Was
It Something I Ate Doc?
Raj Mehta experienced difficulty shaking off the gnawing sensation in his upper
chest and jaw. He even wondered if it was a pain at all – it felt more like an
air hunger. As he scooped up another shovel of snow, he realized that he was
sweating. Strange, he thought. Only yesterday, he used his treadmill for 30
minutes without trouble. Yet, the sweat beads were real despite the cool January
morning air rasping violently through his airways. The next few hours were a
blur. He seemed to vaguely recall the matter of fact attitude of the EMTs
and emergency room staff before he was whisked off to the cardiac
catheterization laboratory of the hospital. He was informed later that a blocked
coronary artery had been successfully re-canalized with a balloon catheter.
A
day later, wired and propped up in coronary care hospital bed, the realization
sunk in. He had suffered a heart attack but the balloon procedure had thwarted
any real damage. Dr. Prakash Dhilwalla, a cardiologist, had spoken to his wife
briefly assuring her that he was over the worst. Rats, he could not help
thinking, he had struggled to settle in this economic capital of the western
civilization 7000 miles from home and he had to be assigned a desi cardiologist!
As the doctor walked in with his entourage of medical students and residents,
his jaw dropped – he wasn’t expecting this tall authoritative well attired
figure. Any doubts regarding the veracity of the nurse’s earlier assertion
that Dhilwalla was listed among the top ten in a recent national publication,
quickly dissipated.
The doctor spoke clearly and softly: “Mr. Mehta, you are a lucky man, any more
delay getting to the hospital and, you could have been in trouble. One of the
three main arteries that supply your heart muscle blocked up and you could have
sustained a large heart attack had it not been for the fact the vessel was
opened up in a timely fashion before any real muscle damage occurred”
Mehta felt at ease. It must have been the physician’s amicable nature and the
hint of desi demeanor that dispelled any anxiety about exposing his ignorance of
medical biology. The questions gushed out like water from a fire hose.
“Does that mean I did not really have a heart attack doc?”
“No, the tests suggest that you did sustain a small heart attack” the doctor
was confident in his tone. “However, because the blocked artery was opened up
within 6 hours of the event, we may have prevented any significant damage and it
is likely that the muscle will recover completely over the next few weeks”.
Some of Mehta’s questions had a sense of urgency in them “Why me doc? I am
just 46 years of age”
“Atherosclerosis, a process of fatty deposition in the inner linings of
arteries, starts at an early age. In fact, post mortem examinations of arteries
of young men dying from other causes have shown that this process can start as
early as the teen years. Atherosclerosis of the coronary
artery that can progress to occlusion of the artery and heart attacks
usually occur at a later age. Regrettably, south Asians develop coronary artery
disease at an earlier age.”
“I just saw my primary physician last month and he told me that I was healthy.
My cholesterol level was normal” Mehta had difficult suppressing a rising
sense of anger.
“Several risk factors have been identified for the development of
atherosclerosis. These are primarily: high lipid levels, high blood pressure and
diabetes. Let’s talk about lipids a.k.a. blood fats. The main lipids are
cholesterol and triglycerides. Cholesterol has two principal components; the low
density lipoproteins (LDL) high levels of which are directly implicated in heart
attacks. The high density lipoprotein or HDL, on the other hand exert a
protective effect and hence, higher levels of HDL are desirable. I note that
although your total cholesterol and LDL was normal Mr. Mehta, your HDL levels
were low. Unfortunately, it is not easy to improve HDL. Drugs have little effect
although exercise is known to improve levels. Elevated levels of triglycerides
are also important in the genesis of heart attacks. Your triglyceride level was
marginally elevated but not sufficient to be treated with a drug at the time you
saw your physician last month. It is of interest that this type of lipid profile
i.e. normal or slightly elevated LDL, low HDL and high triglycerides is the
typical finding in south Asians who develop coronary disease”.
Mehta was not sure he understood all that gobbledygook but made a mental note to
get on to the internet as soon as he got home.
“I have always been a vegetarian doc and never eat meat – so why should I
have these cholesterol problems?” The sense of frustration in his voice was
readily apparent.
Dhilwalla smiled in recognition of this common misconception.
“First of all, Mr. Mehta, the fact that you do not eat meat does not mean that
you do not consume animal fat. All that milk, butter and ghee that is integral
to your good wife’s delicious cooked meal exposes you to all of the dietary
saturated fats and contribute to one’s adverse lipid profile. Secondly,
dietary fat is only a small component of blood cholesterol levels – your
genetic make up plays a significant role in how your body handles fat. Finally,
and most importantly, it is becoming increasingly apparent that high calorie
intake maybe a greater risk for atherosclerosis by aggravating a condition
called “insulin resistance”. Remember Mr. Mehta, you compensate for the lack
of meat in your diet by higher carbohydrate intake. Calories unused by the body
will be stored as fat whatever the original source. That increased abdominal
girth you carry around means that you are taking in more calories than you
burn”.
“Insulin resistance? That’s a new one for me doc”
“Insulin, the hormone secreted by the pancreas is essential for the tissues of
the body to use glucose as source of energy. Insulin resistance is due to a
reduced sensitivity of the target tissues of the body to the action of insulin.
The body attempts to overcome this resistance by secreting more insulin from the
pancreas. This compensatory state of hyperinsulinemia (high insulin levels in
the blood) is felt to contribute to the progression of arterial disease. Ten to
twenty of people are prone to this condition of insulin resistance; the prevalence
maybe much higher in the south Asians such as Indians. Although blood sugar
measurements may not indicate diabetes at an early stage, most progress to
develop full blown diabetes”.
“What am I to do doc? Should I shed my traditional beliefs and give up
vegetarianism?”
“Absolutely not, Mr. Mehta”. The emphatic note in the doctor’s reply was
comforting. “On the contrary, the fact that you avoid meat makes it easier for
you to keep your calorie intake low; fats when metabolized generate twice the
caloric energy of carbohydrates. That having been said, refined carbohydrates
such as sucrose laden sweets, high fructose corn syrups, white bread and white
rice are metabolized rapidly. They cause abrupt increase in blood sugar levels
and induce insulin secretion. Given the high likelihood that you have a degree
of insulin resistance, high glucose levels can stress the pancreas and hasten
development of diabetes. Terribly important to keep that sugar level low
ol’chap.” Dhilwalla’s years of training in Britain were leaking through
into his speech.
“And how about alcohol doc?” Mehta remembered a Boston Globe article on how
alcohol did a heart good.
“Alcohol in any form and in moderation, e.g. one or two drinks 3 or 4 times a
week appears to reduce the chances of heart attacks. However, this observation
has not been conclusively proven by good clinical studies. If you have never
drunk alcohol before, now is probably not a good time to start. You may find
that you are one among the occasional person genetically predisposed to alcohol
addiction and then you’ll have another problem on your hands”
“How can I reduce the chances of another heart attack doc?”
Dr. Dhilwalla was delighted; this man was intelligent, well read and receptive.
He was asking the right questions. It was a pleasure to impart information to
the likes of this patient.
“You will be prescribed several medications that have proven value in reducing
chances of another heart attack. They will include a drug that reduces your
cholesterol further. As for the problem of insulin resistance, regular exercise,
dietary restriction to minimize refined carbohydrate and regulating your weight
offer you the best chance to combat this problem of insulin resistance”.
Raj Mehta glanced furtively at his wife sitting by his bed side as if to
indicate that she needed to take note of this dietary discretion.
“One final question doc. Are my children at risk for developing coronary
artery disease?”
“They may be, given your genetic influence but environmental factors play a
major role. Teach them good eating habits and encourage regular exercise. You
are lucky that you live in a society that looks down upon smoking – used to be
the major environmental enhancer of risk”. The doctor’s hand was warm
in his departing hand shake.
Mehta
felt good about his interaction with Dr. Dhilwalla. A lot of information to take
in but the gist of it was easy to remember: less refined sugars, more regular
exercise and keeping the body weight down. As he drifted back to sleep hung over
from the previous day’s sedatives, he mumbled to his wife – “Neelima, no
more cases of Sprite and Pepsi from that warehouse store. It’s full of sugar
– the kids should learn to drink water instead. And remember to sign us all up
with Gold’s gym. We’ve got to get this “insulin resistance” under
control.
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