Monthly Archives: December 2013

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.

Advertisements

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

Photo credit:  Gualberto107/freedigitalphotos.net

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.

Asian Students are tops in Academic Assessment Again!

Asian girl reading

Photo Credit: By Sira Anamwong from freedigitalphotos.net

The OECD has just published the Programme for International Student Assessment (PISA) report. Who are the top 7?

1. China-Shanghai

2. Singapore

3. China-Hong Kong

4. Taipei

5. Korea

6. China-Macao

7. Japan

What do they have in common? A Confucian culture. Even in America, Asian American students do well academically.

Foreigners may not realize how important studying is in the Asian family. Ever since Confucius taught about the importance of studying and opened a sort of a school, Confucian countries have put lots of importance on studying. The pressure is immense. In Singapore it is not uncommon for a parent to take a year off work to help their child to take the primary school leaving exam.The highest scoring candidates in exams become mandarins. Some popular Chinese saying shows how important it is:

1. All trades are lowly except for studying

2. Study hard and you will find great wealth and a beautiful wife in the books

Ahem. Certainly very chauvinistic. But this is ancient China after all.

There is of course a huge downside: children who have poor grades think they are failures. A lot of children, even those who are successful in the system, are burnt out by the time they enter university and end up hating lifelong learning.

Doing well in life requires more than just grades, and it may shock those top scorers when they start working and learn that grit, determination, EQ, connections and pure luck are far more important. I do try to teach my children those things as well.

3 Scientifically Proven Way to Prevent Diabetes: sleep, move, eat

Tsunami

Photocredit: Danilo Rizzuti/freedigitalphotos.net

My article on the Coming Tsunami of Diabetes: how to dodge it has just been published.

Diabetes is an extremely serious problem in Singapore. 1 in 9 adults have it and by 2030, 1 in 5 adults are going to get it.

I personally love the first scientifically proven way: sleeping. Not sleeping enough increases our stress hormones (adrenalin and cortisol) which raises our sugar, and increases our hunger hormone so we want to eat more.

The second is what all doctors say: exercise. I had previously written about the power of exercise.

The third is to eat healthy. Avoid artificially processed starch such as white bread,  white rice and juices. Whole grains should be taken instead. Yes even Michelle Obama supported it.

Remember: sleep, move, eat.