MISSING THE BOAT

     We often see and talk about the  phrase ,'missing the boat'. Now a days the real estate prices are going up a little bit ,and when we will realize that we did not buy the real estate when we should have bought , we say we miss the boat . This is also said in case of stocks . But I don't think we ever say ( at least  not often ) that we missed the boat .But if we look at the medical conditions , it could be appropriately said that the patient or even doctor missed the boat . I have seen some unfortunate patients , that do seem to have missed the boat . They quit the smoking , and still get cancer . And when this happens after 5 or 7 years after quitting the smoking , then it certainly 'hurts'. The statistics states that it takes 13 or even 14  years the chance of developing cancer of the lung is same as nonsmoker .PLEASE note that nonsmokers do get lung cancers too. So it is never zero. I had a patient who had not smoked and had some fibrosis , scar tissues in lungs and had history of breast cancer , developed lung cancer . In fact I was shocked and even the patient was too . The yearly X-ray that I order on all my patients , except in those who have pure asthma , showed the mass in her case .This is not unusual . In fact there is a constant debate weather we should be doing X-ray or CT scans in smokers or ex-smoker .The argument is against it is that is  not cost effective as we may have to do too many X-ray to diagnose one cancer and so we may be spending too much to get one success. IN MY MIND IT IS COST EFFECTIVE TO THE ONE THAT I COULD DIAGNOSE THE CANCER IN EARLIER STAGE . In her case the cancer popped up in 11 months . And it was 9cms large . It was so large that she thought that I may be seeing her ruptured breast implant . She was inoperable . We gave her radiation and chemotherapy. But it did not make much difference . Again did we miss the boat ? There is no reason to do X-ray more often than yearly , as otherwise we may be increasing the amount of radiation and also the cost .But the story that I am going to tell is that of a patient , that I feel we missed the boat . I am not sure if it could have been prevented . But we did miss the boat .
     This was a 72 years old patient , who could not speak much English . She spoke creo. I saw her for the complains of cough and some shortness of the breath . She had high blood pressure and diabetes and was obese. She probably had sleep apnea too . This was her third admission . During her last admission , she had echo cardiogram and due to complains of chest pain had heart cauterisation. It had shown the blockage and so she had stent put in It was only 6 weeks and the work up for heart attack was negative . I thought that she had asthma and so I started her on inhaler and she felt better . She was discharged . She was readmitted and was discharged again , when the cardiac work up was negative .I saw her again as she was readmitted for the cough . She did not do follow up with me and had stopped her inhaler . The admitting doctor thought that her cough may be due to one of her blood pressure medicine .So he stopped it . She also had chest pain . But it was on both sides and id not sound like cardiac pain . But the cardiologist was consulted again and he wrote that it was non cardiac pain . Her chest x-ray was OK and her oxygen saturation was 100 %. I restarted her on some inhaler and ordered allergy blood test and also gave her on shot of steroids. The next day she was better . But that night I got a call that she was having shortness of breath and some chest pain . I ordered the treatment for asthma and did the test to make sure that it was not heart attack . Next morning when I saw her she had no problems , her lungs were clear and oxygen was 100 % with no oxygen supplement needed . I actually saw her at 2 pm . I was in dentist's office , when the nurse called me . She was short of breath had chest pain , again on both sides and her oxygen was low .The rapid response nurse was there . The had put her on 100% oxygen . I also told them to do stat X-ray and ordered the blood test for the heart attack . I also gave her a shot of steroid and the breathing treatment . It was 4-30pm and I saw her in next 15 minutes .
    When I saw her it was clear to me that she was in heart failure .They had called the cardiologist and his answer was there is nothing wrong with the heart and call the lung specialist . The X-ray confirmed that diagnosis , the blood test confirmed and the diuretic that I had ordered on telephone had helped her . We had her transferred her to ICU . The next day she was off the oxygen and was fine . I had talked to the cardiologist and he scheduled the heart  catheterization  .The cath showed that her heart function had gone down to 20 % and the stent had blocked .Other than giving her medical treatment , nothing much could be done .
DID WE MISS THE BOAT?

WEIGHT LOSS -PRACTICLE USE OF THE KNOWLEDGE

    I talked about the weight loss calories , intake , spending , exercise and more . So now the question comes up , how to make a use of it in day to day life .So let me state some of the ways to make use of this information .
   1. Check the weight and if possible BMI. Weighing daily is useful . It gives us reminder about our weight and BMI and make s try harder , So WEIGHT DAILY and at the same time with same clothes on .
   2.Buy a pedometer . Do an average of your activity for a week and then add to it a REASONABLE number of steps . Make it a point that you will not go to bed unless the goal is achieved . Say you decide that you want to add 5000 more steps a day , in addition to your usual steps . YOU MUST DO IT EVERYDAY AND NO EXCEPTION.
    3 . Walking is good and if you do it more than once a day , it is better , Every time you exercise your metabolic rate goes up and remains higher for longer time than the duration of exercise . So doing it 3 or 4 times is better . If you can run instead of walking , then do it , as with running your metabolic rate goes higher than walking . So one may run for one or two minutes , then walk for 2or 3 minutes , and repeat it for total of 20 minutes .
    4. One must do 3 types of exercises on a daily basis .This is more important for people over 40 , or people who have not done exercise for a longer time ..The stretching , cardio and weight training . The stretching must be done daily . The cardio could be done 3 or 4 times a day to get cardio benefit . But if you want to loose weight, then you must do it as many times a week as possible .
     5 Carry some extra weight, if you are just walking . Do more leg exercise with higher weight than doing arms . Try to build muscles ,as this will help you to burn more calories .
      6. There are many diets and each probably has something to offer . My suggestion is to follow the diet that you can continue for the rest of your life . my suggestions are here , But these are the basic principles .
       a. Eat at least 6 to 8  servings of fruits and vegetables . Keep in freeze some of them , like carrots , cauliflowers  or celery or whatever you like Eat it as many times as you can . You may eat them in significant amount , before you eat main food .
        b. Drink at least 8 glasses of water a day . Drink a glass of water on waking up . You may want to drink a glass before you start .eating. The water and the vegetables with very little calories  , will stretch the stomach muscles and stimulate the satiety center and make you feel full .
       c. Try  to not eat simple carb .or pure sugars. These will  raise the blood sugar , which in turn will stimulate insulin secretion and that will create more fat . So check glycemic index of every food that you consume and either eat the one with low glycemic index or try to see if you can reduce the glycemic index . e.g the bagel  is high glycemic index food , but you can add peanut butter and lower the glycemic index .
       d.NO PROCESS FOOD . Avoid white rice , white bread, wheat pasta or white sugar , white potato . Brown rice , whole grain bread or pasta or sweet potato are better .
        e. I like to avoid animal proteins . Please see a DVD called Forks over knife.
       f . Please remember that 1 gram of carb is 4 calorie, 1 gram of protein is 4 calorie , but 1 gram of fat is 9 calorie . Soft drinks , sodas and alcohol are empty calories .   

WEIGHT LOSS -3

       I tried to talk about some of the theory of the weight loss . Now we need to see how we can put these principles in practice , in our day to day practice . Let me tell couple of things before that . Let us say it is Thanks Giving and you start eating . .When you are finished you feel that you still can eat some more . But then you realize that you had looked at yourself in the mirror and wanted to start cutting back on the intake . So even though you could eat an extra piece of turkey ,you control the desire . But then 15-20 minutes pass by and now you feel that you have overeaten and your stomach is going to burst . So when you 'finished' eating , you did  not feel that full as much as you are feeling after 20 minutes . So what has happened ? This due to the satiety center . We have a center in the brain , that tells us that we are full . But it takes about 20 to 30 minutes for the satiety center to  get stimulated . So we feel more full after about 20 minutes of finishing eating .This can be used to loose weight . So if we eat slowly , then we will feel full and not overeat ..
      One more point is that this center gets stimulate by stretching of the stomach . This sends a signal to the center and then we are suppose to stop eating . IT does not matter as to what stretches the stomach . So we can make use of these two facts . One we can fill  our stomach with low calorie food , like any vegetables like cabbage , cauliflower , broccoli , or carrots , and it will stretch the stomach muscles and we will feel full. Secondly if we eat slowly and allow the satiety center to get stimulated we can avoid the overeating .
      One more thing to make use in loosing weight . I call it area under the curve . Let me explain . If I start running , my metabolic rate will go up . It happens very quickly . and it will continue to be up as long as you continue to exercise . So say my metabolic rate is 40 ,and when we start exercise, it goes to 60 , ( 60 calories per hour ).So when we stop the exercise , the metabolic rate goes down . But it can not go down to 40 , as soon as we stop . But body continues to burn at higher rate , though slowly reducing too baseline  of 40 . So WE CONTINUE TO BURN AT HIGHER RATE EVEN WHEN WE STOP THE EXERCISE . This is bonus for our calories spending .
      We can make use of these facts in our plan to loos weight and get healthier .

WEIGHT LOSS AND SCIENCE 2

       I mentioned some of the things which are important in understanding how to loose weight ..The basic principle is that one has to take in less calories than what we spend . This is not as simple as it looks . One of the misunderstanding about the weight loss is about exercise .. When I see patients , common excuse is that I can not run or jog and so I can not spend enough calories .Let me make it very clear that if I run 1 mile or jog 1 mile or walk run mile , in all these cases I will spend the same calories . THE RUNNING DOES NOT SPEND MORE CALORIES provided the distance is same . The calories spent is related to the distance and not how quickly you do it . So if I run a mole , I will spend "X' calories , say in 10 minutes , I if I walk a mile in 20 minutes , then I would have still spent same 'X' calories. So someone is short of breath walking 1 mile , he can do the mile by walking 1/4th mile at a time 4 times a day , Then he would have spent same calories if he would have run one mile in 10 minutes .
      I am sure you  know someone , who eats more than what you do and still does not seem to gain weight .So then question arises , how come he or she does not gain weight and I gain eat , even when I eat 'hardly anything ' ?The answer is kind of mixed . Many a times I see people who claim to eat very little and exercise , and don't loose weight . On more questioning I realize that the 'very little ' that they eat is not that little or the exercise that they do is not that much or does not 'spend' the same calories , that they consume . Let me give an example . The 31 minutes of bicycling will burn same calories that one will get by eating 53 peanuts!!or how about eating 16 French fries will give same calories that you burn by doing 'housework ' for 90 minutes .There are more examples , but you get the point . IT IS SIMPLY NOT FARE !!. There are hidden calories in many things that we eat and don't realize .
    Let us assume that we are very careful and we eat exactly the same calories that this other 'lucky' person eats and we both do same exercise . But he or she does not gain weight and we do . The answer may be in the %body fat. Let me explain . You weigh 180lbs . and your friend weighs 180lbs You have % body fat of 30 % and your friend has % body fat of 20 %. Fat cells do not contribute much to basal metabolic rate . Our body has lot of water , but if we consider that both have same amount of water , than you have 70 % of cells that are burning calories and your friend has 80 % of the cells that are burning calories actively . So your basal metabolic weight is lower than that of your friend . Naturally he does not gain weight ,but you do . Remember that the muscles burn calories not fat . So more muscular one is , more calories he will burn . So TO LOOSE WEIGHT ONE MUST BUILD MORE MUSCLES . So even though the weight is same the ability to burn calories is different .
   So now the question is how do we burn more calories . The answer is simple . ONE HAS TO DO MORE CALORIE BURNING EXERCISE. If you walk , and walk for 30 minutes , but cover only a mile you may have to walk more distance to spend more calories than one who covers a mile in 15 minutes . So if you can not walk faster, then if you carry more weight , you will loose more calories . It takes more work or takes more calories for a 180lbs man to walk 1 mile than  that needed by 150lbs man to walk 1 mile . So if you carry with you more weight , 10lbs or more , you will burn more calories than if you just walk without those extra weights .
   Suppose you go to gym . and do the 'weights' .If you lift 5lbs of weight you will burn 'x' calories and if you lift 10lbs then you will  burn 2 x calories .But there is a limit as to how much can you lift with bicep curls . So the key to burn more calories is to lift more weight , and higher . If you do leg press , then I can bet you that you can lift significantly more weight than toy can do with biceps or deltoids . So even though good looking biceps are more appreciated as they are noticed that the quadriceps , it is more beneficial to do more leg press and burn more calories .
     

WEIGHT LOSS AND SCIENCE -1

    I know there are many diets for weight loss and many advice columns . There are commercial institutions that do a descent job of giving people some success. I do not claim to know anything special or have done something personally that has worked , but I do believe that certain principles are important to know and follow .  I will start with some basic understanding and then expand upon it to see if one can follow certain principles and do their own plan . So let us start .
    BMI -- This is used to determine if one is overweight or obese or morbidly obese .It is calculated by knowing the height in meter and weight in kilograms .So it is the weight in kilogram divided by height in centimeters. square  . So we can not quickly calculate it as we are not used to metric system . So it is better to use table that will tell you the BMI .If the BMI is less than 25 , you are OK ,( my BMI is24).if it is 25 to 30 , you are overweight . If the BMI is more than 30 then he or she is obese . I have seen patients who have BMI of 70 !!!.
    Percentage body fat - This can be calculated by various techniques . Again there are weighing scales that will calculate body fat percentage , when you stand on them . There are others that you need to hold in your hands to get body fat . Less than 20 % is good , less than 25 % is acceptable . But this will play role in weight law game . So it is important to know it .
     Glycemic index -- This is important to know as it will help one to 'select ' the proper food to be incorporated in your diet , based on the glycemic index. When we eat food , it is absorbed and the blood sugar goes up . The different foods do not increase the blood sugar  by same amount . This is called the glycemic index . The amount of ups and downs are important in the weight control , so it is important to know the glycemic index . If one eats 100grams of carbohydrate as potato (not 100 grams of potato , but 100 grams of carbohydrates from the potato . ) then the sugar rise would be different than the amount of sugar rise that would have occurred with 100 grams carbohydrates from soft drink --coke . The pure sugar in coke will raise the blood sugar quickly and then the body will secrete the insulin and the sugar will come down. The sugar rise that will occur with the complex carbohydrate like potato is more slow and sustained than sharp rise and fall that occurred with coke which contains simple carbohydrate. When the sugar drops down with insulin , then one will feel hungry and the we eat more . Also the insulin is lipogenic and it will deposit or make more fat .
     The thyroid problem -- I have seen too many people giving excuse of abnormal thyroid function as cause of weight gain or inability to loos weight . Though it is true that low function thyroid will make metabolism slower and so the patient will gain weight, it is not the cause of persistent weight gain or inability to loose weight . The problem is not with the Thyroid GLAND  but is with the other gland , namely the salivary glands .
     Use of steroids - This is a real problem . We tend to use the steroids in treating many conditions , including the asthma or colitis .or arthritis or any other inflammatory conditions . This will  cause weight gain by promoting appetite , retaining salt and water and   changing the distribution of the fat in . the body.
      Quitting smoking - Many patients will gain weight when they quite smoking .This may be partly due to improvement in the sense of smell and this in turn will make one eat more as food tastes better . It also could be due to smokers 'munching ' on food as they have more free time as they are not smoking
       Metabolic rate --Our body needs calories to function . Even when I am sitting doing nothing , my heart , brain , kidney etc are still working and so I am burning calories . This is called Basal Metabolic Rate . It goes up with any activity. So we need to make a use of  this .knowledge in weight loss . .
       I will talk about how to make use of this knowledge in next blog .
        

THE LAW OF DIMINISHING RETURN

    I was talking to some of my friends , that I have known for last 40 years or so . All of them are doctors . While talking to them I realized that none of them 'enjoy ' the practice of the medicine as much as they did several years .This may be due to government rules and regulations , which has increased over period of the time or may be high handedness of the insurance company or may be because of the hospitals gobbling the private practices or may be even due to the uncertainty that is brought in by the new Obama care . Whatever may be the reason , but there is less enjoyment in the practice of medicine . But then when I was thinking about it I realized that in life there is always less pleasure in doing things that gave us pleasure in past . One of the friends was also asking as to how many marriages are happy marriages. I asked him a question as to what is happiness ?He was not happy with the question as he could not answer . I was trying to point out that the pleasure does not come from the object out side .Let me explain . Let us say I enjoy eating pizza . So if I start eating it the first slice of pizza will 'give ' pleasure , when I eat second or third or tenth slice of pizza , the pleasure is not same .So if the pleasure is in eating pizza , then the amount of happiness that I get by eating pizza, should be same with first or tenth slice . Think about it , if pleasure is in having sex , then it should not matter if it is rape or regular encounter between husband and wife . (for that matter is the pleasure same comparing many years ago to now ?) So if the pleasure is outside us , then every one should enjoy or feel happy with any food at any time or having sex with any one or every one should enjoy all kind of music .So the source of happiness is in our mind and not in external source .So now we realize  that this the law of diminishing return . This is also seen in biology . If you stimulate a muscle then  response is less with successive stimulus . This is seen in every place in body , does not matter if we are talking about mind or body or may be even intellect .
      So if we talk about happiness , then we should be talking about our own mind and not he outside source . It reminds me of a story of a king . The king was sick . So several doctors came and tried to treat him . He did not get better . So then a saint came in . He talked to the king and realized that it was not a physical illness but mental illness. So he advised that if the king would wear a shirt worn by a 'happy 'man then he would be cured . So the king sent his soldiers to look for a happy man . They went house by house to look for the happy man . Every house had some problem. Someone had some cancer , blood pressure or diabetes . Some houses had problems with kids or parents or job . NO ONE WAS HAPPY . Finally in desperation they ended up going outside of the town . They found a man who was sitting on a big rock , looking over waters and enjoying the morning sun . The soldiers asked him if he was happy . He answered 'yes'  So  they took him to the king . The king asked him same question , if he was happy . He said yes . So then king asked him to give his shirt to him . The man answered 'he does not have a shirt , why do you need a shirt ?'
      So if you look for the happiness outside of you , then there is law of diminishing return .

SCIENCE AND THE GOD

     The other day I was with some friends and were trying to read one of old "sant literature " or for those who know , sant Tukaram gatha . This saint is from the Maharashtra state in India and has many stories . One of his creation is called Tukaram Gatha , which has several Abhang, which for many is worship of the God . Somehow we went in to discussion on why the scientists do not believe in the GOD, and then I started thinking . Many who call them self scientists do not want to believe in existence of God . So is believing in the GOD is not scientific or being believing in science means one has to atheist? I have heard several arguments and I thought of dealing with some of them .
    1 If GOD is kind and merciful , then how come who have problems , murders, wars car accidents and children getting killed and cancers and son and so for .There are 2 problems with this thinking, one is that when we assign the GOD with all these attributes, like kind and merciful and forgiving etc , we are making Him Human being .So if he has 'good ' qualities  like human beings , then he will also have 'bad ' qualities . Then we can't blame Him . Secondly 90 % of the bad things that happen are 'our' doings . The wars are caused by us and every other bad deeds are done by us and then we blame him .If we 'behave ' then many of the bad things will go away Will it eliminate sorrow from the world , no but it will be better. This is call free will . This leads to the law of karma . We make decision on our own and this freedom to make decision giver us our future , good or bad , in this life or next life or next and next .
    2 How come what we were taught in past about the earth , universe is proved to be wrong by science .The things that were  mentioned in so called religious books are not necessarily spoken by or written by the God . This what happens when we take 'literal' meaning of the things that are written in the scripture . Take for example the story of the Adam and Eve . They were happy till they broke the law /rule of the God .And the rule is not one that is 'don't kill ' or don't lie ' , but the rule was 'o not eat the fruit from an apple tree " At least to a casual reader or observer this looks like a rule that 'parents ' lay down , no explanation, but just "Do as I say ". Would the God make such a rule , which does not make any sense , nor there is any moral value to it , other than HE MADE THE RULE . So  how can we make any sense out of this story? The explanation that I have ( and I liked ), is as follows . The Garden of Eden is the human body and the real garden . The fruit tree that was in the middle of the garden is the sex pleasure or may be the engagement in sense organ indulgence. There is nothing that says that we should not 'enjoy ' the beauty of the great things that the God created . But when we indulge in it we commit 'sin'. When the Adam and Eve started engaging in the act of sex for no other reason than lust , then we are breaking the law set by the God . ( most of us do this on multiple occasions and human beings are the only animals that engage in the sexual activity at any time of life cycle ).If you notice , in the story after 'eating ' the apple, they were ashamed of their body and covered the body.
     There are many other similar explanation in the other areas of the scriptures . May be we can talk about other questionable or confusing statements .