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OBESITY 

Person who weight 10 kgs. or more above their ideal body weight have an increased risk of both high blood pressure and coronary artery disease occurring together. If obesity occurs in conjunction with an elevated blood sugar, or a high serum cholesterol, it also significantly increase the risk of developing coronary heart disease. Thus, obesity itself may not be an independent risk factor, but it is importantly related to the development of coronary heart disease. Weight reduction often results in a decrease in blood pressure, improved sugar tolerance, and lower serum lipid levels, reducing several of these known coronary risk factors. In patients who have experienced a heart attack, or who have coronary artery disease with chest pain, obesity has detrimental effects by placing an additional strain on the heart. Obesity can also increase symptoms in patients with valvular heart disease by increasing the workload of the heart.

DIETS

    LOW-CHOLESTEROL, LOW-FAT DIETS. The current epidemic of atherosclerosis has forced attention upon the nature of our diet. There is now considerable evidence that excessive ingestion of fatty foods can increase the blood fats or lipids and that the atherogenic diet consumed by millions of Americans may be responsible in part for the finding that about 30 percent of American males over age thirty and under age forty-five have cholesterol levels in excess of 260 milligrams per 100 milliliters of plasma. Although factors other than diet also are important, the fact remains that the risk of developing coronary heart disease is about 3 times as great in men who have cholesterol levels above 260 milligrams per 100 milliliters as in men with levels under 180 miligrams per 100 milliliters. It is egually clear that weight reduction and diet can lower blood lipid levels.

What is this atherogenic diet ? It consists mainly of eating hundreds of milligrams of cholesterol contained in meats, certain shellfish, and dairy products, and large quantities of fats, primarily of the saturated type rather than the polyunsaturated variety. It is now well-established that in many individuals diets high in cholesterol and saturated fats can lead to elevated blood cholesterol levels. Diets high in carbohydrates can lead to increased blood triglyceride levels by stimulating triglyceride production in the body). Beef, lamb, and pork are particularly high in saturated fats and cholesterol; and eggs, shellfish, and organ meats contribute greatly to a high intake of cholesterol. The increasing use of packaged foods, such as frankfurters and luncheon meats, has added to the high intake of saturated- fats, and saturated- fat shortenings often are used in packaged bakery goods. Concentrated sweets and other carbohydrates, including alcohol, contribute to elevations of the triglycerides.

The question of whether or not diminishing the blood lipids will prevent the development of atherosclerosis in young individuals, or reverse the disease when it is already established, is clearly an important one. The answer is not yet available, but the circumstantial evidence that diet is important is sufficiently compelling to lead us to believe that a special diet should be used by individuals with elevated lipids, whether or not they have recognized coronary heart disease.

Recent research indicates that different patterns of lipid elevations in the bloodstream may require different types of treatment. Thus, a specific diet useful for one type of hyperlipidemia may be inappropriate for another.

OTHER FAD DIETS. Many other diets have been proposed to correct supposed endocrine disorders, or to induce a desirable spiritual state, as well as to cause weight reduction.

The hypoglycemic diet is a low-carbohydrate, high-protein diet, frequently without calorie restriction, which is recommended bu its advocates for relieving a variety of nonspecific symptoms which they attribute to be low blood sugar. In the great majority of instances, however, the blood-sugar level is not low, and such symptoms are not caused by hypoglycemia. The most common cause of a temporary low blood sugar is so-called reactive hypoglycemia, which occurs after a meal; this can occur in mild diabetics, for example. In most cases this does not require treatment, although occasionally, when it is troublesome, frequent feedings and a relatively low-carbohydrate, high-protein diet may be used. In some instances injections of adrenal cortical extract also are given to increase the blood sugar, but they are of no value for this purpose.

One diet popular for nearly twenty years consists of a 500-calorie diet plus injections of the hormone, human chorionic gonadotropin. However, claims for the use of HCG in the treatment of obesity have not been substantiated, and the diet does not provide an adequate range and quantity of nutrients.

A vegetarian diet provides adequate nutrition as long as it contains an adequate quantity of protein and essential amino acids. These can be obtained by adding skim milk, cottage cheese, and several eggs per week to the basic diet.

“SPECIAL ” WEIGHT-REDUCING DIETS. In recent years a large number of best-selling books have appeared on how to lose weight in the hurry. Unfortunately, many of these diets present special problems, and do not contain an adequate amount of all required nutrients.

One type of popular weight-reducing diet consists of severely restricting carbohydrate intake, while obtaining most of the daily calories from foods high in protein and fat. On such a diet, person burn their own fat as a source of calories for energy, and weight loss is produced. However, this process produces acidic ketone bodies which, although they may depress the apetite, can also cause other problems, such as dehydration, elevated blood uric acid, or the development of kidney stones. Moreover, such a high-fat diet can serve to increase blood cholesterol levels, particularly in individuals in whom these levels tend to be high on a normal diet. Finally, certain nutrients such as calcium and iron are deficient in this diet. For these reasons, an individual who wishes to reduce his weight should consult his physician before beginning a diet that requires severe carbohydrate restriction.

Other popular reducing diets with serious nutritional deficiencies include the high protein-high water diet, the gelatin diet, and the skim milk and bananas diet. These, and the low-carbohydrate diets mentioned above, are low in milk and bread and cereal foods, and do not promote sound eating habits.

LOW-SALT DIETS. Patients with a persistently elevated blood pressure and patients with congestive heart failure usually require a diet that is low in sodium. In patients with high blood pressure, a reduction in the sodium intake is frequently associated with a reduction in the blood pressure, and some of the drugs which are successful for treating hypertension increase the excretion of salt and water by the kidney. In patients with heart failure, the kidneys retain salt and water abnormally, leading to fluid accumulation in the lungs, in other organs such as the liver, and in the legs. In order to prevent this accumulation of fluid, it is necessary to limit the sodium intake. This is done by restricting the intake of foods rich in sodium, such as milk breads, and soup, and by limiting the amount of salt used for seasoning. Salt substitutes , which contain little or no sodium, may be used as condiments to make food palatable.

VITAMIN E. Although vitamin E deficiency in sheep, cattle, and rabbits may result in conspicuous abnormalities of the muscle, vitamin E deficiency in primates does not affect the heart even when other organs are involved. No heart disease in man has ever been clearly related to a vitamin E deficiency. The use of vitamin E in doses 10 to 50 times the daily requirement was recommended nearly thirty years ago for the treatment of a variety of heart disorders, including angina pectoris, heart attack, and heart failure, but no convincing evidence of its effectiveness has been forthcoming in the intervening years.

EXERCISE

A number of studies have related the incidence and severity of coronary heart disease to differences in occupational activity. Men in sedentary occupations have been reported to have fatal heart attacks at a younger age than those whose occupations involved vigorous activity, and there is increasing evidence that regular physical activity may help prevent or delay the development of symptoms due to coronary artery disease. An occupational situation also could foster or diminish the development of coronary heart disease by altering a coronary risk factor, such as diet. However, comparative studies of population group with similar dietary intake appear to show a greater incidence of coronary artery disease and heart attack in sedentary than in physically active worker. In a prospective study of 667 middle-aged London men, clinical symptoms of coronary heart disease occurred more commonly among bus drivers than among the more-active conductors on double deck buses; in another study, symptoms were more common among postal clerks, telephone operators, and executives than among the mail-carrying postmen. Although it is possible that no difference exist in the incidence of coronary artery narrowing by atherosclerosis in such studies, the incidence of clinical symptoms due to coronary artery disease in physically active individuals appears to be less than that for more sedentary persons.

Progressive exercise training may be of considerable benefit in preventing or delaying the onset of symptomatic coronary artery disease in normal individuals, and in reducing the severity of symptoms and mortality in patients who have clinical evidence of coronary artery disease. The question as to whether daily physical exercise results in the formation of new coronary arteries in patients with coronary artery disease is unresolved. However, exercise training does reduce several of the risk factors which make an individual more phone to develop coronary artery disease, such as obesity and elevated blood lipids. Furthermore, the heart rate and blood pressure are reduced at any level of exercise in the well-trained individual, resulting in a decrease in the demands of heart muscle for oxygen at that degree of exertion. After a graded program of exercise training many patients with coronary heart disease show an improvement in angina pectoris, so that more exercise can be undertaken before chest pain develops.

Studies performed in Israel comparing the survival rate in patients with a prior heart attack who then underwent a program of progressive exercise rehabilitation, to that in similar patients who led a sedentary existence, showed a fivefold increase in mortality rate in the individuals who did not undergo daily physical exercise during a ten-year period of follow-up.

currently there is considerable enthusiasm for daily exercise, such as walking, jogging, or swimming, as a measure in the prevention of symptomatic coronary artery disease. However, it is important to emphasize that exercise is not free of danger, both to the musculoskeletal and the cardiovascular systems. This is especially true for middle-aged individuals who may have unsuspected coronary artery disease, particularly those with coronary risk factors, and who suddenly undertake vigorous exercise after years of minimal physical activity. such individuals should seek a physicians guidance before beginning a graded program of exercise training.

Exercise rehabilitation of patients with angina pectoris and a previous heart attack is being recommended by many physicians, In several cities, cardiac rehabilitation centers have been organised where patients with known coronary artery disease are monitored for electrocardiographic changes, alterations in blood pressure, rhythm disorders, and symptoms during programs of progressively increasing exercise. Individuals exercise training programs at home are prescribed for each patient based on information obtained during this period of observed exercise. In many of these centers the patient undergoes electrocardiographic monitoring during his daily exercise, and he is retested at given time intervals, any change in his exercise program being related to his improved work performance.

However, the majority of patients with symptomatic coronary artery disease who undertake a period of exercise rehabilitation attempt to improve their exercise tolerance gradually, while under a physicians care, but not under direct supervision during exercise. Unfortunately, self-motivated exercise training generally has been less successful than formal, supervised exercise programs. Patients are cautioned to avoid sudden strenuous activity and to perform graded physical activity to an extent slightly less than that which brings on symptoms of chest pain, fatigue, or shortness of breath. Physical activity which produces slow progressive increases in heart rate, blood pressure, and cardiac output is less likely to produce symptoms than exercise which rapidly increases those factors which determine the oxygen demand of the heart muscle, For example, walking, jogging, swimming, and bicycling are less likely to produce chest pain than handball, volleyball, and tennis. Isometric exercise, such as sustained hand grip or lifting a heavy object, is to be avoided  since this type of exertion is associated with a rapid increase in heart rate, blood pressure, and the oxygen demands of heart muscle.

CARDIAC ARREST (UNDER 1 YEAR )

Description : A life-threatening condition when the heart stops beating.

What you need to know : 

• The procedures for cardiopulmonary resuscitation (CPR) described below are not a substitute for CPR training CPR training is necessary to perform these procedures most effectively and safely.
• If choking is the cause of breathing difficulty, follow the procedures for Choking

When to get help : 

• If you are not alone, immediately have one person call your local emergency number while another person begins CPR.
• If you are alone, shout HELP If you are trained in CPR, administer CPR for about 1 minute, then call your local emergency number.
• If you are alone and trained in CPR, immediately call your local emergency number emergency personnel will tell you what to do.

Treatment : 

1. Rub your infant back or tap her shoulder to determine whether she is conscious.
2. If the infant does not respond, turn her on her back onto a hard surface. Turn your infant as a unit keeping her back in a straight line, firmly supporting her head and neck. Expose her chest.
3. Life your infant chin while tilting her head back to move her tongue away from her windpipe. If you suspect a spinal injury, pull your infant jaw forward without moving her head or neck. Do not let her mouth close.
4. Place your ear close to your infant mouth and watch for chest movement. For 5 seconds, look, listen, and feel for breathing.
5. If your infant is not breathing begin rescue breathing as follows : Maintain her head position and cover her mouth and nose tightly with your mouth. Give 2 slow, gentle breath, each lasting 1 to 1.5  seconds. Pause between the 2 breaths to take a deep breath.
6. If you do not see your infant chest rise, reposition her head and give 2 more breaths. If her chest still does not rise, her airway is obstructed.
7. If you do see your infant chest rise, place two finger on the inside of her upper arm, just above the elbow. Squeeze gently to feel her pulse for 5-10 seconds.
8. If your infant has a pulse, give 1 breath every 3 seconds. Check her pulse after every 20 breaths ( each minute ). After 1 minute, call your local emergency number. Resume giving breaths and checking the pulse.
9. If your infant has no pulse, begin chest compressions, as follows : Maintain her head position and place 2 fingers on the middle of her breastbone, just below her nipples. Within 3 seconds, quickly press your fingers down 1/3 to 1/2 inch the depth of her chest 5 times. Give the compressions in a smooth, rhythmic manner, keeping your fingers on her chest.
10. Give your infant 1 breath, followed by 5 chest compressions. Repeat this sequence 10 times. Recheck your infant pulse for 5-10 seconds.
11. Repeat steps 10 until your infant pulse resumes or help arrives. If your infant pulse resumes, go to step 8.

Caution

• Do not give chest compressions if there is a heartbeat; doing so may cause the heart to stop beating.
• If you suspect a spinal injury, do not move your infant head or neck to check for breathing

CARDIAC ARREST ( 1 TO 8 YEARS )

Description : A life-threatening condition when the heart stops due to breathing emergency or other situation.

What you need to know : 

• The procedures for cardiopulmonary resuscitation ( CPR ) described below are not substitute for CPR training. CPR training is necessary to perform these procedures most effectively and safely.
• If choking is the cause of breathing difficulty, follow the procedures for Choking,

When to get help : 

• If you are not alone, have one person call your local emergency number, while another person begins CPR.
• If you are alone, shout HELP If you are trained in CPR, administer CPR for about 1 minute, then call your local emergency number.
• If you are alone and not trained in CPR, immediately call your local emergency number emergency personnel will tell you what to do.

Treatment : 

1. Tap or shake your child gently and call his name to determine consciousness.
2. If your child does not respond, turn him on his back onto a hard surface. Turn your child as a unit, keeping his back in a straight line, firmly supporting his head and neck. Expose his chest.
3. Life your child chin while tilting his head back to move his tongue away from his windpipe. If you suspect a spinal injury, pull your child jaw forward without moving his head or neck. Do not let his mouth close.
4. Place your ear close to your child mouth and watch for chest movement. For 5 seconds, look, listen, and feel for breathing.
5. If your child is not breathing, begin rescue breathing, as follows : Maintain his head position, close his nostrils by pinching them with your thumb and index finger, and cover his mouth tightly with your mouth. Give 2 slow, full breaths. Pause between the 2 breaths to take a deep breath.
6. If you do not see your child chest rise, reposition his head and give 2 more breaths. If his chest still does not rise, his airway is obstructed.
7. If you do see your child chest rise, place 2 fingers on his Adam apple. Slide your fingers into the groove between the Adam apple and the muscle on the side of his neck to feel his pulse for 5-10 seconds.
8. If your child has a pulse, give 1 breath every 4 seconds. Check his pulse after every 15 breaths. After 1 minute, call your local emergency number. Resume giving breaths and checking the pulse.
9.  If your child has no pulse, begin chest copressions as follows : Maintain his head position and place the heel of your hand 2 finger widths above the lowest notch of his breastbone. Lean your shoulder over your hand and within 4 seconds, quickly press down 1/3 to 1/2 inch the depth of his chest 5 times. Give the compressions in a smooth, rhythmic manner, keeping your hand on his chest.
10. Give your child 1 breath, followed by 5 chest compressions. Repeat this sequence 10 times. Recheck his pulse for 5-10 seconds.
11. Repeat Step 10 until your child pulse resumes or help arrives. If pulse resumes, go to step 8.

Caution : 

• Do not give chest compressions if there is a heartbeat; doing so many cause the heart to stop beating.
• If you suspect a spinal injury, do not move your child head or neck to check for breathing.

CARDIAC ARREST ( OVER 8 YEARS )

Description : A life-threatening condition when the heart stops due to breathing emergency or other situation.

What you need to know : 

• The procedures for cardiopulmonary resuscitation (CPR) described below are not a substitute for CPR training. CPR training is necessary to perform these procedures most effectively and safely.
• If choking is the cause of breathing difficulty, follow procedures for choking.

When to get help : 

• If you are not alone, have one person call your local emergency number while another person begins CPR.
•  If you are alone, shout HELP If you are trained in CPR, administer CPR for about 1 minute, then call your local emergency number.
• If you are alone and not trained in CPR, immediately call your local emergency number personnel will tell you what to do.

Treatment :

1. Tap or shake your child gently, and call her name to determine consciousness.
2. If your child does not respond, turn her on her back onto a hard surface. Turn your child as a unit, keeping her back in a straight line, firmly supporting her head and neck. Expose her chest.
3. Life your child chin while tilting her head back to move her tongue away from her windpipe. If you suspect a spinal injury, pull your child jaw forward without moving her head or neck. Do not let her mouth close.
4. Place your ear close to your child mouth and watch for chest movement. For 5 seconds, look, listen, and feel for breathing.
5. If your child is not breathing, begin rescue breathing, as follows : Maintain her head position, close her nostrils by pinching them with your thumb and index finger, and cover her mouth tightly with your mouth. Give 2 slow, full breaths. Pause between the 2 breaths to take a deep breath.
6. If you do not see your child chest rise, reposition her head and give 2 more breaths. If her chest still does not rise, her airway is obstructed.
7. If you do see your child chest rise, place 2 fingers on her Adam apple. Slide your fingers into the groove between the Adam apple and the muscle on the side of her neck to feel her pulse for 5-10 seconds.
8. If your child has a pulse, give 1 breath every 5 seconds. Check her pulse after every 12 breaths. After 1 minute, call your local emergency number. Resume the breaths and pulse checks.
9. If your child has no pulse, begin chest compressions as follows : Maintain her head position and place the heel of your hand 2 finger-widths above the lowest notch of her breastbone. Place the heel of your other hand directly over the heel of the first hand. Interlock your fingers; do not let them touch your child chest. Lean your shoulder over your hands, and within 10 seconds quickly press down 1/3 to 1/2 inch the depth of her chest 15 times. Give the compressions in a smooth, rhythmic manner, keeping your hands on her chest.
10. Give your child 2 breaths, followed by 15 chest compressions. Repeat this sequence 4 times. Recheck her pulse for 5-10 seconds.
11. Repeat Step 10 units your child pulse resumes or help arrives. If her pulse resumes, go to Step 8.

Caution : 

• Do not give chest compressions if there is a heartbeat; doing so may cause the heart to stop beating.
• If you suspect a spinal injury, do not move your child head or neck to check for breathing.

Breakthroughs that May Save Your Life

Except for the time he had his toncils out as a kid, Howard Kubitz, 63, had never been hospitalised. So when he suffered a stroke on August 10, 1998, the paralysis that seized the right side of his body was matched only by the fear that life,as he knew it, was over. He was already picturing himself confined to a wheelchair or spending the rest of his days in a nursing home.

The stakes were very high, says Dr. Steven Goldstein, the neurologist who treated Kubitz in the emergency room at the University of Pittsburgh Medical Centre. If he had remained in that state, he would have been severely disabled. To many people, that a fate worse than death.

Fortunately for Kubitz, his doctors examined him with a state-of-the-art diagnostic tool that indicated the severity of his stroke and showed precisely where the flow of blood to his brain was interrupted. With that information, they determined it was safe to go ahead and give him tPA, the saME clot-busting drug used to stop heart attacks. Less than two hours later, Kubitz was almost back to normal.

STROKE

Super Scan 

To gauge the severity of Kubitz condition, his doctors peered into his brain with a xenon CT scan, a technique that dramatically improves physicians ability to see the effects of stroke a third leading cause of death and a major cause of disability. Xenon computed tomography not only takes a picture of the brain, as does a traditional CT  scan, but also allows doctors to measure exactly how much blood is flowing to different parts of the brain.

How it works

A patient inhales harmless nonradioactive xenon gas, which is tracked by a scanner as it enters the brain. It takes only minutes for the gas to saturate the brain tissue, showing the stroke exact location and how much blood is reaching key areas.

The clot-buster tPA, if given within three hours of a brain attack can work wonders in people whose stroke was caused by blood clots. But one major side-effect of tPA is brain haemorrhage, which can be fatal. With the precise information revealed in a xenon CT scan, doctors can more accurately determine which patients are at increased risk of haemorrhage, and who can sefety be given the drug.

Is it available 

About 30 major medical centres in the United States have xenon CT technology. Dr. Howard Yonas, the University of Pittsburgh neurosurgeon who was instrumental in developing the technique, estimates that within a few years, one in four American hospitals may be using the xenon CT scan in their emergency rooms.

However, xenon CT scan technology is still not available in India.

Most of the time, the heart functions very well – particularly in view of the amount of work it does. We are, however, demanding more and more from our heart and our blood vessels not perhaps directly but indirectly, through the amount we eat, drink and smoke, the pace of life and the risks to which we are exposed in the environment. It is hardly surprising, then, that things sometimes go wrong. 

The chart below is intended as a quick guide to the problems that can occur. The term environment at the top of the chart means both the external environment and the internal one that exists within the body, mind and spirit

Although we cannot always be sure precisely what causes each of the conditions listed, it is generally accepted that there is an interaction between hereditary and environmental factors.

POSSIBLE DISORDERS

What follow is a description of each of the disorders mentioned on the flowchart. Their order follows the chart and does not bear any specific relationship to the incidence of the problem. Some of the rarer conditions are not described in any more detail in the rest of the book, but the more common problems, such as artherosclerosis, angina, high blood pressure and heart attacks are dealt with time and again in this book.

CONGENITAL HEART DISEASE

This is caused by heart malformation that are present from birth. Some of the deformities are so minor that they can be missed unless looked for. Others, such as the transposition of the great vessels, the aorta and the pulmonary arteries, or the presence of only one ventricle, are more obvious. In most crippling deformities, the deoxygenated, or used blood bypasses the lungs and continues to circulate around the body; this causes the characteristic colour of so-called blue babies.

Causes are not always clear, but certain factors during pregnancy, such as German measles, some drugs and even vitamin deficiency, have all been implicated. Some heart disorders run in families. Down syndrome babies are more likely to have malformed hearts.

Those babies with congenital heart disease who do not have a blueness to their skin can be recognised by breathlessness on feeding because they find it difficult to suck; as such children grow older, they suffer from breathlessness on exertion. Most heart defects can be corrected with surgery; fortunately, serious defects are uncommon.

Congenital Defects

Illustrated below are two of the more common congenital defects. Ventricular septal defect, or hole in the heart, is a hole in the wall, or septum, between the two lower chambers of the heart. In about 25 per cent of these cases the hole will close; if the hole is large, surgery may be required.

The second defect occur when the fetal circulatory system does not make the changes necessary for the baby to breathe on its own immediately after birth. Before birth, the fetus obtains oxygen from its mother via the placenta. To do this, the fetal heart has two bypasses, one of which, the ductus arteriosus, channels deoxygenated blood from the heart to the placenta to be oxygenated in the mother lungs, but occasionally, this does not happen. If detected early, it can be corrected with drugs; otherwise surgery may be necessary.

RHEUMATIC HEART DISEASE

Rheumatic fever is not in itself a heart disease. About 60 per cent of all cases of rheumatic fever do, however, affect the heart. It tends to run in families and chiefly affects children between five and 15 years of age.

The fever is triggered by a throat infection caused by the streptococcal bacteria. The majority of sore throats nowadays are viral, and not all streptococcal infections lead to rheumatic fever, but if your child has a sore throat or feverish illness two to three weeks after a previous sore throat, consult your doctor.

In addition to fever, joint pains and in some cases, a sore throat, rheumatic fever can cause inflammation of various areas of the heart.

Once you have had rheumatic fever, you are prone to further attacks and, if it is not treated early, it can eventually lead to scarring of one or more of the heart valves in later life. In serious cases, surgery can be carried out to repair or replace damaged valves.

Damage caused by Rheumatic Fever

The extent of the damage to the heart caused by rheumatic fever is generally proportional to the number of attacks a person has.

Rheumatic fever can cause inflammation of the heart lining , or, rarely, of the heart covering and the heart muscle itself.

Scarring of the valves

Damage to the valves caused by rheumatic fever can result in stenosis, or narrowing, of the valves, preventing them from opening properly or incompetence, when the valve does not close properly, thus allowing back flow of blood.

HIGH BLOOD PRESSURE

If the force with which the blood flows in the circulation is much greater than normal, it is called high blood pressure, also known as hypertension. This puts the entire circulatory system, including the heart and blood vessels, under considerable strain. If high blood pressure persists for a number of years, it can lead to several complications.

Atheroma in the arteries

Fatty desposits called atheroma build up along the artery walls, reducing their diameter and elesticity; it is sometimes known as hardening of the arteries.

ATHEROSCLEROSIS 

This is the process of silting up of arteries by deposits of fatty material called atheroma. The exact cause is not known but various risk factors increase the chances of atherosclerosis. The chief ones are a family history of this condition, age, cigarette smoking, a fatty diet, high blood pressure, obesity, lack of exercise and stress.

Atherosclerosis can affect any artery in the body. The possible consequences are angina, heart attack, stroke, kidney damage or peripheral vessel disease. Atherosclerosis can largely be prevented.

CARDIAC NEUROSIS

Not all chest pains are due to angina, or a heart attack there can be psychosomatic causes. Anxiety causes tension and, if it is not expressed in words or actions, the pentup emotions express themselves as symptoms relating to any system in the body. When the heart is affected, it is known as neurocirculatory asthenia or psychosomatic heart disease.

The heart has long been regarded as the seat of emotion, so it is hardly surprising that anxiety and tension often have cardiovascular manifestations. The most common symptoms of this are palpitations, breathlessness and sharp stabbing pains in the region of the heart, associated with weakness, fatigue, shakiness or sweating. The symptoms can range from minor discomfort to complete invalidism.

The case history below is a good example of cardiac neurosis, although it should be remembered that not every case of non-specific chest pain is as extreme as this. Sometimes, a person is not even aware of any out-of-the ordinary stress. It is at a subconscious level but it affects his breathing and the way he feels and behaves. People with cardiac neurosis often breathe shallowly, using only the upper part of the chest.

A doctor is able to distinguish between angina and the pains of psychosomatic heart disease. In most cases, reassurance and simple psychotherapy are adequate. Exercise, learning to breathe properly and relaxation will all help to clear up this condition.

Case History

Barry was 33 years old when he first complained of stabbing chest pains and palpitations. The symptoms usually started in the evening when he was resting. He had clammy hands and perspired profusely in his armpits. He was fairly fit and could climb several flights of stairs without experiencing any symptoms. A full medical examination revealed no abnormality and Doctors were able to reassure Barry about the health of his heart.

Further probing revealed that he had a vasectomy two years ago at a private clinic a fact that he had kept secret from his wife, who was now pregnant. He continued to have minor symptoms, on and off, until his wife had the baby, after which he decided to confront her. They parted, and his symptoms did not return.

STROKE

This is an interruption in the supply of blood to part of the brain which can lead to impaired function in the areas of the body controlled by that part of the brain. It can happen if a blood vessel in the brain bursts, or is blocked by a blood clot. There are two types of cerebral infarction : thrombosis, when blood coagulates and blocks a cerebral artery, and embolism, when a blood clot elsewhere in the body is released into the blood stream and wedges in a cerebral artery.

Transient ischaemic attacks are a form of mini stroke that result in slight sensory disturbance and muscle weakness lasting only a few minutes, and the patient always recovers completely within 24 hours.

Severe strokes may lead to unconsciousness, partial paralysis of one side of the body, speech problems, loss of memory, visual disturbances, and behavioural changes. Most patients will recover at least partially with a careful rehabilitation programme.

Cerebral infraction

This is a blockage by a blood clot, of one of the arteries supplying blood to the brain. It results in the part of the brain supplied by that blood vessel being starved of oxygen.

CONGESTIVE HEART FAILURE

Despite its name, heart failure is not an immediately life threatening condition. It simply means that the heart cannot pump with enough force to continue efficient circulation. This may occur, for example, when the heart has to continue pumping blood into a hypertensive circulatory system. The heart eventually gets exhausted and blood does not flow through. This can result in a built-up of blood in the lungs, which in turn allows the fluid part of the blood, the plasma, to leak in the lungs, causing congested lungs and shortness of breath. It also cause fluid retention, usually resulting in swollen ankles. The heart muscle can also be weakened by infection, some degenerative charges or by a heart attack.

ANEURYSM

An aneurysm is a localised dilation, or bulging, in an artery. Aneurysms can occur anywhere, but they are most common and most troublesome when they are in a cerebral artery or in the aorta. Atherosclerosis and high blood pressure may both cause a portion of the muscular layer of the artery wall to degenerate, allowing the lining to balloon out at the point of weakness. Other causes of aneurysm are congenital weakness in the artery wall and, rarely, arterial inflammation.

The best way to prevent an aneurysm is to guard against atherosclerosis and to keep your blood pressure under control. If, however, you develop a sensation of pressure or an inexplicable lump anywhere on the body, but especially on the abdomen, and particularly if it throbs, see your doctor as soon as possible as this could indicate an aneurysm. You will probably have a simple X-ray and an ultrasound scan. Then, if necessary, the doctor will arrange for a special X-ray called an arteriograph to be taken, to help identify the exact location and extent of the problem.

If an aneurysm has already occurred, it cannot be reversed but it can sometimes be prevented from getting any bigger by a reduction in blood pressure. It can also sometimes be surgically removed,  and an artificial graft inserted.

Aneurysms

These may develop where there is a weakness in the artery wall. In one type the pressure of the circulating blood causes that part of the wall to bulge. Another type of aneurysm causes the inner and outer layers of an artery to split apart and blood to collect in between, causing the same balloon effect. Sometimes, a second split develops, which allows the blood clot back into the circulatory system.

SUBARACHNOID HAEMORRHAGE

Small aneurysms in the brain are called berry aneurysms. They are generally symptomless, but sometimes, an aneurysm causes symptoms, such as numbness or headaches, in which case diagnosis can be made by a special brain X-ray called a CT Scan. Occasionally, one of the berry aneurysms bursts;this is especially likely if blood pressure is high. A sudden severe headache is felt at the back of the head and the person may become unconscious. This is called subarachnoid haemorrhage, because the blood collects in the space beneath the arachnoid membrane covering the brain haemorrhage in younger people. A berry aneurysm can be surgically removed. Control of high blood pressure reduces the chances of one bursting.

Antioxidant polyphenols present in both black and green tea reduce the risks of heart disease

In today world, reduce with nervous tension, tea acts as a wonder drink, a panacea for many disease. It is a natural food from the Camellia Sinensis plant. Legend has it that tea was discovered in 2737 BC Emperor Sheng Nung, when tea leaves fell into a pot of boiling water. Since then, tea has had a significant role in human history.

Tea can basically be divided into two varieties : black and green. The majority of the tea leaves harvested is processed into black tea, which has a unique rich taste. In case of green tea on the other hand, the leaves are quickly steamed or heated to retain their green colour.

Generally, black tea is consumed in India, while green tea is popular in China and Japan and some parts of the western World. Both black and green tea contain antioxidant polyhenols and therefore provide excellant means of lowering the risks of heart disease and cancer. Researchers have found that both types of tea worked through similar mechanisms. While both resist the growth and development of various cancers, they also increase apoptosis, a process whereby tumour cells are eliminated. They also suppress unfavourable bacteria, while favouring beneficial bacteria that help improve metabolism.

Although the human body is equipped with oxidative-defence mechanisms, with age, they are over-powered by the reactive species. The oxidative-defence mechanism, reduces with age, with reduced absorption of antioxidants from food or genetically programmed reduction of the synthesis of antioxidants in cells. They arrest the harm caused in the body due to oxidation, but do not eliminate it completely. This damage caused to body tissues accumulates with age, with the increase in the production of the reactive species, and this contributes to the growth of several disease associated with ageing, that grip our bodies permanently, like Alzheimer Cancer, Parkinson Disease and Rheumatoid Arthritis to mention a few. The intake of food rich in antioxidant can prevent oxidation in the body, leading to good heath and youthful well being.

Antioxidant defenses normally protect against DNA damage caused by reactive oxygen species, from endogenous and exogenous sources. The power of antioxidants is correlated to Life Span Energy Potentials. A similar relationship has also been found for uric acid, a powerful water-soluble antioxidant in primates, while carotene also appears to improve longevity, although the effect is non-linear. Concentrations of Vitamin E in the plasma also show a good correlation. There is adequate evidence that supplementing the human diet with the vitamin antioxidants helps to prevent a variety of disease such as cancer and coronary Heart Disease.

Tea and other plant foods are dietary sources of nutrients like carotenoids, tocopherols, ascorbic acid and non nutrient phytochemicals generally classified as Flavonoids. Tea has more antioxidant properties than most common vegetables.

CHD has often resulted from a lifestyle that includes a diet high in saturated fats, combined with low physical activity. Most epidemiological evidence indicates that consumption of Flavonoids from black tea prevents the oxidation of LDL-cholesterol and therefore is associated with a lower incidence of CHD or stroke. Tea Flavonoids, such as catechins, theaflavins and thearubigins, demonstrate powerful antioxidant activities and thereby protect against cardiovascular diseases. There is strong evidence of the relation between high intake of vegetables and fruits and decreased risk of heart disease. In the last decade, both epidemiological and experimental research suggest that tea may also help maintain heart health.

Polyphenolic antioxidants present in black and green tea can reduce cancer risks in a variety of animal tumours. Studies showing the preventive effect of tea were conducted with black and green tea. Tea exerts a major inhibiting effect on the growth and development of many type of cancer,and it increase apoptosis, a process whereby tumour cells are eliminated. The consumption of tea and its polypherolic constituents affords protection against chemical carcinogen or ultra violet radiation-induced skin cancer in mice. Tea consumption also affords protection against cancers induced by chemical carcinogens that involve the lung, fore-stomach, oesophagus duodenum, pancreas, liver, breast, colon and skin in mice, rats and hamsters. Many of the cancer preventive effects of green tea are mediated by EGCG, the major polyphenolic constituents of green tea.

Prior oral administration of black tea extract in rats, for seven days, significantly reduced the incidence of gastric erosions, induced by various uncerogens and cold stress.

Both black and green tea extracts were found to possess preventive as well as curative effects on streptozotocin-induced diabetes in rats

The study revealed a selective absorption of black tea polyphenols by dental enamel. Theaflavin digallate and theaflavin gallates, polyphenolic constituents of black tea, are absorbed maximally, whereas absorption of catechins is less than that of theaflavins.

The anti-tumour effect of tea was evaluated in the 3-Methyl Cholanthrene induced solid tumour model in mice. Tea and tea polyphenols also have a beneficial effect in changing intestinal bacterial flora.

Drug-Coated Stents to Nix Blockage Recurrence

Ongoing trials in the US and Europe indicate that drug-coated stent may revolutionise non-invasive cardiology in the next few years. Early results of human trials show that stents coated with the drug Sirolimus prevents the growth of fibrous tissue around the stent which can cause the blockage to recur after some years, says Dr. Ashok Seth, Chief of Invasive and Interventional Cardiology at the Escorts Heart Institute and Research Centre. It seems we may have conquered the possibility of recurrence, he added.

The March 2002, results of the SIRIUS study of 1,200 patients in the US found that recurrence occurred in 2 per cent cases in the Sirolimus-coated stent group, while it was at a higher 32 per cent in the normal stent group.

Dr. Seth was speaking at a symposium on the Prevention and Treatment of Coronary Artery Disease organised by the Bar Association of India, Fali S. Nariman, the president of the Bar Aasociation, expressed disappointment at the sparse attendance. Its quite clear that lawyers believe they are a healthy lot, but the constant stress and strain of the profession should be enough to make everyone sit up and listen. And listen they did, especially after Dr. Seth began his presentation by declaring that by 2013, heart disease would overtake infectious disease the world biggest killer, accounting for 50 per cent of the death in the Asia-Pacific region.

Just being an India exposes you to risk of cardiovascular disease, he said. Indians are genetically predisposed to truncular obesity, hypertension, high low density lipoproteins, high triglycerides and insulin resistance, all of which when combined with risky behaviours like a sedentary lifestyle, high fat diet and smoking, put Indians at greater risk.

The government National Health Policy 2002 is flawed because it still does not take into account the emerging epidemic of diabetes, hypertension and heart disease, and continues to talk about malaria and tuberculosis as it has been doing for the past 50 years, said Dr. Roopa Salwan, consultant cardiologist from Escorts Heart Institute. Lifestyle modifications are a must as they can reduce the risk by up to 15 per cent within a year, she added.

Exercise remains the most effective lifestyle intervention, but it will take a few more lectures to jog people into activity.

Alcohol Thrills But Kills Too 

The short answer, quite simply, is that there is nothing wrong with a very moderate consumption of alcoholic drinks even if you have already had a heart attack that is provided you are used to alcohol, do not start if you are not used to it but there is plenty wrong with heavy drinking. The difficulty, however, lies in defining exactly what is meant by heavy. Many of those people who drink more alcohol than is good for their health do so without even realizing how much they are consuming. Put quite simply, the more you drink and the more often you drink, the higher the risk of developing alcohol-related disease but because different people can tolerate different levels of alcohol, it is difficult to lay down strict rules.

What is a Moderate Drinker 

In the main a very moderate drinker is a man who has fewer than 20 drinks in a week or a women who has less than 13: a heavy drinker is a man who has more than 51 drinks a week or a women who has more than 36. These definitions may vary slightly from one source to another, but after reviewing surveys from different parts of the world it becomes obvious that drinking more than two standard drinker per day increases the risk of developing coronary artery disease, high blood pressure and other related diseases, such as peripheral vessel disease or strokes.

Other Reasons For Limiting Intake 

There are a great other compelling reasons for avoiding an excessive consumption of alcohol. Apart from cirrhosis of the liver, excessive drinking can cause brain damage, inflammation of the pancreas and cancer of the digestive tract, mouth, throat and gullet.

Its Effect On Men And Women 

Alcohol is absorbed into the blood via the stomach and intestines. It is then quickly and uniformly distributed throughout the body water. Men hold between 55 and 65 per cent of their total body weight in water, in comparison with only 45 to 55 per cent in women. Alcohol is therefore more diluted in men than in women, which is why men can take more alcohol than women. Men are also generally heavier than women of the same size so have more total fluids in their body.

How Alcohol Affects The Heart 

The precise role of alcohol in heart disease is difficult to assess. There are several reasons for this. The first is the difficulty in establishing links between the two in a particular patient; the only clue may be the patient self-confessed drinking history. The second reason is that there is evidence to suggest that a small amount of alcohol not more than the two standard drinks per day can actually be beneficial to the cardiovascular system because in these fairly small amounts, alcohol appears to be a relaxant. What is certain, however, is that more than that can contribute to several other risk factors.

Combined With Risk Factors

For a start, even moderate amounts of alcohol can raise blood pressure in susceptible individuals, while heavy drinking can cause, or at least aggravate, high blood pressure. If you are in any doubt about your own susceptibility, consult your doctor. Alcoholics who manage to remain dry after withdrawal, have in fact been shown to have lower blood pressure than those who start drinking again. Even small amount of alcohol can make effective drug treatment very difficult because alcohol can interfere with the medication either by inhibiting the action of the drug or by causing a dangerous reaction.

Excess alcohol is thought to raise the levels of cholesterol and triglycerides in the blood and thus to accelerate the process of atherosclerosis. Alcohol also gives rise to another harmful process known as coronary steal. Alcohol can cause normal blood vessels to dilate, allowing more blood to flow through them. Blood is correspondingly stolen from those arteries which have been narrowed by disease.

People who drink a lot of alcohol are often overweight. As well as being very high in calories there are 180 calories in the average 600 ml of beer and poor in essential nutrients, alcohol tends to stimulate the appetite. It takes only some simple arithmetic to add the calorific value of everything you drinks to that of everything you eat, and its not difficult to see where a beer gut comes from Heavy drinkers also tend to take too little exercise, which not only adds to any weight problems but also means that they miss out on all the cardiovascular benefits that regular physical exercise can bring.

Drinking to excess goes hand in hand with several other risk factors. For instance, the person who drinks to excess often smokes, drinks a lot of coffee and displays Type A behaviour patterns. Also, alcohol is closely related to stress, whether as a cause or a symptom.

In view of all these factors, it is hardly surprising that a high consumption of alcohol doubles the risk of suffering a stroke, or that it is extremely common in heart attack victims.

STRUCTURE AND FUNCTIONING

The heart is divided into four main chambers : each one is a bag of muscles with walls that are able to contract in order to push blood out. Each walls thickness varies according to the amount of work it does. The walls of the left ventricle are the thickest because it does most of the pumping.

The chambers on either side of the heart are arranged in pairs. Each side has an atrium, with thin walls, to receive blood from the veins. The atrium pumps blood into a thicker walled ventricle, through which the blood is pumped into a main artery.

The heart is involved in two separate circulatory functions. Oxygen rich blood is pumped from the heart into the body through the aorta. This is called systemic circulation. When this blood is returned to the heart, after the cells have absorbed all the oxygen and nutrients, the heart pumps the blood into the lungs through the pulmonary artery. Here, the oxygen supply is replenished and the blood is returned to the heart. This is known as pulmonary circulation.

Pulmonary veins bring the newly-oxygenated blood from the lungs to the heart. It reaches the left atrium, which contracts and pushes the blood out through the mitral valve into the left ventricle. Then the left ventricle contracts. The blood moves through the open aortic valve into the aorta, and on to the system of arteries and capillaries, and into the tissues.

The deoxygenated blood from the body comes back to the heart through a large vein called the inferior vena cava, and from the head through the superior vena cava. The blood goes into the right atrium, via the tricuspid valve, and into the right ventricle. The ventricular contraction sends the blood through the pulmonic valve into the pulmonary artery, and then to the lungs. From here, the blood comes into the pulmonary veins. And the process repeats itself, about 50-60 times a minute.

CONTROL SYSTEM

The two atria contract together and fill the ventricles with blood. Then both the ventricles contract together. This is controlled by an electrical timing system located in the right atrium : the sino-atrial node. The atrioventricular node delays the electrical impulse so that the ventricles contract only after the atria.

INTENSIVE CARE

Intensive care was introduced in the sixties. This made it possible for specialised staff to monitor and measure vital parameters continuously. With the introduction of cardiac intensive care there has been a drastic reduction in mortality and morbidity in cases of heart attacks and cardiac failure.

Intensive cardiac care units in hospitals offer the right conditions for a patients brought in with fatal complications. These units have nurses and doctors round the clock attending to the patients. Every patients is connected to an ECG machine by electrodes to enable the staff to monitor blood pressure and heartbeat.

Another advancement in the field of intensive care has been the development of defibrillators. These are lifesaving instruments which convert dangerous heart irregularities to normal by applying a small electric shock.

While in the intensive care, the emphasis is on trying to save as many heart muscles as possible. But once the patients is out of danger, the doctor shifts the focus to rehabilitation. While rest is important, it is also important to slowly resume physical activity. Besides the cardiologist, a dietician and a physiotherapist would chalk out a programme to bring the patients back to normal.

DRUGS

In addition to the benefits obtained from intensive care, a number of drugs have made a foray into the treatment of heart attacks. These are drugs that help dissolve clots in the coronary arteries, aspirin and similar drugs which prevent blood clotting, and beta blockers and ACE inhibitors that restrict the extent of the damage to heart muscles. These drugs not only provide immediate benefit, but prevent long-term complications.

There are three categories of drugs used in the management of angina pectoris nitrates, beta blockers and calcium channel blockers.

NITRATES 

Nitrates help relax vascular muscle. These are usually taken under the tongue or sprayed in the mouth for quick relief from symptoms such as pressure in the heart, radiating pain in the chest, pain in the back and teeth.

BETA BLOCKERS

Beta blockers effectively treat angina by decreasing blood pressure and heart rate from normal to amount 50-60. However, these have some side-effect. Beta blockers have been found to lower good cholestrol and also cause asthma.

Though there are other side-effects like depression, hair loss, pain in the legs, fatigue and nightmares, it is important that the patients takes it without a break. An abrupt break can cause the symptoms to recur.

ASPIRIN 

Through aspirin was created by a German chemist at the end of the 19th century to ease the pain of arthritis, since the early 1980s it has been approved for preventing second heart attack and stroke. Now it is increasingly being used in treating heart attacks as they occur. Aspirin works by interfering with the synthesis of prostaglandins, which help control the body response to injuries and infections. Prostaglandins act on the nervous system to help transmit pain. They signal blood platelets to form clots and also promote inflammation. But blood clots can cause heart attacks and inflammation is a likely culprit in atherosclerosis. Aspirin prevents blood clots and inflammation.

ACE inhibitors are angiotensin converting enzyme inhibitors that dilate arteries. Drugs in this category are also beneficial to patients with leaky valves.

STATINS

These are wonder drugs used to decrease cholesterol level in the blood. Statins reduce the thickness of the plaque, thus increasing the lumen of the blood vessel. These drugs are probably as good as angioplasty in treating angina. Some of the statins in the market are simvastatin, Atorvastatin and Pravastatin.

INTERVENTIONAL CARDIOLOGY

In some cases of coronary artery disease medications alone may not be enough to remove the arterial obstructions. While cases of blocked artery were treated first with medicines and then surgery earlier, today there are various options such as angioplasty and stenting which have several advantages over conventional surgery.

The first balloon angioplasty performed in 1964 was a failure and did not have many takers. It became popular after it was performed successfully in Switzerland in 1977.

Known as percutaneous transluminal coronary angioplasty in medical parlance, balloon angioplasty takes around two hours and is very similar to an angiogram. Performed in a catheterisation lab, it is done under local anaesthesia. The doctor makes a tiny incision over an artery, usually in the thigh, to thread the catheter in. X-ray imaging helps the doctor keep track of the catheter. Once it reaches the site of the plaque the balloon is inflated, of a few seconds or a few mintures depending on the requirement, to flatten the plaque and open the passage.

Some patients experience chest pain when the balloon is inflated. This is because the inflated balloon interrupts blood flow in the artery. The catheter is then withdrawn and the doctor takes X-ray pictures to assess the success of the procedure. The patients is taken to the cardiac intensive care unit after the procedure and can leave the hospital in a day or two.

STENTING 

Angioplasty has a high success rate, but there are cases where the plaque returns and the artery becomes narrow again. This is called restenosis. Scaffoldings called stents have been developed to prevent the vessel from closing again.

The initial steps are similar to catheterisation where a small incision is made over an artery to insert the catheter. A stent, usually made of stainless steel, is first mounted on the deflated balloon on the catheter tube. When it reaches the site of the plaque the balloon is inflated. This expands the stent. The balloon is then deflated and removed, leaving the stent fixed in the plaque-affected area of the artery. Stents have been found to be useful in emergency situations and also in reducing restenosis.

OTHER ANGIOPLASTIC TECHNIQUES

1: Rotational atherectomy

2: Directional atherectomy

3: Laser angioplasty

Atherectomy is a process where a catheter with a rotor blade is used to remove plaque

In Laser angioplasty, the doctor uses a Laser catheter to vapourise the plaque.

It is a remarkable achievement that narrow valves can be opened using similar techniques, without surgery. The other successful interventions have been the closure of holes in the heart using devices delivered through catheters. A hole in the heart is a congenital defect and an infant born with such a defect is called a blue baby. Holes in the heart allow impure blood to flow into the body. Holes can be between the left and right atria or the left and right ventricles. In some cases the defect may be in the openings to the chambers. It can also be a case of pure blood mixing with impure blood flowing through the major vessels of the heart.

Symptoms of a congenital defect include inability to cry or swallow, blue colour and clubbing of finger nails. An X-ray, an ECG and other non-invasive tests can show the defect in the heart. The doctor then decides a treatment based on the test results.

Treatment often consists of surgery which can be performed even on a newborn. However, in some cases the hole may close on its own as the child grows. A hole between the left and right ventricle is a condition which commonly requires surgery. The hole is either sewn up. If the hole is too large, a plastic patch is used to close it.

SURGERY

HEART TRANSPLANT

Heart transplant was a grand milestone in cardiology and Dr. Christain Barnard, a south African surgeon, was the first to perform a successful transplant on a human being in 1967 candidates for a transplant are of course, patients of sick with heart disease that only a healthy donors heart can save them. People with other general disease such as diabetes are advised not to go in for the surgery because such conditions could hamper recovery.

The introduction of open heart surgery in the fifties was a landmark in cardiology. Surgery has made repairing defects of heart valves and congenital abnormalities possible. Advanced techniques currently available also make it possible to operate on babies from day one.

CORONARY ARTERY BYPASS SURGERY 

Coronary artery bypass surgery was first performed in 1964. A procedure where the blocks in the coronary artery are bypassed using another blood vessel, it is an alternative for people who do not get relief from medications or angioplasty. This has been useful for some patients with angina.

The technique involves taking a blood vessel from the leg or the chest and attaching it in such a way that it bypasses the blocked coronary artery. The blocked vessel is not replaced. The number of graftings a patients needs depends on how many of his coronary arterise are blocked

Surgery requires cutting the breast bone from top to bottom to expose the cardiac region and the heart. The temperature is brought down to make the heart stop beating so that surgeons can operate on it. So during surgery, the patients is connected to a heart-lung machine where blood gets oxygenated and returns to the aorta to be circulated in the body.

The surgery may go on for three hours after which the patients remains in the intensive care unit for a few days. During this times, he may have a tube going down his larynx to ensure proper ventilation and a catheter to drain his urine. Medicines may be administered intravenously.

The patient starts feeling relaxed and well a day or two after the operation. However, pain in the operated area may persist for some time. Patient is encouraged to take a few steps two days after surgery but not allowed to sit for a long time to avoid swelling in the legs.

Complications infection, heart attack, stroke and death are rare. However, many experience a temporary decrease in thinking capacity and have problems with vision. Women seem to be at greater risk during surgery and seem to benefit less from bypass.

DIAGNOSIS

It is very important to make a correct diagnosis of stroke syndromes as the management of the first four to five days determines the outcome of the patient. The proper and correct diagnosis requires the following steps to be established in the sequential order :

1. Is it a stroke  ?
2. If it is a stroke then what type is it ?
3. What is the site and extent of the lesion ?
4. What is the vascular territory of the lesion ?
5. What is the extent of functional impairment of the patient ?
6. Are there associated diseases ?

A good working knowledge of the brain and vascular supply is important. The family member and the patient will then be better placed to understand day-to-day-day event in stroke management.

The diagnosis of a stroke at the beside is rarely difficult because the mode of presentation is so distinctive. This is called clinical temporal profile. The symptoms develop abruptly or very rapidly, progress in the next few hours or days to a maximum, and then the clinical condition stabilises. If the patient survives then there is fair degree of improvement. Stroke syndromes may be very mild and may consist of trivial neurological signs and may not draw the patient attention to seek medical advice as happens in transient ischaemic attacks. But it may also manifest with such abruptness that the patient may slip into coma in a few minutes and die as may happen in massive intracerebral haemorrhage or sub-araachnoid haemorrhage. There are all grades of severity between these two extremes.

Once the diagnosis of a stroke syndrome is suspected, the neurologist would like to know and establish the type of stroke at the bedside. This seldom presents much difficulty. Some of the important and frequent conditions have been discussed earlier. These have characteristic evolution and temporal profile and pose no great problem. Transient ischaemic attacks, ischaemic thromoboembolic strokes, intracerebral haemorrhage, and venous infarcts can be diagnosed. It is the clinical setting in which these stroke syndromes develop that is important for their identification. A stroke following an uncontrolled hypertension is more likely to be caused by intracerebral haemorrhage.

Neurologists would also like to establish the site and extent of the lesion in every stroke syndrome. All functions are located somewhere in the brain at different sites. Anatomical location of these functions is an important prerequisite for establishing the site of lesion. Examination of the cranial nerves is an important exercise as these are distinctly located in the brain. We also know that motor and sensory functions are located on the opposite sides of the brain. Complications of pathological lesions like cerebral oedema, herniation of brain, displacement of brain, compression of vascular channels, etc. may produce their effect and exhibit new signs and symptoms. These would complicate the original symptoms and signs and make diagnosis difficult. Therefore, proper investigation and awareness and knowledge of the events that are taking place are essential for the diagnosis and management of neurovascular syndromes.

Motor weakness, that is, inability to move limbs in one half of the body, may result from several sites within the brain. At one site a tiny lesion may produce a dense motor weakness while at another site the lesion has to be of large size to produce a similarly dense motor weakness. This has got great bearing on the recovery after a stroke. Therefore, the treating doctor should try to establish the functional disturbance at a given time in every case.

It is usually important to know and establish the alterations on other organs like heart,lung, stomach or metabolic functions from the brain lesions or stroke syndromes. Some ECG charge are common in stroke syndromes and can be interpreted as ischaemic heart disease. There may be stress ulcers in stomach and can lead to bleeding. A rise in sugar levels in blood and urine is quite frequent in stroke patients and at times may be quite marked in latent diabetic patients and accordingly would require necessary medical management. Electrolyte disturbances, poor intake of fluids may have effect on other systems as well as on the brain. Therefore, laboratory investigations and other diagnostic methods for assessing the systemic diseases or their involvement are important in the total management of the stroke syndromes.

INVESTIGATIONS

The role of correct diagnosis in clinical medicine is indisputable. The correct diagnosis not only saves life or reduces morbidity but greatly influences the health economics. Sequential diagnostic goals have been identified in the management of stroke syndromes in the previous pages. Correct diagnosis requires proper investigations at the right time. There are several investigations available : some are cheap and others are relatively expensive. It is understandable that all investigations can not be ordered in every case. Choice of investigation and sequence of investigation should best be left to the treating doctor. There are, however, limitations on the choice of investigations in a particular hospital, city or country. Financial constrains also limit the choice of investigations. Therefore, it is very essential for the treating doctor to take all factors into consideration and order the available investigation which can provide the maximum and best information in the management of the patient. It is a good policy to discuss with the family members or the patient the possible investigations and their role in the management of the case.

There are a number of diagnostic tests. These can be divided broadly into two groups : general and special, i.e. specifically related to stroke syndromes. These investigatory tests can also be divided into non-invasive and invasive Computerised tomography has completely revolutionised the diagnostic technologies. Many traditional tests done in the pre-CT era have now been abandoned. General tests may include haematological and biochemical investigations, X-rays, EEG, radioisotope brain scan and cerebro-spinal fluid examination.

CRANIAL COMPUTERISED TOMOGRAPHY 

The different parts of the body like the thorax, abdomen now can be examined by the whole body CT scanner. In stroke syndromes we are interested in cranial computerised tomography. Different brain tissue slices are examined in sequential order by X-ray beam and with the help of a computer complete skull pictures are developed. These pictures are taken in different directions for better visualisation of different brain regions and structures. CCT  can be done with or without contrast media. In stroke syndromes non-enhanced CT is preferred and should always be first done. Blood vessels can be made visible by infusion of contrast media. CT is very good to differentiate between ischaemia or haemorrhage or to eliminate tumours or subdural haematoma simulating acute vascular episode.

MAGNETIC RESONANCE IMAGING

MRI is based on the application of magnetic field where protons absorb and then re-emit radiowaves. It is possible to change the direction of the magnetic movement of protons by applying to the sample short bursts of radiowaves of a specific frequency. The radiowaves are analysed by computer and pictures are developed for interpretations.

Advantages of MRI include the absence of X-ray exposure, improved contrast between structures and absence of bone artefacts. In many situations MRI is better than CT, particularly in evaluation of brain-stem lesions. MRI gives better anatomical correlation but it is much more expensive. CT and MRI are complementary tests in the evaluation of stroke syndromes. Both are non-invasive and can easily be repeated during the course of illness.

Recently MRI technology has further advanced. Magnetic resonance angiography can partly replace angiography. Without the use of contrast media, radio-frequency signals from flowing blood are used to visualise the cerebro-vascular system. Another advance in MR technology is the development of magnetic resonance spectroscopy. Brain metabolism can be studied by MRS.

ARTERIOGRAPHY

The role of arteriography in cerebrovascular diseases has been well established since 1948. It can be used to image the extracranial vasculature in the neck in stroke syndrome, aneurysms, and arteriovenous malformations in the brain and has played a vital role in the surgical management of strokes. It is equally good to demonstrate subdural haematoma. Major advances have taken place in the development of contrast materials and new imaging techniques, such as four-vessels angiography by femoral route which has provided lots of advantages. The technique has been further developed in order to reduce the complications and take better pictures with the help of the computer. This technique is called digital subtraction angiography. This can be done by either injecting contrast material into the vein or into the artery. Venous DSA is an almost non-invassive procedure.

ULTRASONOGRAPHY 

Improvements in electronics and computer technology have greatly helpedin the utilisation of diagnostic ultrasound for the evaluation of stroke syndromes. This technology is non-invasive,relatively inexpensive and safe. It is of  two : real time imaging and  Doppler imaging. B-mode scanning images the arterial wall, not the moving red blood cells. Doppler scanning image the blood flow velocity through vessels. Duplex scan is the combination of high resolution B-mode imaging with Doppler flow detection. It provides the physiologic information of blood flow with 2-dimensional imaging of the walls of the artery or vein. Transcranial Doppler is a new non-invasive technique to measure the flow velocities through the large intracranial arteries.

VENOUS STROKE

Any bedside discussion on stroke syndromes gets confined to the arterial system. Venous pathology as a cause of stroke is either not entertained or overlooked, though these have been known to neurologists for centuries. It is true that venous strokes are very rare. But obstruction in venous outflow can cause stagnation of blood and accumulation of injurious metabolic end products, which in turn can cause tissue damage, leading to a venous stroke.

Blockage by thrombus is the most common cause. The thrombosis may be primary or non-infective, or secondary or infective. Dehydration, blood disorders, hormone effect, tumour growth, etc., all can lead to blockage of a vein. Infection of the veins called phlebitis, commonly leads to formation of thrombus and blockage of the vein lumen. Despite the many potential causes, however, disease of the veins is rather unusual. One reason may be that because of valveless flow the blood flows in either direction and allows instantaneous shunting of blood. In clinical practice, infection of paranasal sinuses or middle ear is knows to result in intracranial spread of infection.

Clinical features of a venous stroke are very variable and include seizures, weakness, paralysis, raised intracranial pressure, sub-arachnoid haemorrhage, or coma. The clinical manifestations depend upon the sinus involved, or superficial or cortical veins. Severe headache, vomiting, or seizures in a patient with infection of paranasal sinuses or middle ear should alert the patient and the doctor and should be investigated. The evidence of infection should be established. CT and MRI are the investigations of choice. Digital subtraction angiography or MRI angiography may show whether the blockage is complete or partial. The use of antibiotics can save many patients. The recovery is rapid and without much residual disability in many patients. Steroids are required at time to reduce the brain oedema. Role of blood anticoagulants and fibronolytic agents in the management of venous stroke is very controversial. Surgical treatment is required if the infection is localised, like brain abscess. Surgical attention will also be required for conditions like severe sinusitis or otitis media, once the brain condition is taken care of. Otherwise, there is the risk of recurrence.

STROKE IN THE YOUNG CAN BE QUITE TRAUMATIC

Stroke as a disease entity is better appreciated in the community by its occurrence in elderly people. Stroke in the young is described as stroke syndromes in persons below the age of 45 years. If one takes all stroke cases in all age groups in the community then it is believed that 15 to 20 per cent cases fall in this group. Stroke in the young cause much more social, economic, and psychological problems. Persons in this age group are mostly bread-winners for the family and the stroke may cripple the family. There are some specific disease conditions leading to strokes which are more common in this age group. For all these reasons stroke in the young is considered separately. One should not forget that primary brain haemorrhage due to hypertension or atherosclerotic ischaemic infarction can also occur within the younger age group.

Coronary Artery disease as the major health problem: CAD and other cardiovascular disease occur earlier and with greater frequency in patients with NIDDM than in the general population. Several mechanisms contribute to this excess. First CAD and NIDDM frequently occur together in families. For example : patients with NIDDM are more likely to have a parent with CAD or controls without diabetes. Second, hyperinsulinemia and insulin resistence which precede by many years the development of NIDDM also are predictors of the development of elevated blood pressure and lipid abnormalities. Several studies have demonstrated that an elevated serum insulin level in the fasting is an independent predictor of CAD. After NIDDM develops, risk factors for CAD become more prevalent and more intense.

Hypertension: Hypertension is more prevalent both among persons with IDDM and those with NIDDM  than in the general population. The role of hypertension as a risk factor for atheroscrosis is at least as strong for diabetic as for non diabetic person. Hypertersion can be the result of diabetic nephropathy, although the frequency of hypertension appears to be higher in the diabetic population. In NIDDM, hypertension occur as part of a syndrome in which it can co-exist with central obesity, insulin resistance, and dyslipidemia.

Microvascular complications of diabetes represent one of the most serious consequences of the disease. It is likely that all blood vessels both large and small, are abnormal in patients with diabetes of long duration. The changes involve both the vascular cells making up the capillaries and arterioles and their basements membranes.

The main function of the vasculature is to provide a conduit for the delivery of the nutrients required by the individual tissues and for the removal of materials from specific tissues. To achieve this important goal, the cells of the vascular need to monitor the needs of the tissue continuously and either increase or decrease functional capacity appropriately.

The classic morphologic finding in diabetic is the thickening of basement membranes in capillaries. The basement membranes of mammary duets, testes, and sweat glands are thickened. Once there changes have occurred, the blood vessels lose their ability to regulate blood flow, and the capillaries in turn lose their ability to receive blood, a deficit that leads to the formation of ghost capillaries. With the formation of ghost vessels areas of anoxia are formed which can lead to serious stage of diabetic retinopathy called proliferative retinopathy. These new blood vessels do not form the usual retinal blood barrier. There properties increase the risk of bleeding and as a consequence can cause blindness.

The prevalence of macro vascular disease is markedly increased among individuals with diabetes mellitus. Antopy studies have reportedly demonstrated that atherosclerosis in diabetic individuals is more extensive and accelerated than in individuals without diabetes.

Smoking: There is strong evidence that smoking markedly increases the risk of heart ailments and vascular diseases particularly myocardial infarction. Smoking is believed to be associated with adverse changes in plasma lipids especially with the levels of cholesterol.

Aging processes. Both IDDM and NIDDM are characterized by the periods of hyperglycemia. Proteins with long-half lives are likely to undergo more extensive monenzymatic glycation in those with diabetes than in those without diabetes. Since protein glycation has been linked to the aging process, the diabetic state might be considered a state of accelerated aging. One life-threatening complication is keto-acidosis in diabetic mellitus. This is a condition characterized by the blood sugar level of more than 250 ml with blood PH of less than 7.3 presence of ketones in urine and elevated serum ketones of above 5 ml. General in young diabetic patients treated with insulin this complication can be due to some infection such as pneumonia, urinary tract infection or by acute emotional stress and depression. This complication demands immediate effective insulin therapy.

Diabetes and the Disease of the skin: The skin is a fabroelastic membrane which may be called the living envelope of the human body. It is complex in structure and endowed with active and passive functions so that it affords covering and protection to the deeper tissues and receives impressions from the external world to which it is continually exposed. It is closely related to the structures beneath through its connective tissue, blood vessels, nerves and lymphatics.

Many different agents may cause a dermatitis which eventually becomes gangrenous. Among these may be mentioned excessive cold or heat, external application of chemical agents, ingestion of drugs, disease of the nervous system, other diseased conditions of the blood vessels and diabetes.

1 Multiple Gangrene: This condition has developed independently of any disease but usually follows or developed independently of any disease but usually follows or complicates such infectious as scarlatina, variola, typhoid, fever. Although persistent recovery usually takes place. When children are affected, the result may be fatal.

2 Hysterical Gangrene : This type of gangrene is noticed in hysterical and anaemic young women suffering from diabetes. This condition may be an imposture or possible due to some central nerve lesion. It occurs first as a raised reddened spot, varying in size accompanied by burning sensation.

3 Diabetic Gangrene: No doubt the chief cause of this form is the diminished tissue resistance which diabetes occasions. Hence micro organisms can give gain easy access. In some primary forms, The origin is purely neurotic. It may be unilateral or bilateral and is opt to affect the middle of the extremities rather than the finger or toes although rarely it may affect any portion. Cases of spontaneous origin may heal but complication of a most serious underlying condition.

4 Symmetric Gangrene: It is of rare affection occurring at the periphery of the circulation and characterized by local Ischemia and asphyxia and usually ending in gangrene of the skin and deeper tissues which is often symmetrically distributed. Extremities such as the fingers and toes or less often the nose, ears and brows may be attacked. The first indications are the coldness and paleness of the parts affected. Numbness, loss of sensation, pain and pallor may precede or follow the initial symptoms. Unless the disease be arrested at this or at earlier period, the second stage develops with sensations of prickling, crawling, stinging and pain with a swollen dark, red livid or bluish appearance. Unless the disease be arrested at this or an earlier period, the third stage that of superficial dry gangrene is developed. At this time, the skin may be cold, firm and dark in colour. This condition usually follows directly firm cold but has been observed after the exanthemata, diphtheria, malaria, gout, and diabetes.

5 Carbunculus: It is an acute circumscribed, cutaneous, inflammation characterized by multiple foci of necrosis and sloughing of the superficial tissues. Carbunculosis is a condition where the lesions occur singly or in crops. Mild prodromata usually precede the carbunde, such as chill, fever, and malaise but when the lesions are extensive, numerous or situated on the head, the prostration may be alarming.

A burning, tense pain is felt at the site of the beginning lesion which appears as a deep, flat hard swelling at first covered by reddened skin which soon becomes more darkly tinted. From the size of a boil or large, the infitltration may spread until it reaches the size of the palm. At the end of a week or ten days, the carbuncle appears as a flatly convex, hard tumor, livid in colour, gradually merging into the surrounding skin.

Prognosis of carbuncle depends entirely upon the influence of pre-disposing factors. In conditions like nephritis and diabetes or in the aged, debilitated or alcoholic or in such locations as the scalp, face or abdomen.

6 Acne: Acne is a common inflammatory skin disease that mainly affects the face, neck, chest and upper back. It is caused by an interaction between hormones, bacteria and sebum produced by the sebaceous glands in the skin, symptoms show as comedones, pustiles and occasionally cysts with diabetes patients. Acne is traditionally thought to develop at puberty but many women suffering from diabetes have acne throughout life. It can develop permanently or may be associated with taking or stopping of oral contraceptive pills. This is possibly caused by changing harmonic levels. In diabetes very sever cases can be treated using a derivative of Vitamin A .

7 Diffused symmetrical soleroderma : Soleroderma is a chronic disease characterized by diffused tinted in durations, fixation, rigidity, stiffness and sometimes atrophy. Two forms which are widely different in appearance, distribution and extent, although they sometimes co-exist are described a. diffused symmetrical soleroderma b. circumscribed soleroderma.

Diffused symmetrical soleroderma often follows exposure to cold and wet, with antecedent rheumatic pains and stiffness in the limbs or joints. The onset may be insidious and not clearly noted by the patients. The initial lesion is non-inflammatory with or without edema. If with Edema, the surface may pit on hard pressure but owing to the density of the part there is none of the doughty feeling of ordinary odema. More often edema is absent. After sometime progressive hardness and rigidity develop. While it always attacks the upper segment of the body first. The sites of preference in their order are the upper extremities, trunk, face, head and hands. The parts affected appear frozen but are without coldness. Dilated capillaries may appear in contrast with the abnormally pale surface and brown or black pigmentation may be seen in lines or spots generally diffused.

The disease pursues a symmetrical course changing its situation with periods of aggravation lasting for years. Restoration may follow when the maximum involvement is reached or treatment arrests the process. In such cases elasticity, mobility and function of the skin are partially restored. If this happy condition does not take place, atrophy begins with reduction of the parts involved to such an extent that the muscles may disappear.

This disease is more prevalent in early adult life. Two out of every three cases occur in women. Possible causes are exposure of cold and heat, rheumatism, thyroid, mental and nervous emotions and diabetes.

The Diabetic Foot: Our patients with diabetes no longer die from acute conditions stemming from hyperglycemia. Rather it is the chronic complications of the disease that dominate. Chief among these complications is pathology of the diabetic foot which is the most common reason for hospital admission among people with diabetes. Over the past generation, care of the diabetic foot has so much advanced that many lower-extremity complications of diabetes are preventable. Foot ulceration is a disturbing complication of diabetes that often results in a diminishing quality of life.

In diabetic patients, the foot is the cross road of several pathological processes. Almost all components of the lower extremity are involved; skin, subcutaneous tissue, muscles, bones, joints and blood vessels. Because each of these components can contribute to foot ulcers, a multidisciplinary approach is needed. A diabetic foot ulcer is defined as any full thickness lesion of the skin-that is, a wound penetrating through the dermis. If patients have loss of sensation, limited mobility, and poor vision, they may not even be aware that they have a foot ulcer. The location of an ulcer can give clues to its cause and will help to determine if and how pressure relief should be applied. Neuropathic ulcers are usually located on areas with elevated pressure, such as the planter side of the foot, ischemic ulcers are more common on the tips of the toes. Injection of the diabetic foot is one of the major reason for lower extremity amputation. Unfortunately no standard exists for diagnosing an infection. A superficial infection without systematic signs can be diagnosed based on local swelling, purulent discharge, erythema, foul smell, or local tenderness or pain. Polyneuropathy is a major factor in foot ulceration, resulting in loss of protective sensation, muscle paralysis with subsequent deformities, abnormal walking pattern, and abnormal loading of the foot. callus and foot deformities- such as hallux valgus, grominent metatarsal heads, or clawing of the toes are usually recognized during inspection of the feet. Both of the shoes and socks should be examined. The fit of the footwear is important to evaluate, as most ulcers are caused by poorly fitting shoes and insoles.

Today, as we confront history most complex economic and social problems, a great hiatus exists between. What we profess and what we are, what we say and what we do. The unhealthy and polluted atmosphere of our society has been the cause of great concern. Not a single day passes without an event of anxiety, the shooting prices, increasing unemployment both in rural and urban areas, the indiscipline, population explosion, regional imbalances, rampant corruption, free operation of black money, expensive election system, defective education system, bureaucratic delays and hurdles. Disintegrated families, broken marriages are the major cause of the existing unrest, violence and agitations. We are living in an age of explorations, explosions and paradoxes. We have conquered the unconquerable and achieved things beyond the wildest dreams of our ancestors. Science has changed our world into a place of abundance and plenty. But the lust for money has hardened our hearts, silenced our scruples and corrupted our moral sense. We are hardly conscious of the fact that the pace of biological degeneration is fast accelerating. Dishonest pretences and disco influences. We are also living in a world of stress and strain, struggle and strife. Everybody seem to be in a hurry in this age of anxiety. If you are an average busy man or woman, coping with just routine problems, your day is too short. You rush to work in the morning and return at night fighting your way through crowds, and boarding buses. Your daily schedule on the job or in the home is so tight that at the end of the day you are up against so many pulls, pressures and complications. Different people have different ways of responding, acting and reacting to all these pressures situations and problems. In many cases of hypertension, the cause is unknown. But certain cause and psychological factors can give birth to hypertension.

PHYSICAL ACTIVITY

The world is too much with us. We have no time or mood to enjoy the beautiful sights and sounds of nature. Modern man has become lazy and lethargic. He has no time for doing physical exercise. The incidence of hypertension is low in people who maintain a high degree of physical activity. The risk of developing hypertension is 40% greater in persons who donot do any physical exercises. Physical exercises such as brisk walking, yoga and playing games have beneficial effects and can maintain the blood pressure.

OBESITY 

Obesity is caused due to the disturbances of some of the endocrime glands, like the thyroid, pituitary and the sex glands. In most cases obesity is the direct result of a life of ease and over eating. Medical experience strongly suggests greater risks for overweight persons in respect to most of the disease and disorders. Although overweight and obesity are not the same, most over weight persons are obese. Psychological factors are operative in every person whether  he is obese or not. An increased body weight or obesity has a great impact on Blood pressure; The caloric restriction may influence in reversing this process.

DIET

The diet plays an important role in maintaining blood pressure. The diet rich in plant fibers either alone or with a low fat, low sodium can lower the BP in hypertensive patients. The more intake of diet rich in plants fibers or fats raise the blood pressure.

CAFFEINE

Medical evidence suggests that caffeine contained in two cups of coffee may rise the blood pressure by 5 mm Hg in infrequent uses of caffeine. The B.P. does not rise in habitual users, indicating a phenomenon tolerance in them. It is also observed that there was no effect on BP when hypertensive abstained from coffee.

NARCOTIC DRUG

There is psychological or sometimes a physical dependence upon the effect of the drug. Generally these drugs which cause psychological dependence are termed as habit forming and those drugs which cause physical dependence are called addicting. Since psychological and physiological reactions are closely related. Psychological dependence rests upon a state of Euphoric which a narcotic drug creates. When heroin, opium are used frequently they create craving for the drugs which raise the blood pressure in particular and proves a hazard for the health. The action of cocaine on the brain is very powerful, a single injection may cause serious troubles of the function of the brain. The prolonged abuse of drugs may affect the spinal cord and cause convulsions. By the regular use and abuse of drugs, will power diminishes, capricious temper, irritability, obstinacy, nervousness, insomnia, and mental disorders are developed which in turn can raise the blood pressure.

DEFICIENCY OF VITAMIN C 

The story of the vitamins, their discovery, their positive functions in maintaining health is fascinating. Vitamins are one of a group of organic substances present in minute amount in natural food stuffs which are essential to normal metabolism and lack of which in the diet causes deficiency disease. Asorbic Acid is a white, crystalline compound which dissolves readily in water. The most important function of the Ascorbic Acid is to control which it exercise on the ability of cells to produce inter Cellular material. In other words vitamin C is like a binding which holds the cells in proper relation to each other and to the fluid which bathes and nourished them. There is an inverse relationship between. BP and plasma vitamin C also lower the BP in hypertensives and diabetics.

MISUSE OF REST AND RELAXATION 

Modern man feels tense, over wrought, nervous and anxious. He says Yes, Relaxation is fine but I have not the time. In the hours of leisure and rest, he takes recourse to drugs leisure and rest, he takes recourse to drugs pills, tranquillisers and beverages which give him temporary relief but they prove disastrous to his mental and physical health. He misuses the hours of rest and relaxation by sitting in coffee houses, and clubs, puffing a cigarette and having some rounds of whisky. All these things prove disastrous to his health and contribute in increasing hypertension. The necessity for relaxation with yoga is far more pressing than it ever was.

SALT RESTRICTIONS

It has been established that a high consumption of salt raise the blood pressure and low consumption decreases it. The effect of salt does not only depend upon the common salt that we add to our food but also upon the sodium chloride that is naturally present in foodstuffs. Four decades back when we had no adequate medicine to lower the blood pressure, the doctors would advise salt-free-diet to their patients.

CALCIUM AND POTASSIUM SUPPLEMENTS

It is also established that low potassium content in the food elevates the blood pressure. It is important to maintain balance between sodium and potassium. A diet rich in sodium and poor in potassium is likely to elevate the blood pressure. Potassium is contained in green vegetables and fruits. The relationship between the calcium intake and the BP is still debatable. Some studies showed a little fall in BP while there was no charge in others, the calcium intake has also been found to be less among hypertensives as compared to normotensives.

From the heart, blood surges thought the aorta to the arteries throughout the body. From the arteries, smaller vessels called arterioles branch out. From the arterioles, the blood flows to the smallest vessels, the capillaries. The capillaries carry the blood to the individual cells of the body where oxygen and other chemicals are delivered and waste products are collected. The capillaries then connect with venules, which run into veins which in turn, flow in to the venue cavae. The arteries have layers of smooth muscle cells, elastic fibers and connective tissue. Arteries are called the life lines of the body. By a slow and steady process of degeneration, hypertension produces a thickening of the arterial wall and deposits of fatty material on the walls of the arteries. These deposits obstruct the flow of blood in the effected arteries supplying blood to the heart, brain, kidneys and legs. In the heart angina appears and in the brain attack of paralysis may occur. The deposition of cholesterol on the arterials wall do not occur in the day or so. It is a gradual process which occurs in many years. High blood pressure aided by the metabolic abnormalities of high blood cholesterol results in clogging of the arteries.

CHOLESTEROL

Cholesterol is a fatty insoluble molecule that is widely found in the body and is synthesized from saturated fatty acids in the liver. Cholesterol is an important substance in the body, being a component of cell membranes and a precursor in the production of steroid Hormones and bile salts. An elevated level of blood cholesterol is associated with Arteriosclerosis and this may occur with Diabetes. There appears to be a relationship between the high consumption of saturated animal fats (which contain cholesterol and greater chances of coronary heart disease. It is generally recommended that people should reduce their consumption of saturated fat and look for alternative in the form of unsaturated fats which are found in vegetables. In the blood, cholesterol forms complexes with proteins to produce lipoproteins. There are two forms of cholesterol lipoproteins high density lipoproteins and low density lipoproteins. Low density lipoproteins is the form that promotes the builds up fatty plaques in artery walls, leading to higher risks of heart diseases and stroke.

cholesterol is an important component of all cell membranes and is vital to cell survival and growth. Cholestrol is also key precursor or intermediate compound in the production by the body of numerous biologically important substances, collectively called steroids. These include various essential hormones plus bile acids the major excretory product of cholesterol metabolism but also important in the absorption of dietary fat.

The human body contains about 140-145 grams of cholesterol which is constantly being used and replenished, though at different rates in different tissues. Except among  strict vegetarians, the diet provides part of the body cholesterol needs directly, the rest is produced internally from other foodstuffs, chiefly fats. Although most body tissues can make cholesterol, the main non dietary source is the liver. Like other fatty substances, cholesterol is insoluble in plasma unless combined with carrier molecules called lipoproteins.

Disturbances in cholesterol metabolism or its transport may be associated directly or indirectly with various disorders including gallstones, certain type of cysts and tumors and fatty deposits, which may be laid down under the skin, around tendons or elsewhere. The most important cholesterol associated disease is atherosclerosis. This is degenerative disease of the blood vessels and usually begins with the deposition of lipoprotein borne fatty substances especially cholesterol, in the inner most layers of the walls of arteries. In some instances elevated blood cholesterol levels may be genetically determined. The three major dietary factors, affecting the level of LDL cholesterol in the blood are the total amount of fat consumed. The most effective dietary methods of lowering LDL cholesterol levels are to remove the total amount of fat eaten

STRESS AND SLEEP DISORDERS

Stress is a regular, recurrent, easily reversible state that is characterized by relative quiescence and by a great increase in the threshhold of response to external stimuli relative to the walking state. Sleep is a physiologic state of relative unconsciousness and inaction of the voluntary muscles. Sleep is made up of two physiological states, non-rapid eye movement sleep and rapid eye movement sleep. In normal people NREM sleep is a peaceful state relative to waking. The pules rate is typically, slowed 5 to 10 beats a minute below the level of restful waking and is very regular. Respiration is similarly affected and blood pressure also tends to be low, with few minute to minute variations. The resting muscle potential of the body musculature is lower in REM sleep than in a walking state. Episodic, involuntary body movements are present in NREM sleep. There are few rapid eye movements, if any, and seldom any penile erections in men. Blood flow through most tissues, including cerebral blood flow is slightly reduced. REM sleep has also been termed Paradoxical sleep Pulse respiration and blood pressure in human are all high during REM sleep much higher than during NREM sleep and often higher than during waking. Brain oxygen use increase during REM sleep. The most distinctive feature of REM sleep is dreaming. Dreams during REM sleep are typically abstract. Dreaming does occur during NREM sleep but it is typically lucid.

Diet is told oldest and most important treatment for diabetes. The primary goal of therapy for person with Insulin-dependent diabetes mellitus are the maintenance of appropriate body weight and the prevention of hypoglycemia and hyperglycemia. The patient reaches these goals by consuming meals with an appropriate caloric content at regular intervals in co-ordination with the timing of insulin injections and the level of physical activity. Individuals with Insulin- dependent diabetes are usually young and lean, their caloric intake should be adequate to support normal growth and development.

Eighty to ninety percent of individuals with non-insulin dependent diabetes mellitus are over-weight and the goal-of dietary therapy is weight loss. For many of these person, restriction of  caloric intake and increased physical activity will produce a moderate weight loss that may be sufficient to control blood glucose levels and make insulin or oral medication unnecessary. It is very essential that person suffering from diabetes should never take sugar or thing containing sugar. They should avoid sweets or those vegetables or fruits which contain sugar.

The caloric intake should achieve and maintain a desirable weight in the person with diabetes. The calorie prescription is an important element of nutritional management and should be carefully considered. Caloric requirements for person with diabetes are not different from those for person without diabetes, if the person with diabetes is not losing calories through glycosuria. Caloric needs vary with the patients age, sex, and activity level. The recommended caloric level is based on an individuals desred weight and her activity patterns.

For infants, children and adolescents, the caloric needs associated with normal growth and sexual maturation must be carefully considered and growth rated should be vigilantly followed.

PROTEIN 

Individuals whose diabetes is under good control appear to have the same protein requirement as non diabetic individuals. When insulin levels are normal, protein is considers in the body and the use of amino acids for glucose synthesis is limited. How ever, individuals with poorly controlled diabetes may have increased needs for protein because it may be used by the liver to synthesis. There is non evidence that individuals with diabetes and renal insufficiency should avoid eating excessive amount of protein.

CARBOHYDRATES 

Carbohydrates should comprise 55 to 60% of caloric intake of the diabetic patients, with the form and amount of carbohydrate determined by individual eating patterns and the levels of blood glucose and lipids achieved. Unrefined carbohydrates should be substituted for refined carbohydrates to the extent possible. A diet in which approximately 60% of the total calories are from carbohydrates is recommended for individuals with diabetes because it results in a reduction in dietary fat particularly saturated fat thought to be beneficial in reducing cardiovascular risk. Recommendations for increased carbohydrate consumption are now coupled with the recommendation that foods high in fiber, especially soluble fiber be encouraged.

FAT

Consumption of total fat saturated fat and cholesterol by individuals with diabetes should be restricted. Total fat comprise less than 30% of total calories and the amount of cholesterol should be less than 300 mg/ day. A diet low in total fat, saturated fat and cholesterol is recommended for individual with diabetes to help decrease the risk for coronary heart disease. Sodium intake should be restricted. Concern about sodium is primarily directed at individuals with congestive heart failure or high blood pressure. Since people with diabetes are frequently hypertensive, it has been deemed prudent to make modest restrictions in their sodium intake. Alcohol use should be restricted entirely in persons with diabetes and insulin induced hypoglycemia, poor control of blood sugar or blood lipids or obesity. The use of alcohol may need to be restricted in over weight persons and the use of excessive alcohol consumption by a person who is fating or skipping meals can lead to hypoglycemia and may pose a serious risk for persons taking insulin. Injection of alcohol may raise fasting and postprandial levels of triglycerides. Since person with diabetes are at increased risk for cardiovascular disease, injection of alcohal should be avoided. It also recommended that pregnant women should avoid intake of alcohol. Peripheral neuropathy is a frequent complication of diabetes and neuropathic effects of alcohol may be additive with those of diabetes.

Special consideration for dietary management in the elderly: As person age, greater attention needs to be paid to their nutritional status and the dietary recommendations and advice. The provision of optional nutrition for the elderly is a major concern. Even without the complication presence of diabetes. Unfortunately, the nutritional needs of the elderly and particularly of the elderly with diabetes have not been considered. Only in recent years has this problem drawn the special attention it deserves. In general, the elderly have a higher percentage of the body fat, a lower lean body mass, and lower caloric requirement. The eating patterns in the elderly can be influenced. By the many physical, mental and emotional factors that affect them. Impaired vision, smell, hearing, taste, decreasing dexterity and memory, loneliness, illness and use of many medications, limited financial resources and transportation can all cause problem with eating. Poor teeth and gums or ill-fitting dentures are wide spread problems in the elderly and commonly lead to their consumption of softer foods high in sugar and fat. Foods containing greater amount of fiber such as fry fruits, whole grains cereals or breads can be more difficult for them to chew Depressional and physical limitations can limit their access to food.

In general it is probably best to keep the diabetic diet regimen of the elderly simple, balanced meals that fit long-standing eating habits, life-style and the physical and psychological needs of the individual. The nutritional needs of children with diabetes do not differ from those of children who do not have diabetes, not do they require special foods or different amount of vitamins or minerals. The total intake of energy and nutrients must balance the daily expenditure of energy and satisfy the requirements of normal growth. The energy content of the meal plan is based on the child age, sex, height, weight, stage of sexual development and level of physical activity when insulin is given.

DIABETES AND PREGNANCY 

The nutritional requirements of a diabetic pregnancy are essentially the same as those of a non diabetic pregnancy. In addition, pregnancy does not significantly change the basic tenets management of diabetes. The remarkable decreases in the morbidity and mortality rates among infants born to women with diabetes are thought to be due in large part to the emphasis that has been placed on rigid control of material glucose levels throughout the course of pregnancy and on the avoidance of ketonuria. During pregnancy levels of carbohydrates of 30 to 40% of total caloric intake are recommended.

FIBER

Recent studies suggest that increased consumption of dietary fiber might improve many clinical conditions, including diabetes. Some studies have demonstrated that diets containing higher amount of fiber and carbohydrates are associated with lower levels of blood glucose and serum lipids. The water soluble fibers such as cellulose, lignin, grain breads, cereals and wheat bran affect gastro intestinal transit and have little impact on plasma glucose, insulin or cholesterol levels.

Diets very high in carbohydrates and fiber consistently improve glucose tolerance, decrease fasting levels of plasma glucose, lower insulin needs and decrease serum cholesterol concentrations.

THE YOGIC DIET

In the science of yoga, diet is of great importance in the development and promotion of health and prevention of disease. Half of India is undernourished, the order half is eating the wrong food leading to a spurt in diseases like diabetes. People need guidelines on the right diet. All articles of food must be chewed thoroughly before they are swallowed. The first fundamental yogic Principal is to masticate, grind and churn every mouthful. Proper digestion is mainly responsible for healthy nervous system. Our ill health is also due to methods of handling and cooking foods. It is said , Heaven sends us goods foods but the devil-sends us bad cooks. Peeling, Soaking, Roasting, frying and over-cooking story the vitamin content and enzymes of foods. It is said hunger is the best sauce. We must eat when we are hunger. Even simplest dishes become delicious when taken under the spell of hunger. Yogic diet is not queer. It is one which contains different type of simple and natural food in such quantities that the need for energy, amino acids, vitamins, minerals, fats, carbohydrates and other nutrients is met for maintaining physical and mental health. Diet directly or indirectly influence the mind. Just as when curd is churned, its fine particles from butter. Similarly when foods is consumed, the fine particles from the mind. Food,  emotions and mind do influence each other. Yogic diet aims at harmonious development, physical, mental and spiritual. It is nutritious, vegetable, simple and easy to digest. A yogic diet increases effiaency, stamina, vim and vigour. Lord Krishna says to Arjuna, Verily, yoga is not for him who eateth too much, nor who abstaineth to excess. Yoga killeth all pain for him who is regulated in eating and amusement, regulated in performing action, regulated in sleeping and waking. Yoga practitioners avoid all narcotics, alcohol, drugs, and smoke that stimulate the senses. Yogic diet is sattvik diet and lays stress on fresh, simple, whole some and nutritious diet. It includes among other things fruits, milk, butter, cheese, wheat, salad, ghee, soya beans, green and yellow vegetables curd, lemon, oranges, rich in protein and vitamins. High blood sugar or glucose level over time can lead to deposits of fatty materials on or inside blood vessel walls. This may affect blood flow, and increase the change of clogging or cause arteries to lose elasticity. According to yogic diet principles for a diabetes patient, daily carbohydrate intake should be 45 to 55% of total caloric intake. Foods like oats, unpolished rice, pulses, beans and legumes, fruits like guava, apple should be preferred. Fat should provide not more than 20% of total energy. The protein intake should be as per body weight. A 60 kg man needs 60 gms of protein daily which can be obtained from wheat flour, dal, and milk. For a patient of diabetes sugar, alcohol, drugs are harmful. In diabetes boiled, steamed, roasted, grilled, poached is recommended over frying as it reduces the fat content in the food.

ROLE OF YOGA

Ancient India has gifted the world a great treasure in the ideology and technology of yoga. This art and science of healthy living-physically, emotionally, morally, intellectually and spiritually has been handed down to us from time immemorial. Hiranyagarbha of the earliest vedic period is said to be the first being to reveal yoga. Yoga is the sum and substance of a conceptual science to aid the progress of evolution and therefore it is eternal. Even gods could not have achieved their divinity without the knowledge of yoga. Such is the unique place that yoga enjoys in the cultural history of India.

The rigveda reveals what yoga is like when it refers to it as a vehicle a means by which a deity and through him the object in view can be achieved. It suggests yoga as a communication link or a bond between the individual and the universe and between microcosm and macrocosm. In this context the popular definition of yoga as an instrument for achieving all objects of life is significant. The unique process of knowing and achieving which is yoga is obviously different from the material science and therefore to many yoga is something extra-mundane, metaphysical miraculous or mystical. Yoga is for all living beings. We are however concerned with the human being especially the modern man at the present stage of evolution, let us then approach man as we see him in his day-to-day life and them answer.

Why must we go on a reducing diet if we want to lose weight ? The answer is simple : Because consciously or unconsciously (and probably both) we have been on a weight-gaining diet in order to put on our added pounds. we have been systematically overfeeding ourselves with results that now show up on the scale and around hips, waist, and chin line, and probably elsewhere. Now we must reverse the process.

we are going to be underfed-but only in one important respect. we are going to supply the body with each and every nutrient it needs for daily life and to keep up its reserve-except fuel. The diet is going to be calorie-deficient.

This means that for some of the energy it needs for activity, body will be forced to burn its own fat. If this calorie-deficient diet is continued for long enough, we shall gradually shrink into a form that is more to our liking. Most of the surplus fat that makes us looks and feel overweight is stored in the layers beneath the skin. It is this excess fat that, with the a consistent calorie-deficient diet, will gradually be used up.

WHAT IS A CALORIE?

A calorie is a unit of the heat-producing, or energy-producing, value of fuel. It is not itself a nutrient. When we say that a glass of milk has 116 calories, we mean that  when burned in the tissues of the body, the food will produce a certain amount of energy that can then be expended by the muscles or by other body activity. The nutrients and the fuel we need to get from our food are found in proteins, fats, carbohydrates (sugar and starch), vitamins, and certain minerals. Proteins, fat, and sugar and starches all can be burned in the body to produce energy; the energy they provide is measurable in calories.

When we count calories, we are counting units of energy-and this is why we can count the energy we expend in activity as well as the food we take in when we are planning a reducing program that will work for us. To lose a pound a week on your diet you will have to take in 500 fewer calories (or use up an extra 500) than you require each day. This 500-calorie deficit will then be made up from stored body fat.

 WHAT ARE YOUR CALORIE NEEDS? 

Energy (measured in calories) is needed to digest and store the food you eat-and energy is also used to keep other body processes going. The beating of the heart, the circulation of the blood, the activity of the brains and other organs-these all consume fuel. The average 120-pound women uses about 1,300 calories in 24 hours, even in a state of rest. This is, however, an average figure only. A great deal depends upon body size, metabolic rate, and so forth. You can, however, assume that your basic body need for fuel is about 0.45 calories an hour per pound. For example: 0.45 calories x 120 pounds x 24 hours = 1296 calories per day-or In addition to the calories needed to keep the body processes going, body fuel is needed to meet the demands of the muscles. Your daily calorie requirement thus depends to a great extent upon how active you are. The more active you are, the higher the calorie allotment on your weigh-loss diet can be. And this is why it is suggest that you increase your activity along with cutting calories-your calorie cut can be less drastic if you burn up more fuel daily in your work and play.

Age is another factors. Your basic body calorie needs gradually decline as the body processes gradually slow. For each decade of life after age 25 this calorie allotment must be reduced

Today a 1,500-calorie diet can be considered a weight maintenance diet for many 40-plus women. For other particularly younger women it will be reducing diet. How will it work for you?

PLANNING YOUR DIET 

The best way to find the diet that will lower your weight by a pound a week is to go to doctor and let him work it out for you. You should do this anyway if you have any health problem, if you are pregnant or nursing, or if you are 10% or more overweight.

If you have a reasonable number of pound to take off, you can work out your diet for yourself.

Start by making a list of all the foods you ordinarily eat each day. be sure the list is complete and includes snacks, the extras such as mayonnaise, sugar, and cream, and fairly accurately estimated portions of any food meat, vegetables, desserts, and so forth.

With this list in hand, calculate each item for its calorie content and total them-this is your average daily calorie intake.

Are you gaining on this diet? If so, multiply the number of pounds you have gained by 3,500 and divide by the number of days it has taken you to gain this amount. This will give you your average daily calorie surplus. Deduct this number from your daily calorie intake, and you have what should be your daily calorie intake for maintaining your present weight. By cutting another 500 calories from this amount, you will have a calorie budget on which you should lose a pound a week.

If you are simply maintaining your overweight on your present diet, you need only drop to a calorie count that is 500 below your present diet, and see how rapid is your weight loss. If 1,500 calories a day would maintain your weight, drop to the 1,000-calorie-a-day diet or to the 1,200-calorie-a-day diet and increase your activity by another 200-calorie expenditure daily and again you will have a loss of about pound a week.

The simplest method is to assume that the daily calorie allowance for your desirable weight will be a reducing diet for you.

HOW LOW MUST YOU GO?

With any diet there has to be some experimenting you have to see how you respond. If you gain or maintain your weight on the program you set up for yourself, you will have to decrease the calorie allotment still further or increase your activity still more.

But take care to give your diet a fair chance before you decide it is not working. In the early weeks of a diet, water may replace fat and your weight loss will not immediately show up on the scale. Or you may at the start lose as you expect to and then maintain weight on the diet for the several weeks that follow. Again, this may be a result of water fat balance. Or you may also have to consider weight gain from retention of body fluids in the monthly cycle.

At the end of six weeks you should know whether you are actually losing and whether the weigh loss is going on at a reasonable rate.

If there is no change by this time, you may have to reduce your calorie intake by dropping to a still lower calorie count.

Sometimes it is necessary for the reducer to take in no more than 900 or even 800 calories a day to realize an adequate weight loss. Any diet under 1,000 calories should have your doctors approval and supervision.  All foods needs other than calories can barely be provided in an 800 calorie diet. Planning of menus at this low calorie intake must be extremely careful to ensure that you are not losing needed nutrients as you cut calories.

WHAT ABOUT SKIPPED MEALS?

It is usually advisable to set up your menus on a three meal-a-day plan. The gives you food intake during the day when you are using most fuel for activity. Blood sugar will thus not fall bellow normal,  and you will not be overcome by lassitude or fatigue. With a three-meal-a-day diet the meals eaten at the same time of day each day a rhythm of eating and fasting is established that can make it easier to stay on your diet without snacking.

Each of us is, however, an individual and we have to use the plan that works well for us. Recent medical studies have shown that some women who could not lose on a 1,000-calorie three-meal-a-day diet could lose on an 1,100-calorie daily ration if they consumed their food on a two-meal-a-day basis. Another study has shown that a NIBBLE diet six small meals a day has been effective for some person who could not lose weight on conventional three-meal menu plans. If you get along perfectly well by skipping lunch or another of your meals and find that everything goes better that way, no one will gainsay your doing what works best for you. It is important to realize, however, that diet planners who work with large groups of would-be reducers suggest that the three-meal-a-day menu plan be followed

BE AWARE OF BODY CHANGES

For any dieter some or many of the hunger that threaten a weight-loss plan will be emotional. Food can serve as a substitute satisfaction for many needs other than those of the body for nourishment. The needs to give yourself a treat, the needs to relieve tension, the need for companionship are a few. Still, some of the seemingly psychological urges to break your diet can arise from the changes that are going on in your body as you loss weight.

For the body to burn its own fat rather than to get instant fuel from food intake means a change in body processes. Your constitution may well express alarm at having to call upon its reserves for its present needs. And you may well react emotionally with a feeling of depression, of deprivation, and of anxiety. Compare the situation with the desperation you might experience if, in an emergency, you had to start making a cake from basic ingredients when always before you have had instant cake mix.

To force your body to burn its own fat, your diet must be calorie deficient. But your diet must also be planned to satisfy many of your physical and emotional needs.

Your diet will go better if each of your daily portions is planned ahead to be most satisfying to both these needs. Realize that the meal plan you use should be the one that works best for you. The generally accepted food allotment pattern is 40% of your calories at breakfast 20% at lunch, black coffee only at morning and afternoon snacks, 40% at dinner. The milk allotment can be kept,if desired, for between-meal or bedtime snacks.

Some women prefer to eat a smaller portion at breakfast and more at lunch and dinner; some women get along perfectly all right without snacking. Other feel they must have a large allotment for their between meal nibbling. So long as you do not go over your daily calorie quota, you will lose weight no matter at what time of day you take your food.

YOUR DIET AND FAMILY MEALS

The menu plans and recipes in this guide are designed for a women who will be eating with the family and it should be possible for you to eat at least some of many items your family eats. Sometimes breakfast, lunch, and between- meal snacks can be planned for you to eat alone, but dinner for family women should be a family affair

Plan ahead what portions you will have, what foods you can share, and try not to call attention to what the family can eat and you can not touch. Keep mealtime a relaxed and cheerful occasion, and this means: Do not complain. Stimulate conversation and eat slowly so that you finish with the family even if they go on to second helpings.

A good deal of your diet success in the family eating pattern will depend on your planning your food allotment for the whole day and in your knowing clearly what portions you can have.

It is also important that the different calorie needs of family members be considered. Family member also differ in nutritional needs. Each of your family members will probably have a higher calorie requirement than your own. Your husband can probably take in more calories because of body size and activity. Children need calories for both growth and activity. The need for added calories persists through teen years.