Thursday, July 15, 2021

Weight loss - No Time to “Diet”

    "Diet and exercise" is a very common "prescription" for a lot of medical issues encountered at the doctor's office. It is the treatment for a variety of diseases from knee pain due to osteoarthritis to type 2 diabetes. The goal of this lifestyle modification (commonly called TLC - therapeutic lifestyle changes) is to lose some weight. Most of us have tried some sort of diet, a lot of which came and went, like Atkins, South Beach. Now, in the year of 2021, the word is Keto or intermittent fasting. It is also noticed that a lot of people went on diet, initially lost the weight but only to gain it all back, or even more! On this blog, my cousin, Charmain Dietitian, and I decided to discuss this very important lifestyle modification - the key to health.

Why do we gain weight so easily?
    The body stores the excess energy when caloric intake is more than expenditure, and fat is the best energy source.

    Aging starts at the age of 20!!! Starting with skin, brain and lung at 20, muscle at 30-40, then smell, hearing, vision, liver and kidneys after 50 years old. Metabolism slows down very gradually once adulthood is reached and a sharper decline after midlife or menopause for women.  Solely with the reduced metabolic rate as we age, eating the same amount of food without increasing the exercise activities, will eventually lead to weight gain. 

    Humans are evolved to store energy. Throughout the history of mankind, people eat to survive and food was not as abundant and easily available as it is now. The body then became very efficient in keeping any excess calories and stored it as fat. With industrialization and modernization of the society, processed food, which is much higher in calories, becomes abundant and readily available. Lifestyle also changed from having lots of manual activities to a more sedentary one, mostly sitting at a desk all day long. Caloric intake is easily in excess of caloric output, leading to weight gain. I dare say, modernization is one of the causes of the obesity pandemic in the world. 

    There are also medications and medical conditions that cause weight gain, so please check with your doctor when you notice unusual weight gain.

How can we lose weight?
    Weight loss is achieved when there is a caloric deficit, when caloric output is more than caloric intake

    Certain diseases cause unintentional weight loss, for example, hyperthyroidism and severe diabetes. The metabolic rate is increased in hyperthyroidism, while in severe diabetes, calories in the form of glucose, are lost in the urine; both cases thereby resulting in abnormally increased caloric output. Diet and exercise intends to create this caloric deficit normally. 

    The most important part of the diet is to find one that can last! So, the best diet is a "Forever Diet". Macronutrients are the nutrients the body needs in large quantities - fats, carbohydrates and proteins. They are the energy source and are essential for daily body functions. Micronutrients are needed in less amounts - vitamins and minerals. Most diets like Paleo, Atkins and South Beach, change the macronutrient composition, reducing or nearly eliminating carbohydrates and replacing them with fats. There are a lot of medical studies that have shown that these "popular" diets that limit any of these macronutrients do not impact long term weight loss. Keto or Ketogenic diet - a low carb high fat diet, has been shown to have  significant weight loss at the end of its 6 months period. However, it is mainly water weight and the diet is not sustainable nor recommended for long term because of all the problems associated with having a high fat diet. These kinds of restrictive diets on the whole, limiting a whole group of macronutrients such as carbohydrates, are very hard to adhere to, and usually do not last and are not sustainable. Once they stop the diet, most people find themselves gaining all the weight, sometimes more. This is known as weight cycling, and the reason for this phenomenon is that the metabolic rate slows down permanently with weight loss. Exercise only increases it slightly but not significantly. So, when the diet is no longer adhered to, caloric intake then easily exceeds output, leading to weight gain again. At the end of the day, the most important thing about a diet is sustainability, it has to be a diet that can last forever so that you will not gain the weight back!

    Intermittent fasting has also been shown to result in some weight loss. The "fasting" itself does not promote weight loss, it just shortens the hours in a day that you can eat. Therefore, this method will not lead to weight loss if someone eats a large amount of high caloric food during the non-fasting period. It is most effective for people who eat late, and to avoid the midnight snack which actually causes the most weight gain. 

What is the best way to create a caloric deficit?   
    This is where a dietitian consultation will be beneficial and helpful. Besides having professional guidance to ensure sufficient nutrients, it also helps with monitoring. It is important to monitor daily and keep a food diary initially. It is usually recommended to start with a deficit of 500 calories a day, and the easiest calories to eliminate are liquid calories, such as juice, soda and alcohol. 

    Portion control is the best diet because it is a diet that can be adhered to longest. Charmain dietitian has mentioned in her previous blogs the Plate method and Harvard Healthy Eating Plate. These are simple ways to imagine what a healthy meal should contain and the website at Harvard Healthy Eating Plate gives examples of the different kinds of food in different languages. It even has food suggestions for those who are environmentally conscious!

What about exercise?
    Exercise has minimal impact on initial weight loss, that is why the weight often stays the same when one starts exercising only without dieting. In fact, a lot of people complain that they gain weight after they start exercising! They are eating because they are hungrier and also feel that they have done the exercise to deserve more food. Eating less is the key for weight loss. Exercise is important for metabolic health and for maintenance of weight loss.

    The most recent recommendations according to website are copied below, please go to the official website via the link for more details:
Key Guidelines for Adults 
  • Adults should move more and sit less throughout the day. Some physical activity is better than none. Adults who sit less and do any amount of moderate-to-vigorous physical activity gain some health benefits.
  • For substantial health benefits, adults should do at least 150 minutes (2 hours and 30 minutes) to 300 minutes (5 hours) a week of moderate-intensity, or 75 minutes (1 hour and 15 minutes) to 150 minutes (2 hours and 30 minutes) a week of vigorous-intensity aerobic physical activity, or an equivalent combination of moderate- and vigorous-intensity aerobic activity. Preferably, aerobic activity should be spread throughout the week.  
  • Additional health benefits are gained by engaging in physical activity beyond the equivalent of 300 minutes (5 hours) of moderate-intensity physical activity a week.  
  • Adults should also do muscle-strengthening activities of moderate or greater intensity and that involve all major muscle groups on 2 or more days a week, as these activities provide additional health benefits.
Key Guidelines for Older Adults 
    The key guidelines for adults also apply to older adults. In addition, the following key guidelines are just for older adults:  
  • As part of their weekly physical activity, older adults should do multicomponent physical activity that includes balance training as well as aerobic and muscle-strengthening activities.  
  • Older adults should determine their level of effort for physical activity relative to their level of fitness. • Older adults with chronic conditions should understand whether and how their conditions affect their ability to do regular physical activity safely.  
  • When older adults cannot do 150 minutes of moderate-intensity aerobic activity a week because of chronic conditions, they should be as physically active as their abilities and conditions allow. 

When TLC fails.....
    I will briefly discuss medications and surgeries that are FDA approved. These are prescribed by physicians when weight loss is medically necessary. All the medications have side effects and need to be discussed in detail with the physicians before initiating. All the weight loss below are average number. Lifestyle modification is still very important, otherwise all the weight will eventually be regained. Yes, even with surgeries!

  • 5-7 lbs weight loss a year
  • 3-5 % of initial body weight loss
  • a capsule taken during or after the meal to block the fat from being absorbed, now available without prescriptions 
  • most common side effect is oily stool and fecal incontinence
  • not useful if already on a low fat diet
  • 9-13 lbs weight loss a year
  • 5-7 % of initial body weight loss
  • an injection of GLP-1 (glucagon like peptide-1) agonist  
    • GLP-1 agonist in lower dose is used for the treatment of diabetes
  • patients feel full and satisfied with less food
  • most common side effect is nausea 
  • can cause pancreatitis or gallstone
  • NOT for people with history of or family history of medullary thyroid cancer   
  • 10 lbs weight loss
  • 5% of initial body weight loss
  • a combination pill taken twice daily that needs to be slowly titrated up
  • patients feel full and have less appetite
  • most common side effect is nausea, insomnia, dizziness and headache
  • can cause mood disturbance
  • NOT for people with uncontrolled hypertension, seizure or eating disorder
  • 19.5 lbs weight loss
  • 10% of initial body weight loss
  •  a combination medication taken daily
  • suppress appetite
  • common side effect is insomnia, dry mouth and constipation
  • Need to monitor blood pressure 
  • NOT for people with glaucoma, hyperthyroidism
( I have no financial gains for the above medications)

Last are the surgeries, most commonly:
  • Sleeve gastrectomy - this is probably the more commonly done surgery at present 
  • Gastric band - not as popularly done now because of high rate of re-operation
  • Roux-en-Y Gastric Bypass - complicated surgery, good weight loss but has a lot of nutritional issues
  • Biliopancreatic Diversion with duodenal switch - very complicated surgery, but helps with metabolic disease as well like diabetes
Surgeries are only done when absolutely necessary. Most patients have to go through intense diet and exercise programs and extensive evaluations prior to even discussing surgical options. 

    The key point of this blog is that the diet for weight loss needs to be a sustainable one, something that can be done forever. Exercising portion control and learning to choose the right calories to put in the body is probably the best way. Maintaining a healthy weight CAN prevent a lot of medical issues and diseases!

Sunday, July 4, 2021

Diabetes Part 2 - Not So Sweet!

     In the last blog of the 3 "highs" series, we discussed about how diet and exercise can prevent insulin resistance and type 2 diabetes. Here, we will talk about why it is so important to control this disease. 

What are the effects of hyperglycemia?

    Let's think about what sugar water can do to hair. It can make the hair so stiff that it can stand straight up against gravity! Similarly, high glucose level in our blood stream contributes to the hardening of the blood vessel walls leading to vascular disease. When the larger blood vessels such as arteries are affected, it is called macrovascular disease. Damage to organs secondary to disease of the smaller vessels are called microvascular disease. The macrovascular complications of diabetes, especially cardiovascular diseases (heart attack), are the main causes of death for patients with diabetes. Microvascular diseases from diabetes, which are much more common, are the effect of persistent hyperglycemia on the small vessels of the eyes, kidneys and nerves. Keeping the glucose near normal level can prevent most of the microvascular complications of diabetes.

  • Macrovasular complications (large vessels)
    • Brain: Stroke or Cerebrovascular Disease (CVD)
    • Heart - Heart attack or Coronary Artery Disease (CAD)
    • Other arteries - Peripheral Arterial Disease (PAD)
  • Microvascular complications (small vessels):
    • Eye- Retinopathy which may eventually lead to blindness
    • Kidneys - Nephropathy, leaking of protein from the kidneys, one of the main reason for hemodialysis
    • Nervous system 
      • Dementia  
      • Peripheral neuropathy - the tingling and painful sensations of the fingers and toes
      • Gastroparesis - the slowing of the movement and emptying of the stomach resulting in food and liquid staying in the stomach for longer than normal

    Macrovascular complications from diabetes are compounded by other factors such as hypertension, hypercholesterolemia, obesity and smoking which are often present in diabetic patients. Usually, once someone is diagnosed with diabetes, cholesterol and blood pressure medications are needed as well to reduce the risks of the macrovascular complications. Lifestyle changes such as weight loss and smoking cessation also play a very important role in reducing these devastating complications. 

    Microvascular complications have been shown by 2 landmark studies, UKPDS (United Kingdom Prospective Diabetes Study) and DCCT (The Diabetic Control and Complications Trial), to be markedly reduced by tight control of diabetes. Keeping the glucose level near normal can prevent blindness, kidney damages and the nerve damages. Conversely, every 1% increase in Hemoglobin A1c (HbA1c),  for example from 6.5% to 7.5%, the risks for microvascular complications double! (Remember, the unit for HbA1c is expressed in %).

How to achieve tight control?

    The treatment for type 2 diabetes has changed a lot over the last 20 years, particularly in the last 5 years. The guidelines and algorhithms are updated very frequently as well because of continuous new knowledge, findings and understandings of the disease process. With the new classes of medications, the disease can be controlled so much better that we are seeing a lot less of the diabetic complications such as amputation of toes and legs! Besides lowering the blood glucose level, these new medications on their own, protect the kidneys and heart as well. 

    In addition to taking medications, regular visits to your primary care physician or endocrinologist, once a diagnosis of diabetes is made, one should immediately:

  • STOP smoking
  • Diet - Consultation with a dietitian is highly recommended. My cousin, Charmain Dietitian,also has a whole blog on what to eat, so do visit and learn about it! 
    • Avoid concentrated sweets and refined carbohydrates
    • Reduce total caloric intake, best less than 1800kcal/day. Avoid liquid calories; drink water!
    • Eat more protein and vegetables
  • Exercise regularly
  • Get a Pneumococcal vaccine, because the immune system is also affected by diabetes
  • Check glucose regularly. Now, there are continuous glucose monitoring device that do not require finger stick such as the Freestyle Libre made by Abbott

Patients with diabetes should make sure they do the following regularly:
  • Get Flu vaccine every year
  • See an eye doctor annually
  • A special urine test called microalbumin at least once a year 
  • See a podiatrist regularly or check your feet for wounds and sensory loss
  • Most of all, follow up with your doctor or endocrinologist regularly!
    I hope this blog clarifies some of the complications of type 2 diabetes, most of which can be prevented by keeping the glucose level near normal. With all the different classes of diabetic medications and better understanding of the disease process, it is possible to control type 2 diabetes! 

Monday, June 14, 2021

Diabetes Part 1 - Oh So Sweet!

            Among the 3 diseases in our 3 "high" series, I would argue that type 2 diabetes is the most complicated disease but probably the most preventable one. If we eat healthily, exercise regularly, and keep our BMI (body mass index) normal, we can delay the onset and slow down progression of type 2 diabetes! In this blog, my cousin, Charmain, and I will discuss what we can do to prevent type 2 diabetes. 

What is high blood glucose? 

Glucose, which is the end product of sugar, is a source of energy for the cells in our body.  Foods, particularly carbohydrates, are digested and broken down into glucose for absorption in the small intestines.   

As you all probably know, blood glucose levels are different before and after a meal, which is why most people fast for at least 8 hours before getting a blood test. The body has a very intricate system to prevent blood glucose from being too high or too low, and the pancreas is the main organ responsible for producing the hormones that control it. Insulin is secreted when glucose levels are too high, and glucagon when they are too low. Insulin signals a lot of organs, mainly the liver, muscle and fat cells, to increase glucose uptake, thereby reducing the level of blood glucose. In the liver, glucose is stored as glycogen, in fat cells as triglycerides. In the muscle, glucose is metabolized and used up. Glucagon, on the other hand, tells the liver to break down glycogen and produce glucose. In diabetes, the blood glucose level is high, a term called hyperglycemia. Persistent hyperglycemia is the cause of most diabetic complications. 

What is Hemoglobin A1C (HbA1C)?

    HbA1C, also known as glycosylated hemoglobin, is a blood test that physicians order for the screening of diabetes. It is the percentage of glucose attached to walls of the red blood cells. Glucose in the blood sticks to the red blood cells, which generally circulate in the blood for about 90 days. The more glucose in the blood, the more glucose is “stuck”. Therefore, the amount of glucose on the red cells indirectly measures the level of blood glucose circulating in the blood stream for the last 2-3 months. Normally, less than 5.6% of the red blood cell wall is glycosylated. When the percentage is persistently over 6.5, the diagnosis of diabetes is made. Unlike fasting glucose that can be “cheated” by eating healthily for the few days prior to the blood test, the HbA1C cannot be “cheated”. The blood glucose level has to be persistently less than 140mg/ml (7.8mmol/l) to have a normal result of <5.6%.

What is type 2 diabetes?

    Diabetes Mellitus has type 1 and type 2. Type 1 diabetes is not preventable, and is usually diagnosed in childhood or young adulthood. Patients with type 1 diabetes need to be on insulin and are closely monitored by their doctors, so we will concentrate on type 2 on our blogs. 

    Type 2 diabetes results from insulin resistance. As we grow older and gain weight, the body stops responding to the insulin produced. The liver, muscles and fat cells are not as responsive and need more “push” to do their work. The pancreas, trying to keep the blood glucose normal, then secretes more insulin to “push” the liver, muscles and fat cells to work harder. Leading to a state of insulin resistance. At this stage, the blood glucose is high and the insulin level is also high! The problem is the body not knowing how to respond to the insulin anymore. Without intervention, the pancreas will become “exhausted”, unable to produce enough insulin to reduce the amount of blood glucose. As blood glucose continues to rise, insulin resistance will lead to pre-diabetes and eventually diabetes. However, with diet, exercise, and weight loss, all of this can be prevented! Insulin resistance can be reversed!

How do we reverse insulin resistance?

Insulin resistance is mainly a result of aging and weight gain. The aging process cannot be reversed yet as of 2021, but we can definitely work on weight gain. As we age, the fat distribution when we gain weight also changes. It is the intra-abdominal visceral fat which is metabolically active, and that is the culprit for insulin resistance. Here, genetic predisposition comes to play a role. Asians tend to gain weight centrally. There is actually a term, TOFI - Thin Outside Fat Inside, to describe the propensity for asians to store fat intra-abdominally! In general, a BMI of >25 is considered overweight, triggering the screening for diabetes. For Asians, a BMI of >23 is already considered overweight and at risk for diabetes! So, at the early stage when glucose is only slightly elevated, diet and exercise has the most impact. Even with just a 5 lbs weight loss, the course can be reversed and diabetes can be prevented!

        To reverse insulin resistance, it is also important to:

  • exercise
  • stop smoking
  • drink less alcohol
  • sleep more
        Sounds familiar? Very similar to what you can do for high cholesterol and high blood pressure too!

For most people, it is easy to gain weight but very hard to lose it. Weight gain is something that we cannot allow ourselves to do once we reach adulthood! A lot of diseases, besides the 3 ”high” that we have been discussing, can also be avoided by not gaining weight. Diseases that range from arthritis to cancer, like breast cancer! One of the methods that I find helpful is not allowing myself to purchase larger size clothes. When the pants are feeling tight around the waist, that means I need to eat less and exercise more and get rid of that belly fat! Staying on a strict diet and exercise regimen is difficult, but we all have to strive and work hard on it. Starting with portion control and eating less, the stomach (the organ) will eventually shrink! Feeling 75% full is more than sufficient. Whatever diet you decide on, it has to be a forever diet. For more on what to eat, please visit Charmain dietitian. 

This blog is already long enough, but we have only touched on the surface of diabetes. I hope you understand the role of insulin and the significance of insulin resistance. We will discuss more on the complications and treatment of diabetes in our next blog.

Until our next blog! Resist the temptation! 

Sunday, June 6, 2021

Cholesterol - the good and the bad

    The next of the 3 "highs" that my cousin Charmain and I will be discussing is high cholesterol. High cholesterol is probably the most common among the 3 "highs".  The recommendation for treatment and diet is still evolving and changing as we learn more about it. The information that we are writing now in 2021, may be different from 2011 and probably will change again by 2031! 

    One of the most common blood tests patients request is for cholesterol. Physicians will usually order the lipid panel which includes the total cholesterol, triglycerides, high density lipoproteins (HDL), very low density lipoproteins (VLDL), and a calculated low density lipoprotein (LDL). I will go over what all these mean in this post and explain some of the misconceptions about cholesterol. 

What is Cholesterol?

    Cholesterol is the type of fat circulating in our blood. Every cell needs cholesterol, and it is the building block of hormone synthesis. One of the most important organs in our bodies, the brain, is largely made up of cholesterol. However, we all know that too much cholesterol can be harmful to our health. Most people probably imagine these fat to stick onto the inside wall of the blood vessel like a mound. In fact, these waxy fats start to accumulate within the blood vessel wall in a crystalized form, gradually narrowing the lumen where blood flows. This accumulation is called plaque or atherosclerotic plaque. There is a layer of the inside wall of the blood vessel, called epithelium, over the plaque. As the plaque grows larger, the epithelium is stretched and thinned. When it tears, exposing the cholesterol crystals underneath (called ruptured plaque), the body will attempt to immediately wall it off with platelets and fibrin like a wound, thereby blocking the entire lumen of the blood vessel. This sudden blockage of blood flow in a coronary artery will cause a heart attack; in one of the arteries supplying blood to the brain, it will lead to a stroke. 

    Triglycerides is another type of cholesterol and is the most common type of fat in our body. They are the fats from the food we eat—the storage form that any excess calories are converted to, and released when we need the energy. High levels of triglycerides contribute to fatty deposits on the blood vessel walls, increasing risk of heart attack and stroke. Very high level of triglycerides in the blood can "clog" arteries, causing pancreatitis. Imagine pouring oil down the drain! 

 LDL and HDL, low and high, which do you want high or low?

   Cholesterol is carried in the blood by a protein called lipoprotein. 

    LDL - low density lipoprotein, the "bad" cholesterol that deposits within the wall of the arteries causing atherosclerosis. 

    HDL- high density lipoprotein, the "good" cholesterol that picks up the excess cholesterol and transports it to the liver.  

    VLDL- very low density lipoprotein, transports triglycerides. So, its level goes up and down with triglycerides. 

    Too much LDL or too little HDL increases the risk for cardiovascular diseases (CVD) such as heart attack or stroke. There are subtypes of LDL, some larger and less dense, some smaller and denser and thought to be more atherogenic. There are a few laboratories that perform tests to further classify them, but in general the more LDL, the higher the risks for CVD. So, to summarize this, you want the bad LDL to be low and the good HDL to be high to reduce your risk for CVD.

What is high cholesterol? Hypercholesterolemia or Hyperlipidemia? or others?

    Hypercholesterolemia or hyperlipidemia is the term usually used for high cholesterol level in the blood. Since cholesterol is further broken down into LDL and triglycerides, there are other more specific terms. There are also classification based on lipoprotein dysfunction and genetics. Here, we will just use hypercholesterolemia. 

When do we start treatment for high cholesterol?

    Primary treatment for hypercholesterolemia is to prevent heart attack or stroke, so the level of cholesterol to start treatment is different for everyone. It depends on family history, other diseases and cardiovascular risk factors the person may have. The guidelines for treatment also changes frequently. As of 2021, normal person without any other risk factor, will consider medication for LDL higher than 160. Statins are the medications widely used for the treatment of high LDL. They are relatively safe and usually very effective in bringing down the LDL levels. There are also magnitudes of data showing that statins can significantly lower the risks of heart attack and stroke. 

What about fish oil or omega 3?

    Omega 3 has been used for the treatment of hypertriglyceridemia, high triglycerides in the blood. The 2 most studied omega 3 fatty acids are EPA and DHA. EPA has been shown recently to be beneficial in reducing the risks of CVD. While DHA is important in fetal development and thought to reduce the risk of Alzheimer's disease, recent studies have shown DHA to increase total cholesterol. So now the treatment of choice for hypertriglyceridemia is pure EPA omega 3 fatty acids. 

What can we do?

    Now that I have confused everyone with all the alphabet soup, let me confuse you more with what we can eat! We used to say eating fatty foods is bad, to avoid oil, red meat, eggs, shellfish and so on. Although we haven't really completely turned a 180, it is now OK to eat eggs, shellfish and butter! This part is where my cousin, Charmain dietitian can help and clarify. 

    Other things you can do:

  • Eat less sugar and carbohydrates
  • Exercise regularly
  • Lose some weight
  • Stop smoking
  • Drink less alcohol
    I hope this article helps you understand more about cholesterol. Feel free to ask us questions and we would love to hear comments and suggestions. Until the next blog on high sugar then!

Saturday, May 8, 2021

Hypertension - the silent killer!


    On the last blog that my cousin Charmain and I collaborated on, we talked about the 3 "highs"- high blood pressure, high cholesterol and high blood sugar. On this blog, we will specifically discuss high blood pressure. 

What is High Blood Pressure?

    Blood pressure is a measurement that is taken at every doctor's visit. There are 2 numbers to the blood pressure reading, one over the other, normal is around 110/70. The upper number, also known as systolic pressure, is the pressure in the artery when the heart contracts or pumps blood. The lower number, diastolic pressure, is the pressure when the heart is relaxed. The measurement is usually taken with a cuff around the left arm while you are in a sitting position. Nowadays, most medical facilities use machine to measures blood pressure although some doctors may still listen for it with a stethoscope. Many external factors affect the reading such as how you sit, the size of the cuff, just being in the exam room and so on. As such, a single reading of high blood pressure in one setting may not be clinically significant.

What does it mean to have high blood pressure?

    Abnormal blood pressure is an indicator that something is wrong with the the blood vessels in our body. When the numbers are consistently higher than normal, that suggests that the wall of the blood vessels are starting to change and stiffen. It may also be a sign that there is something wrong with the kidneys, and occasionally the adrenal glands. The doctor will order blood tests, urine tests, occasionally some heart tests depending on each individual’s case and conditions, and the diagnosis of hypertension will be given accordingly. Once you are diagnosed with hypertension, the blood vessels have started to stiffen and become narrow, eventually damaging the vital organs: brain, heart and kidneys. 

What is hypertension?

    When the blood pressure is higher than 130/80, that is stage I hypertension. Therapeutic lifestyle changes (TLC) is the the treatment. At this stage, eating healthy, exercising and losing weight will be the most important and can actually prevent disease progression!  Stage II hypertension is when the blood pressure is over 140/90. At this point, medications will usually be prescribed to control the blood pressure and to protect the internal organs such as heart, brain and kidneys. Progressing onto stage II hypertension does not mean that you have failed to sufficiently alter your diet and exercise, as it is part of the aging and disease process. Diet and exercise is still very important, but medications will be needed as well to prevent the complications of hypertension.

What are the complications of hypertension? 
    Throughout this time with high blood pressure, stage I and stage II hypertension, there are usually no symptoms. Unlike what you might have seen in Korean dramas, there is usually no headache, no chest pain or discomfort of any kind. A lot of people feel normal walking around with hypertension! However, it is quietly damaging your body. We call hypertension the silent killer because hypertension itself is generally asymptomatic; unfortunately, once you have symptoms, it is already too late. It is the complications of hypertension that led to symptoms: chest pain from a heart attack, inability to move one side of the body from stroke, swelling and inability to breathe because of heart or kidney failure. 

    Some of the common complications of hypertension are:
  • Heart -     Heart attack, enlarged heart (cardiomegaly), weakened and enlarged blood vessel (aneurysm), heart failure
  • Brain -     Stroke, memory loss and even dementia
  • Kidneys - Kidney damage and eventually kidney failure
  • Eyes -      Retinopathy from bleeding into the back of the eye causing blurred vision and sometimes loss of vision

       Most of these complications of hypertension may not be fatal, but they lead to long term disability.

What can we do?

    This is where your hard work can pay off. Taking care of your body helps not just yourself, but your family members too! Nobody wants to be a burden on their family! Besides TLC, which my cousin Charmain will elaborate on, it is very important to take medications as prescribed and to follow up regularly with your doctor. Medications do not just bring down the blood pressure numbers, the newer classes of anti-hypertensives can specifically protect the kidneys and heart! Sometimes, we use these medications on patients who do not have hypertension, just for the sole purpose of protecting the heart and kidneys. Work with your doctor to find the best medication for you. 

    Immediate things you can do:
  • Eat less sodium or salt. Definitely, do not use table salt. 
  • Eat more fresh food, especially celery, cucumber, green apple, bitter melon. 
  • Eat less processed food.  
  • Walk at least 30 minutes daily, better if you can exercise more
  • Drink less caffeine! This one is the hard one for me! 
  • Stop smoking. 
  • Drink less alcohol. 
  • Reduce your stress, which is easier said than done. Try meditation and remember to love yourself! 
  • Buy a blood pressure monitor, about US $30 at Costco, and monitor yourself. 
    Controlling your blood pressure can slow down the disease process. To emphasize one more time, taking your medications regularly, together with dieting and exercising, will reduce your risks for heart attack, stroke and kidney failure!
    Hopefully, this gives you a general idea of what hypertension is. We will be happy to answer any questions. If you find this helpful, please follow us and read our next blogs on high cholesterol and high blood sugar!


Friday, April 30, 2021

3 "highs”- 三高- is not a death sentence

    A chance encounter with my cousin Charmain online, we came to realize that we both started blogging! So, we thought it would be a great idea to collaborate and write about nutrition and health as well. She is a Registered Dietitian Nutritionist while I am a retired physician, so hopefully we can help our readers achieve a healthier life. We thought we will start with something common, the "3 highs" - 三高. Through this series of blogs, we hope to explain the "3 highs" in ways everyone can understand and to work through some lifestyle modifications.

    Now that we are in the latter half of our life's journey, we pay more attention to our health, or at least we should. We eat healthily and exercise so that we can get a good report card during our annual well visit. I actually first heard the name "3 highs" from patients! They believed that once you have the "3 highs", you are on your way to your grave! Well, while there is some truth to it, the “3 highs” markedly increase one’s cardiovascular risk, but it is not a death sentence. The risk of cardiovascular death can be reduced with medications and therapeutic lifestyle changes (TLC).

    The 3 "high"s are:

        high blood pressure

        high cholesterol

        high blood sugar. 

    The diseases they can lead to are:




    It may be too simplistic to think of them as just numbers that are elevated. In fact, they are indications that certain organs in the body are not functioning normally anymore, the blood vessels are starting to change and are signs of diseases at the early stages. It will be a super long blog to write about all 3 and nobody wants read lengthy articles. It is long enough as it is! So, we will discuss the 3 separately.

   Why do people fear the "3 highs"? With every one "high" and the subsequent disease, the cardiovascular risk is increased. So, for example with just high blood pressure, the risk for a heart attack and stroke is significantly increased compared to someone without. Adding high cholesterol, the risk is further increased. Having all 3, the risk for cardiovascular disease is even higher. Again, things are actually not that simple with risks not exactly additive and other factors do play their roles, but hopefully, you get the sense of it. 

    When the numbers are elevated but not to the level of the definition of disease, lifestyle modification is the most important treatment. Let's use high blood pressure as an example. Normal blood pressure for a normal weight adult is around 110/70. When the reading is over 130/80, then they have hypertension. Before it gets to hypertension, it is elevated blood pressure. At this stage, eating healthily, exercising and losing some weight are key in preventing or slowing down the disease progression.  

    As we grow older, our internal organs and blood vessels begin to age. Living a healthy lifestyle helps but eventually, a lot of us still need medications. Many people hesitate do take medication and always bargain with physicians for more time for TLC (not tender loving care, but therapeutic lifestyle changes). The need to start medication does not mean that you failed. It is actually an adjunct to the overall treatment and to reduce your overall cardiovascular risk. So when your doctor prescribes medications for you, they are not just treating the numbers, they want to protect your internal organs, like your brain, heart, kidneys, etc, as well as your overall health. The numbers are just a barometer that represents the state of your body.

    The next part of the blog is from Charmain Dietitian on how to change your diet, which includes:

        1. Eat a variety of whole and fresh foods everyday. Frozen, canned or dried nutritious foods are equally good to use. Read label on the package and choose the most natural ones with less ingredients, and keep a check on fat, salt and sugar content. 

        2. Enjoy a rainbow color of fruits and vegetables to achieve a wide spectrum of vitamins and minerals. 5 A Day ( 5 servings of fruits and vegetables a day) is a good start.

        3. Choose a variety of options from each food group

                - high fiber starchy food

                - low fat dairy or dairy alternatives such as soy drinks

                - eat some beans, pulses, fish, eggs, meat and other lean protein. Among protein foods, consume plant-based protein more often, such as legumes, nuts, seeds, tofu, fortified soy beverage

                - choose unsaturated oils and spreads, and eat them in small amounts

                - fluids 6-8 cups per day. Water should be the beverage of choice

        4. Pay attention to portion size

        5. Limit foods and beverages high in add sugar, saturated fat and sodium; i.e. eat less processed foods

        6. Stop smoking

        7. If you drink, limit alcohol to 2 drinks or less in a day for men and 1 drink or less a day for women, according to CDC and NHS. Spread your drinking over 3 or more days if you regularly drink as much as 14 units a week. If you wish to cut down the amount you drink, a good way to help achieve this is to have several drink-free days each week.

        8. People at high risk of or people with cardiovascular disease who are overweight or obese, seek advice and support to work towards achieving and maintaining a healthy weight.  

        9. Resources American Dietary Guidelines, Canada's Food Guide, UK Eat Well Guide.

    For more details for specific dietary changes, refer to Charmain's blog.  If you find the above dietary information useful and wants to start making some lifestyle changes, Charmain would like to help. Feel free to contact her for 1:1 consultation or group sessions. 

    So, I hope that you will be interested in learning more about the 3 “highs” and have the incentive to further improve your lifestyle by subscribing to our blogs! Do not hesitate to ask questions!

Sunday, March 28, 2021

Will learning a new language really prevent aging of the brain?

    Brain aging is probably the most worrisome aspect of aging that most people would be interested in preventing. It is known that memory declines sharply after menopause. I am personally going through this now and can attest to the truth of this statement. Besides having difficulties recalling names of movie stars and even friends and relatives! I used to have really good memory, and could reproduce 75% of a lecture; now I would be happy if I could remember just a couple of points!

    There are mountains of research and books on the topic of memory loss. In regards to the menopause-related decline, researchers have tried hormone replacement therapy to see if that would help. There is now a disclaimer on the hormone treatment, indicating that it will not help in the prevention of Alzheimer's. So, our quest to search for the miracle drug for eternal brain youth continues. 

   Medications aside, there are also lots of research and books on what we can do to keep our brain young and healthy. Some of the well known factors that can reduce the risks of dementia are:

1. Healthy and balanced diet 

2. Physical activity

3. Sufficient sleep

4. Social interaction

5. Community service

    In addition to doing all of the above, some researchers suggested that learning a new language or musical instruments will open up areas of our brain that have not been utilized, and in doing so help reduce the chance of dementia. The theory is that we only use about 10% of our brain capacity, so learning something completely new will form new pathways and connections in our brain, “opening” up new areas that have not been used, and hopefully reducing the risks for dementia. Since there is no harm in learning new things, I decided to learn Japanese. It was fun learning a new language and going back to school made me feel young, especially when I was interacting and learning with people half my age! Unfortunately, the pandemic changed the learning process for the whole world. The classes all became online and we no longer interacted like we used to. We attended class via Zoom, listened to the teacher explaining the grammar structure and went into little discussion “rooms” to practice with fellow students. Gone were the little conversations with fellow students. We hardly saw each other’s faces! Nobody showed their face online! I feel that I am not learning as well online as I was in person. I am still studying as hard as I was before the switch, and I am doing all the assigned homework. I understood the teacher perfectly during the lecture but once the video is off, I find that I can’t remember as well and kept having to refer to the textbook. So, what was it that was helping the brain? Was it really just learning a new language? Or was it the action of going to school, learning with a group of people and interacting with them and the teacher? 

    I am going to continue learning Japanese and possibly another language as well. It is fun learning for the sake of knowledge and self improvement! Speaking and understanding another language open up a whole new world and the ability to interact with people in their native language is something that I would love to do when we get to travel again. Furthermore, if learning a new language can help me reduce the risk for dementia, it would be a bonus! So, let’s explore the world and pick up a new language!