. It only occurs when high doses are given over long periods, particularly in the elderly, that too among those who are prone to depression. Judicious use of statins under medical supervision is safe.

(I. Sathyamurthy, an interventional cardiologist, is Director of the Department of Cardiology, Apollo Hospitals, Chennai. He was conferred the Padma Shri in 2000, the B.C. Roy National Award in 2002 and a D.Sc (Honoris Causa) from the Dr. M.G.R. Medical University in 2008).

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Sunday, September 5, 2010

High Spirits, Low Calories

Malvika Nanda, Hindustan Times (5 September 2010)

Drink too much and you get flabby. And it's not just the calories in liquor that are at play. Alcohol reduces the amount of fat the body burns as energy, slowing down weight-loss.

Given the high caloric value of most spirits, the body is forced to store the excessive amount of unburned fat calories in the form of flab and the despised beer belly. For those who love their poison, total abstinence is not an option. The thing to do is be smart with your choice of alcohol and more importantly, watch those mixers.

Model Ramneek Pantal says on days she doesn't feel like downing empty calories, she sticks to a clever mix of three-quarters water and one quarter-cola for flavour with lots of ice. "I never put on weight due to drinking, but I have friends who do. So, just a dash of flavour can do the trick there."

The spirit math
To start with, get familiar with the basics of different types of spirits. Hard liquors are high in calories —30 ml whisky is about 118 ml. Cream-based drinks are generally more fattening. But the real sin lies in the cocktails. They are loaded with syrups, juices and other sweetened flavouring, which together with alcohol can push the calories in one drink from 600 to 1,000.

For the 28-year-old IT professional and events coordinator Shalabh Pratap Singh, the drink of choice is vodka with warm water. It has among the least calories. "Adding flavoured carbonated water to your drink also breaks the monotony without adding calories," says Singh.

Model and DJ Iggy aka Ignatius Camilo believes that "each body type is different, so it's important you identify what works for you." Iggy drinks wine or beer that's brewed from rice, barley or hops. "I don't drink beer made from wheat or corn unless it's a beer I haven't tasted before."

Different strokes
The way the body processes alcohol varies with individuals. "Our body isn't a drum where the stomach and metabolism are the only factors at play. There's the liver that's responsible for filtering and processing alcoholic content. So when people drink, they should give some thought to the condition of their liver as well as their general health," says nutritionist Dr Shikha Sharma.

Also, it's not just about the number of calories, she adds. "Wine may have fewer calories than a whiskey or vodka, but the body tends to retain more calories from wines," she says.

The rule of the thumb for diet watchers is to go for clear spirits as compared to darker ones. And avoid cocktails altogether, unless you have the option of asking for low-calorie diet mixers.

ICELAND DIARY

By Vir Sanghwi as appeared in HT Magazine – Sep 5, 2010

It's a place that has a beauty of its own. And a relaxed, informal charm. If you haven't been to Iceland, then I suggest you consider it for your next vacation.

Sometimes the names of countries can lie to us. There is, for instance, little greenery in Greenland (only a lot of ice) despite its name. And there's rather a lot of greenery in Iceland and not as much ice as you would expect.

Before I went to Iceland, I knew very little about it. I knew it as the home of the unpronounceable volcano (pilots called it E15 to avoid tripping over their tongues) that disrupted air travel in Europe for so many weeks. I had heard of its President Olafur Grimsson, a long-time friend of India from Indira Gandhi's day and winner of the Nehru Prize earlier this year.

And I was dimly aware that its improbable burst of prosperity – at one stage, Icelandic companies owned half of the British high street – had came to an inglorious end a couple of years ago and that the country was now – in a strict fiscal sense – effectively bankrupt.

That's not a lot of knowledge to base a visit on but when the Icelandic ambassador to New Delhi phoned on behalf of his Foreign Ministry to ask if I would visit his country, I accepted the invitation on a sudden impulse. And I am glad I did.

The first thing I discovered when I got to Iceland was that there were very few countries like it (though New Zealand is not dissimilar). For a start, it is very isolated. The country is about the size of England but its total population of around 3.5 lakh is roughly equal to the population of a Delhi locality – say, Karol Bagh. When we got to the countryside, we would drive for miles and miles without seeing a soul, the quiet isolation only relieved by the occasional herd of magnificent stallions.

Then, there's the landscape. According to geologists, Iceland is one of the world's youngest countries. It was created millions of years after, say, India which means it probably rose out of the Atlantic Ocean as a consequence of volcanic activity.

So, Iceland is still a land in ferment. Forget about E15, much of Iceland is volcanic. Driving into Reykjavik from Keflavik Airport (a distance of around 40 km), I was stunned by the landscape. For most of the way, I did not see a single tree.

Instead the land was covered with mounds of an unusual rock. It turned out to be lava, the legacy of innumerable volcanic explosions over the centuries. At various places, the earth itself would seem to be boiling and hot steam would rise from holes in the ground – another consequence of volcanic activity is that hot springs bubble away under the soil.

By the time we got to Reykjavik, however, the landscape changed again.

Now, it was typically Northern European, full of greenery, manicured grass, tall trees and verdant bushes. I was to learn that this was not unusual in Iceland. In 20 minutes you could go from a sort of lunar landscape to a lush forest.

Despite their President's status as an honorary Indian, there has been little contact between the people of Iceland and the people of India.

The Indian community is microscopic and there were times when I felt like the only brown person in a land of tall, blue-eyed, blonde men and women. Over the last couple of years, we have finally established full diplomatic relations and proper embassies have opened in both countries.

Now, the Icelanders want to have more to do with us. They want Indian tourists (doesn't everyone?) believing that their country's spectacular natural beauty and proximity to London (just over two hours by plane) makes it a perfect destination. They want Bollywood to come and shoot there (it is certainly less chocolate-boxy than Switzerland) and are offering a fabulous part-of-your-money-back deal to the film industry.

For our part, we are fascinated by their experiences with geo-thermal energy. Iceland has some of the world's cheapest and cleanest electricity. I visited a power plant in which the turbines were driven by the steam escaping from the earth.

While the initial cost was significant, the plant was then virtually cost-free to operate because the natural steam was free. It produced more energy than a city like Reykjavik would need, had only eight employees and at night all employees went home leaving the plant to keep producing cheap, entirely clean electricity without any human supervision.

The Indian ambassador to Iceland told me that we had enough geo-thermal energy beneath the surface in Ladakh to run similar plants and that he was hoping to use Icelandic expertise to introduce India to clean energy that was not dependant on expensive petroleum or coal.

Iceland is still recovering from the banking crash. This is a complex phenomenon. From what I can tell, the country seems to have been a victim of capitalism gone mad.

During the greed-fuelled global boom years, Icelandic banks followed the example of Wall Street and expanded wildly. They made dubious loans without sufficient collateral and ran international operations where they paid out needlessly high rates of interest. The governmental regulators tried to keep a check on the borrowing culture by making it expensive to borrow in Icelandic Kroner. No matter. The banks by-passed this regulation by offering loans in foreign currency.

Eventually it got to the stage where some banks had turnovers that were 12 times Iceland's GDP.

When the global financial crisis occurred, the consequences for Iceland were sadly predictable. The banks failed. The government had to guarantee their deposits so that Icelanders did not lose faith in their currency. But the Kroner collapsed anyway.

Then Britain and Holland announced that they would pay back those of their citizens who had put their money in Icelandic banks. When Iceland went to the IMF for help, the Brits and Dutch asked the Icelandic government to pay back the money they had handed out to their citizens. The Icelanders had no choice but to agree or to risk losing the IMF package – with the consequence that the country is now saddled with a massive debt.

Meanwhile those Icelanders who had taken foreign currency loans found that while they were earning in severely devalued Kroner, their borrowings were dollar or Euro denominated. Therefore the real cost of their debts (and their interest payments) had shot up.

Iceland is now struggling to find a way out of this crisis (as a matter of interest nearly everyone of consequence I met in Iceland congratulated India for not having listened to the international banking whiz kids and thus having escaped the global collapse).

But it should not be too difficult to find a solution. The population is tiny. Iceland's fisheries sector is still going strong. It got half a million tourists last year (more than its total population). And it has the world's cheapest energy.

The first thing you notice about the people of Iceland is how informal they are. Everybody uses first names. There is very little sense of hierarchy. In many ways, Iceland is a truly egalitarian society.

But nothing had prepared me for the informality of the President's house. Olafur Grimsson, who had been President for over a decade, lives in a nice bungalow with no security whatsoever. There is not even a proper ring fence around the property. Anybody can walk up to the front door and ring his doorbell. It is even possible that the President will open the door himself.

When I went for dinner, I was startled to find that he did not even have much in the way of staff. A lady opened the door, served the food, etc. and presumably there was a cook who made all the delicious food we ate. But that was it.

The President and his hyper-elegant wife Dorrit are great India lovers. He came often to Delhi when Rajiv Gandhi was Prime Minister and had launched an initiative for nuclear disarmament. Since then, he had been a frequent visitor, has many friends in India (of whom Murli Deora is possibly the closest – they were both office-bearers of Parliamentarians for Global Action) and is a long-time admirer of the Gandhis.

When the Congress was in Opposition and Sonia Gandhi and Manmohan Singh visited Iceland, he accorded them full protocol over the objections of his Foreign Ministry which pointed out that Opposition leaders did not usually get banquets hosted in their honour.

I asked him about the lack of security. Did he ever feel concerned or feel insecure? By way of reply, he walked me to the lawn in front of his house and wandered around in the open. It would not be a problem to get some security, he said.

After all, how much would it cost to post a policeman at the door? But he regarded the complete absence of any security as a statement about Iceland's openness. He meant to demonstrate that Iceland was a country with few hierarchies, no needless formality and complete accessibility.

The Icelanders have a remarkably open attitude to sexual preferences.

Unlike many Scandinavian countries, they ban pornography (though you can order satellite porn channels) and do not encourage displays of nudity. But they are largely non-judgemental about people's private lives.

The current Prime Minister is a woman who recently married her female partner. Though this made headlines all over the world, the Icelanders seemed largely unperturbed. Her sexual preferences have never been an issue and attract virtually no comment.

The day before I got there, the annual Gay and Lesbian Parade went through the streets of the capital. In some countries (the US and India, for instance) such parades are symbols of defiance, a means of asserting a gay identity. In Iceland – judging by what I was told – the lack of any visible hostility towards gay people makes the parade a more good-natured affair. This year, the mayor of Reykjavik (about whom more later) was in one of the lead floats, dressed as a woman and waved happily to the assembled crowds.

It is hard to think of another country where the mayor of a national capital city would be willing to lead a gay parade in drag.

The Mayor, Jon Gnarr, is something of a global phenomenon himself. He is a well-known stand-up comedian and comic actor who fought the election as head of a new independent party against candidates from the two major coalitions.

His candidacy made news because he was seen as a joke candidate.

Certainly, many of his campaign commitments seemed funny. He wanted all politicians to sign a pledge stating that they regarded the Wire as the greatest TV show of all time. He wanted to put a polar bear in the city zoo, etc.

Against the odds, his party won the city election (just slightly short of an overall majority) and the joke candidate was declared the Mayor.

I was not sure what to expect when I went to see him. A comedian running a major city in India is unthinkable – imagine Raju Shrivastav as chief minister of Delhi or Raj Thackeray as chief minister of Maharashtra! But he was very different from the press caricatures. Yes he is a comedian and he can be both funny and witty.

But I found him to be a deeply thoughtful person with a clear political agenda. He had never seen his candidacy as a joke, he said. He had always hoped to win and halfway through the campaign when the pollsters and pundits were writing him off, he was convinced he would triumph.

He sees his party as representing a new generation of Icelanders who have ignored the political process so far and regards it as the job of politicians to not just practise politics but also to make people smile. Amen to that.

Like many other countries, Iceland offers tourists a chance to go whale-watching. Unlike most other countries, however, it also offers a chance to go whale-eating.

The Icelandic relationship with whales is a complex one. Whale meat is not an integral part of their diet. There is only one significant market for whale meat – the Japanese, who scupper all agreements to end whaling. So, there is no major economic benefit. But Iceland opposes restrictions on whaling because it believes that the anti-whaling lobby has got it wrong.

According to Icelanders, there is not much difference between killing a whale and eating it and killing a cow or a goat or a lamb and eating it. The only argument against it would be one of conservation and the whales around Iceland are in no danger of extinction or so the Icelanders believe.

The prevailing view in Iceland is that the objection to whaling in the North Atlantic consists of an emotional appeal: whales are such intelligent, wonderful creatures, how can you possibly kill them? Etc.

This, they say, is a cultural rather than an environmental objection.

Many of us are horrified by the thought of killing horses and eating them. But the French do it all the time. It seems harsh to slaughter a poor donkey but the Italians like eating its flesh. Why kill the peacock? But it has been a table bird in Europe for centuries.

Consequently, the whaling issue in Iceland is more patriotic (who are they to stop us from whaling?) than practical. (It would make very little difference to Iceland's economy or to its food habits if the country gave up whaling.) At present, whale is served as a sort of odd-bod delicacy for tourists. I tried whale carpaccio, seared whale and whale sashimi. It was an interesting flavour, a sort of cross between tuna and beef but I don't think I will miss it if whaling is banned worldwide.

If you haven't been to Iceland – and I am guessing that most of you have not – then I suggest you consider it for your next vacation. It is cheaper than most European destinations and easy to get to if you take a Helsinki connection on Finnair.

Otherwise you can combine it with a trip to London. It is certainly cheaper than France, Italy or Germany. It is a place that has a beauty of its own. And a relaxed, informal charm. I know I will be back (probably in the winter to see the Northern Lights).