Saturated Fat Found Not Related to Heart Disease

Stuart Miles/freedigitalphotos.net

Stuart Miles/freedigitalphotos.net

A recent article from the Annals of Internal Medicine had found that saturated fat was not related to heart disease. That was after a BMJ article said roughly the same thing.

Almost all guidelines around the world still ask everyone to avoid saturated fat. Amazingly, even after all the recent data, the British Heart Foundation had no plans to alter the guidelines as yet.

This is a huge study looking at the relationship between both self-reported saturated fat and measured saturated fat, and risk of heart disease and stroke. No relationship was found.

A few other important observations of the study:

1. Omega-3 fatty acids (fat from fish) are good for you.

2. Trans-fatty acid (fat from margarine, biscuits and other baked products) are bad for you.

3. Fat from dairy products are good for you.

4. Arachidonic acid (omega-6 fatty acids from chicken, eggs and beef) are good for you.

The points about fish and trans-fat are probably not surprising to most of us. However, for too long we had been advising patients to avoid milk and egg. Those food are turning out to be really good for us!

What I usually advise my patients is to eat a Mediterranean diet, with lots of non-starchy vegetables, fish, nuts and olive oil. Milk and eggs are alright. Avoid sugar and refined white starch such as white bread and white rice.

But in view of the latest evidence, I would not say no to the chicken and the beef. Bon appetit!

Universal Screening of Gestational Diabetes Proposed

Pregnancy

Photo credit:  Stuart Miles/freedigitalphotos.net

The U.S. Preventive Services Task Force (USPSTF) has just recommended that all pregnant women be screened for gestational diabetes. For health care professionals, the document is here.

In pregnancy, the baby and the placenta induces a higher of sugar level in the mother, to ensure that the baby will have enough sugar for use and growth. Normally, the mother’s pancreas will work harder to overcome this by making more insulin. However, sometimes that fails and blood sugar starts to rise, causing gestational diabetes. The main problem of gestational diabetes is that the baby has too much sugar and so grows to too big a size, sometimes more than 4kg. This may make giving birth difficult.

Gestational Diabetes was last reported in Singapore to affect 13.8% of all pregnant mothers in 1988.

Fortunately, the Australian Carbohydrate Intolerance Study in Pregnant Women (ACHOIS) Trial cleared showed that proper treatment to normalize the blood sugar helps to prevent complications . For healthcare professionals, the paper is here.

Because effective treatment protects the mother and baby, all women in the US are now encouraged to have an oral glucose tolerance test (OGTT). In Singapore, women who are high risk are encouraged to have the OGTT. These risk factors are: obesity, family history of diabetes, previous gestational diabetes, and previous birth to a baby heavier than 4kg.

In pregnancy, diet and exercise is key to control the blood sugar. A lot of pregnant women can control their blood sugar with simple changes to their diet by decreasing refined carbohydrates such as white sugar, white rice, rice-based noodles (bee-hoon) and white bread.

However, in severe cases insulin will be needed. Oral medication are generally not advised for pregnant mothers.

To know more, here is a video shot by Leonny Atmadja from Our Channel.

The Hidden Danger of Taking Supplements

herbal pills

Photo credit:  cjansuebsri / freedigitalphotos.net

My patients often ask me whether they can take herbal supplements to help their liver or kidneys. I must say that I am increasingly becoming skeptical of the quality of the supplements. A group of Canadian researchers had recently found that many herbal supplements do not contain any of the plants that they are supposed to.

Worse still, in some circumstances, some people develop severe liver failure requiring transplant. There has been a spike in reports of liver failure caused by supplements. Some of the cases were caused by high-dose green tea extracts for weight loss, and others from undeclared steroids in the supplements.

In Singapore, the Health Science Authority had banned a few supplements that damaged livers: kava-kava from Germany/Switzerland, OxyElite Pro from America, and black cohosh supplements.

Adulterated pills from ‘traditional medicine’ herbs had been found to be adulterated with corticosteroids resulting in Cushing’s Syndrome: weight gain, decreased immunity and other side effects. Indeed similar ingredients had been found with Malay traditional treatment as well (Pili Ajaib).

I would therefore advise staying away from most of these supplements until the regulations are changed to proactively monitor them.

8 Causes of Dry Skin & Solutions

Hands

Photo credit:  photostock/freedigitalphotos.net

Amazingly, medical journals only look at skin diseases, but have always overlooked the humble dry skin. It is however an extremely common problem that patients have. I was so happy when I found this article written by Dr Anneke Andriessen, a Consultant at UMC, St Radboud Nijmegen, Netherlands at the British Journal of Nursing, published in January 2013. That is an extremely comprehensive article, unfortunately not for public assess. So here are the causes:

1. Dry weather.

2. Central heating and air-conditioning.

3. Tight clothing.

4. Detergents, deodorant, soaps (especially anti-bacterial ones) that strip away the lipids and water from the skin.

5. Sun exposure.

6. Aging.

7. Zinc, essential fatty acid and vitamin D deficiency.

8. Diseases such as hypothyroidism (low thyroid levels), kidney failure, diabetes, HIV, skin diseases and nerve problems that decrease sweating.

Here are the solutions:

1. Consider an air humidifier indoor.

2. Use gentle washers such as those that are suitable for babies.

3. Use moisturizers generously.

4. Take a healthy and balanced diet. Zinc is available in many food. Essential fatty acids are the omega-3 and omega-6 that are rich in fish, nuts and oil olive, amongst others. A study done last year found that low vitamin D levels is associated with dry skin, and using a moisturizer enriched with vitamin D improves the situation. Milk and salmon are rich sources of vitamin D, and we can also make our own under sunlight. However, lack of vitamin D is common, 90% in winter in Switzerland (expected), but is actually worse in Singapore, a country in the equator. Singaporeans mostly work indoor and avoid the hot sun whenever possible.

Flu Vaccines Proven to Prevent the flu, especially serious ones

Child receiving Vaccine

 

Image courtesy of  David Castillo Dominici / FreeDigitalPhotos.net

The influenza vaccine has been shown in a major study involving many countries to prevent 59% of influenza infections, and 74% of serious ones.

This was published in the New England Journal of Medicine, involving 5220 children in 15 medical centers across the world. Notably it was a randomized-controlled trial, with half the children getting a sham injection, and the others the real thing.

The flu jab also decreased fever, doctor visits, school absence, and parent absence from work. There were also no difference in the serious side effects in both groups.

Vaccines work by tricking our immune system to form immunity to them. The vaccines contain the same coating as the real virus, but without sickness-causing ability. So they are like decoys. It has helped eradicate smallpox, and much decreased polio in large parts of the world. The flu virus, however, changes its coat every season, thus requiring yearly vaccination against the new strains.

New York City has now decreed mandatory flu vaccination for its preschool and day care centers. This should greatly reduce the sickness caused by the flu virus.

The Latest ACC/AHA Cholesterol Guideline: A sea change

Cholesterol check

Photo Credit:  Stuart Miles/freedigitalphotos.net

The American College of Cardiology/American Heart Association published their latest cholesterol management guideline last month. It is a complete change of the prior American guidelines that aim at a particular cholesterol target.

First of all, it recommends treatment for the 4 groups of patients:

1. All who already have heart disease, stroke or peripheral blood vessel disease (“cardiovascular diseases”)

2. Everyone with diabetes between 40-75 years of age

3. Those with an LDL (bad) cholesterol of 190 mg/dl (5.0 mmol/l) or more

4. Those with a calculated 10-year risk of cardiovascular disease of 7.5% or more.

Secondly, they suggest using only statins, and no other cholesterol-lowering medication.

Thirdly, they recommend stopping the routine monitoring of cholesterol levels after treatment, because of the lack of evidence.

Lastly, they place far less emphasis on additional screening tests such as hsCRP, a mark of inflammation in the body and cardiovascular risk

Since then Dr Nancy Cook and Dr Paul Ridker had published an article in the New York Times that call into question the calculator used, unusally before their critique paper in the journal Lancet has been published. Cook and Ridker pointed out that the calculator overestimates the cardiovascular risk in their own data set of patient population. Dr David Goff, co-chair of the guideline committee, explained that the population set used by Cook and Ridker are more recent and those patients have reduced risk probably because they are volunteers, and might have already taken statins and so their risk became lower. Interestingly, Goff was also puzzled by Ridker’s lack of comment in 2012 when the guidelines were sent to Ridker, and revealed that Ridker’s suggestion to use hsCRP in the risk calculation was rejected. Ridker receives royalties as co-holder of patent on hsCRP, which is a blood test used for risk-stratification for cardiovascular risk.

Hmm. I had not seen a guideline critique being so personal before. Previously, lead authors exchange disagreements in the journals, in an usually courteous manner.

The American Association of Clinical Endocrinologists had just rejected the guideline. They disagree with removing the cholesterol targets, the out-dated risk calculator, and the omission of medication other than statins in lowering cardiovascular risk.

Do we doctors agree on anything now about cholesterol? Well there are:

1. High cholesterol is associated with blood vessel blockage (atherosclerosis), heart attacks and stroke.

2. Lowering cholesterol generally lowers that risk. Most studies were done on statins, but other studies on other medication, such as niacin,  fibrates and Vytorin, had also shown benefits before.

3. The relative benefits are rather constant. So patients with high risk benefit more. For example, if a patient has a 50% risk of having a heart attack in 10 years, lowering the cholesterol can reduce the risk to 25-30%. So 1 in 4 patients are saved. But for a low risk person with 1% risk of having a heart attack in 10 years, lowering the cholesterol reduce the risk by 0.4-0.5%. So 200 people needs to be treated before one is saved.

4. All cholesterol-lowering medication has a small risk of side effects. Muscle ache, increased liver enzymes, and diabetes are the commonest.

Ultimately, it is best that you discuss with your doctor whether you need treatment. You should ask about the benefits and the risks of taking the drug.

Avoid Glibenclamide for patients who are elderly or have renal failure

Finger prick meter

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Glibenclamdie (glyburide in America) is a common and useful drug for type 2 diabetes. It is effective and the blood sugar lowering effect long-lasting. However, the strength is also a weakness: it can sometimes be so powerful that the patient can suffer prolonged hypoglycemia (low blood sugar level).

The Health Sciences Authority of Singapore had looked at the data and found that in Singapore, patients who are above 60 or those with kidney failure have a much increased risk of severe and protracted hypoglycemia. They have now advised all doctors to avoid using glibenclamide in those patients.

There are many other alternative drugs in the same class such as gliclazide and they are also generics, available at a low price at our clinics.

If you are taking glibenclamide and had recently turned 60 or have renal failure, please do not stop your medicine immediately, but talk to your doctor about it.