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Sunday, June 23, 2013

Vitamin Alcohol: Is it a cardio tonic ?

Alcohol or liquor.  दारू or शराब in local lingo. The word is a deterrent in social circles especially the Muslim community. The topic itself is taboo and any discussion related to that would be considered a heinous crime. 
But, doctors as we are. Our medical history isn't complete without the mandatory questions related to alcohol or tobacco intake. 
Just the other day, I was put in a terrible professional dilemma. A middle aged, educated Muslim gentleman who had visited my chambers for a consultation, didn't deny that he was a social drinker. Since it was a routine health check up, I safely sidestepped the sensitive issue of alcoholism and gave the other relevant medical advice. But, Mr.X then posed the most difficult question to me. Doctor, he said, "Can I safely still continue my social drinking if all my parameters are normal?"
Being a Muslim myself, it was tough for me to allow him that liberty. But being a medico, I tried to sound politically correct and said, "better to avoid". And it was then that he asked the inevitable. The question that I dreaded to answer since long. "On the contrary, medical science says that moderate drinking is healthy for the heart and and helpful in various other conditions", he argued. I was left speechless. 

Heavy or binge alcohol consumption unquestionably leads to increased morbidity and mortality. Nevertheless, moderate alcohol consumption, especially alcoholic beverages rich in polyphenols, such as wine and beer, seem to confer cardiovascular protective effects in patients with documented CVD and even in healthy subjects.

Alcohol is absolutely contraindicated for pregnant women, children, patients with liver disease and in combination with certain medications. 

The basis of this theory dates back a long way to the times of the French Paradox

French Paradox:

It was the paradoxical observation that the French have a low incidence of coronary heart disease (CHD) despite subsisting on a diet rich in saturated fats.      

The two possible explanations are: First, the theory linking saturated fats to CHD is totally invalid. 
Second, the link between saturated fats and CHD is correct, but some intermediate factor in the diet or lifestyle of the French mitigates this risk. This factor was then identified as Red wine

This French paradox then triggered many a study where the effects of red wine and its components - polyphenols and resveratrol were evaluated. It also opened a debate as to which alcoholic beverage was more cardio protective. 

Moderate alcohol consumption is cardio protective. But how much is moderate?
The common man defines it thus: Moderate drinking may be defined as drinking that does not generally cause problems, either for the drinker or for the society. 

But US National Institute on Alcohol Abuse and Alcoholism (NIAAA) has defined moderate levels categorically as:-

Men: Maximum of 2 drinks per day or 14 drinks per week or 
4 drinks in a single day
Women: Maximum of 1 drink per day or 7 drinks per week or
3 drinks in a single day

Examples of one drink include:

Beer: 12 fluid ounces (355 milliliters)
Wine: 5 fluid ounces (148 milliliters)
Distilled spirits (80 proof): 1.5 fluid ounces (44 milliliters).

This difference in the gender is because the female sex is unable to metabolize alcohol as efficiently as its male counterpart due to reduced levels of the enzymes alcohol and aldehyde dehydrogenase. These enzymes help in the breakdown of alcohol and since females have a relative deficiency of these enzymes, they show higher levels of intoxication for the same amount of alcohol ingestion. 

To conclude,

The latest dietary guidelines thus make it clear that no one should begin drinking or drink more frequently on the basis of potential health benefits. So don't feel pressured to drink alcohol. But if you do drink alcohol and you're healthy, there's probably no need to stop as long as you drink responsibly and in moderation.

Tuesday, June 18, 2013

Fish Oils: Food for thought

Omega-3 fatty acids refers to a group of three fats called ALA - α-linolenic acid (found in plant oils like flaxseed) , EPA-eicosapentaenoic acid and DHA- docosahexaenoic acid (both commonly found in fish oils). 

Omega-3 fatty acids or PUFA are considered essential fatty acids because these are not made in the body or are inefficiently converted from ALA to EPA and DHA. Thus, we need to get them from our diet .

Omega-3 fatty acids reduce the risk of arrhythmias, decrease the triglyceride levels, slow the growth of the atherosclerosis and marginally reduce the blood pressure -by reducing the inflammation and lowering the clotting risk. They also play a beneficial role in dementia, depression, arthritis and certain cancers. 

American Heart Association has recommended eating fish like salmon, mackerel, tuna, herring and sardines which are rich in omega-3 at least twice a week. Some types of fish like the shark, swordfish contain high levels of mercury
and environmental contaminants and need to be avoided especially in pregnant ladies. 

Experts usually recommend 1 gram of DHA and EPA combined from fish oil daily for those with heart disease. People with high levels of triglycerides may take doses of up to 4 grams a day under the supervision of a physician. There is an increased tendency of bleeding in people taking high doses and especially those who are on anti platelet drugs and anti coagulants. 

However, the recent randomized trials
in high-risk populations (those with either multiple risk factors or a history of cardiovascular disease) have suggested very little benefit from omega-3 fatty acids.

Patients with multiple cardiovascular risk factors were given 1 gram of fish oil per day vs placebo, and it showed no benefit. Also, other meta-analyses have been published in the past year that looked at all of the randomized trials in aggregate. These are secondary-prevention, randomized trials with high-risk populations. In general, these meta-analyses have shown disappointing results.

It is very important to keep in mind that these high-risk populations -- include many individuals who are already taking multiple heart medications such as statins, aspirin, and ACE inhibitors, which may obscure the effect of omega-3 fatty acids. There may be very little incremental benefit from omega-3 fatty acids in that setting. 


First, these randomized trials of fish oil do not advise against the recommendation to have at least 2 servings of dietary fish per week. That is a recommendation from the American Heart Association and many other professional societies, and many studies suggest benefit. Some of the benefit may be because dietary fish is replacing other foods that could increase risk, such as red meat or foods high in saturated fat.

Second, in patients who are candidates for prescription omega-3 fatty acids, especially those who have very high triglyceride levels, these findings do not cast a doubt on that indication for use. That would still be an appropriate use. In patients who are taking fish oil and are doing very well on it and feel strongly that the fish oil is helping their symptoms or are a benefit to them, there is no strong basis from these studies for encouraging them to stop, because there were no major risks associated with fish oil found in the studies.

To sum it all up. Omega-3 fatty acids are not needed nor recommended for primary or secondary prevention of cardiovascular-related mortality and morbidity. However if the patient is using it and is tolerating it, it can be continued. 
But, in those people whose triglycerides are very high, these may still be a good recommendation.