HCFI Update: Acetone in the urine means fat is used as a source of energy

Anna Hazare’s urine shown presence of acetone which means that his fat is now becoming the source of energy, said Padmashri and Dr B C Roy National Awardee Dr K K Aggarwal President Heart Care Foundation of India and MTNL Perfect Health mela. As long as fat content in the body remains more than 10% the body can tolerate fasting. Anna being 70 kg can afford to lose 10 kg weight.

The fall of upper BP by 30 and rise of pulse by 10 means dehydration and need for more fluids.

1. Ketonuria is a medical condition in which ketone bodies are present in the urine. Medically it is presence of acetone in the urine.

2. It is seen in conditions in which the body produces excess ketones as an alternative source of energy. It is seen during starvation or in diabetes. Higher levels of ketones in the urine indicate that the body is using fat as the major source of energy.

3. Production of ketone bodies is a normal response to a shortage of glucose, meant to provide an alternate source of fuel from fatty acids.

4. In prolonged fasting insulin deficiency increases fat lysis and increased free fatty acid delivery to the liver. Glucagon excess promotes conversion of free fatty acids into ketoacids in the liver.

5. Ketone bodies that appear in the urine when fats are burned for energy are acetoacetate and beta-hydroxybutyric acid. Acetone is also produced. Normally, the urine should not contain a noticeable concentration of ketones to give a positive reading.

6. The body continues to use fat for as long as there is fat to consume. The body will generally indicate to the faster when fat levels are running extremely low (less than 7% and 10% of body weight for males and females, respectively) with an increased urge for food. Fasts are usually broken long before this point. If the fast is not broken, starvation begins to occur, as the body begins to use protein for fuel. Health complications associated with fast-induced starvation include electrolyte imbalances, thinning hair, lanugo, cardiac arrhythmia and renal failure. Death can occur if fasting is pursued to the point of complete starvation.

7. While fasting one should not take paracetamol as it can case fatal liver damage.

8. Acetone can be tested by a dipstick or by a lab. The results are reported as small, moderate, or large amounts of acetone. A small amount of acetone is a value under 20 mg/dl; a moderate amount is a value of 30–40 mg/dl, and a finding of 80 mg/dl or greater is reported as a large amount. In prolonged fasting the Ketoacid levels do not exceed 10meq/L and plasma bicarbonate concentration is typically above 14meq/L. The limitation in the degree of ketone formation with fasting in part reflects the ability of ketonemia to promote insulin secretion, thereby limiting the availability of free fatty acids. There is also increased ketoacid uptake by the brain as it switches from glucose to ketones as a source of fuel.

9. Fasting ketoacidosis is treated by administration of dextrose and saline solutions. The dextrose will increase insulin and reduce glucagon secretion, while the saline will repair any fluid deficit.

10. The plasma phosphate concentration may fall to low levels with therapy as insulin drives phosphate into the cells. When present, severe hypophosphatemia may be associated with marked and possibly life-threatening complications in these patients, including heart attack.

The success behind Anna Wave

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Lage Rahon Anna Bhai: The science behind what makes a wave?

As we have been witnessing over the last few days, there is an ‘Anna wave’ in the country. People of all ages, from all walks of life have come out on the streets in large numbers in support of Anna. Till about few months back, Anna was a relatively unknown name to most people. Since then, he has become the biggest name in the country.  A new term has been coined. Just like Gandhigiri, Annagiri is the talk of the town.

What is the reason for this wave of support? Why has there been such an upsurge of people?

The success of a wave depends on the subject and on the principle of critical mass being achieved.

If the chosen issue is based on the principles of truthfulness, non violence and sarvodaya (welfare for all) it can turn into a wave.

Now for a wave to spread across the entire nation, it must cover one percent of the population. This can be explained by the 100th-monkey phenomenon, as explained by Deepak Chopra.

“Long time back there was a monkey called Emo in a far off village in Japan. Monkeys at that time used to eat apples lying in the gardens full of dust. One day Emo by mistake washed the apple in the pond before eating. From then onwards he washed every apple he ate. The message went from one monkey to the second monkey and then to the third and so on. Many monkeys started washing apples before eating. After sometime, some neighboring monkeys from other villages also started washing their apples before eating. The day the 100th monkey washed the apple and ate it, a strange phenomenon was observed all over the country. Monkeys all over started washing apples before eating. The critical mass in that area therefore was 100. Once the critical mass was achieved, the information spread like wildfire to each and every monkey and everybody started washing apples before eating.”

In campaigning also the politicians make use of this principle and make sure that the critical mass is achieved to start with. In local political meetings also, the same principle of 1% critical mass is used. For a gathering of 1000 people, politicians make sure that they have minimum 10 of their own people are sitting in the audience to initiate clapping. When 10 people clap, the rest 990 will also follow and clap. Similarly, for a gathering of 2000 they will need 20 people and for 10,000 they will need 100 people.............more http://www.itimes.com/users/iti475269/blogs

About the author: Dr K K Aggarwal is Padmashri and Dr B C Roy National Awardee, President Heart Care Foundation of India, Dean Board of Medical Education Moolchand Medcity, Sr. Physician & Cardiologist, Chairman Ethics Committee Delhi Medical Council, Visiting professor Clinical Research DIPSAR, Past President Delhi Medical Association and Past Academic and Research Wing Heads IMA.

HCFI Update: Breaking the fast should be slow

Anna is on fast as are many others all over India. Not only fasting but even re-feeding can be dangerous after a fast.

Once acetone appears in the urine, the fast must be broken slowly else one can end up with re-feeding syndrome which can even be fatal said Padma Shri and Dr B C Roy National Awardee Dr K K Aggarwal President Heart Care Foundation of India and MTNL Perfect Health Mela.

Facts about hunger strike of Satygraha

1. Most hunger strikers do not wish to die as per the medical literature.

2. Many doctors who graduated before 1990 may not be aware about the guidelines as regards hunger strikers. The first declaration of World Medical Assembly was adopted in 1991, revised in 1992 and then again revised in 2006. It is called the ‘WMA Declaration of Malta on Hunger Strikers’. It describes the duties of a doctor and guidelines for the management of hunger strikers. As per the WMA Declaration, all physicians are bound by Medical Ethics even when not providing therapy. They must try to prevent coercion or maltreatment of detainees and must protest if it occurs. It is the duty of the physicians to take the hunger striker in confidence in isolation and find out his or her intention before and during the fast.

3. The Rough formula of 3 is that one cannot live for three minutes without air, three days without water and three weeks without food. But this formula is for healthy muscular and fatty people. When you fast you can stay healthy for long if you have good muscles and have good fat content.
4. There are three phases of fast: The 1st phase is conversion of stored glycogen into energy and lasts a few days. The 2nd phase is burning of fat into energy. Acetone appears in the urine in this phase, which lasts as long as body fat is up to 10% in females and 7% in males. At this time there will be a strong urge to eat. If one does not eat at this time, the 3rd phase will start, when proteins start breaking down leading to starvation effects which can be fatal due the kidney failure and heart irregularity.

5. The basic aim of breaking any fast is to prevent occurrence of re-feeding syndrome, a metabolic complication that occurs when nutritional support is given to severely malnourished patients or to someone recovering from prolonged fast or hunger strike. Any individual who has had negligible nutrient intake for 5 consecutive days is at risk. It occurs within four days of starting to feed. Patients who weigh less than 70 percent of ideal body weight or lose weight rapidly are at greatest risk for the syndrome.

During prolonged fasting the body conserves muscle and protein breakdown by switching to ketone bodies derived from fatty acids as the main energy source. The liver decreases its rate of gluconeogenesis thus conserving muscle and protein. Many intracellular minerals become severely depleted during this period, although serum levels may remain normal. Insulin secretion is suppressed and glucagon secretion is increased.

During re-feeding, the metabolism shifts from a catabolic to an anabolic state. Insulin is released on carbohydrate intake resulting in increased glycogen, fat and protein synthesis. Insulin release triggers cellular uptake of potassium, phosphate, and magnesium which are already depleted and the stores rapidly become used up.

When the serum concentrations of these electrolytes are reduced, serious complications, such as irregular heart beat can occur. Patients can also develop fluid and electrolyte imbalance, low phosphate levels, neurologic, lung, heart, neuromuscular, and blood related complications. Irregular heart rhythm is the most common cause of death with other significant risks including confusion, coma and convulsions and cardiac failure.

The diagnostic feature is presence of low phosphate, potassium, magnesium, vitamin B1 levels and fluid overload with edema feet. Low phosphate levels are the essential criteria for diagnosis.

If the refeeding syndrome occurs, doctors should immediately slow nutritional replenishment and correct low levels of phosphates, potassium and magnesium while monitoring the cardiovascular system. In patients at risk of re-feeding syndrome, nutritional support is initially delivered at a maximum of 10 kcal/kg/day and raised gradually to full needs within a week. In extreme cases this energy intake is limited to 5 kcal/kg/day.

Before and during the first 10 days of feeding, it is important to give 200-300 mg oral thiamine a day, 1-2 vitamin B complex tablets three times a day or intravenous vitamin B, and a balanced multivitamin and mineral supplement each day.

One should monitor and supplement oral, enteral, or intravenous potassium, phosphate and magnesium in such patients. On average, patients should receive 2-4 mmol/kg/day potassium, 0.3-0.6 mmol/kg/day phosphate, and 0.2 mmol/kg/day intravenous or 0.4 mmol/kg/day oral magnesium.
Moderately to severely ill patients with marked edema or a serum phosphorous < 2 mg/dL should be hospitalized to intravenously correct electrolyte deficiencies. Sugarcane juice is the best juice to break the fast. Unrefined sugarcane contains many minerals and nutrients including phosphorus, calcium, iron, magnesium and potassium. Pure sugar cane has 11 calories per teaspoon.

Satyagraha a Vedic way of protesting

The recent Anna movement has opened a pandora of alternatives for fighting justice. From time immemorial people have been fighting for justice.

Mahatma Gandhi fought a long battle against the British. His way of protest was based on non-violence utilizing the concept of Satyagraha. The Vedic concept of Satyagraha consists of satya, ahimsa and tapasya. ‘Satya’ implies openness, honesty and truthfulness involving the opinion of every person as a part of the truth. ‘Ahimsa’ refers to non-violence and treats the opponents with the same love as that of our own and ‘Tapasya’ is willingness to sacrifice. A Satyagrahi always provide a face saving way out for the opponents. The goal of a Satyagraha is to fight for the truth and justice and not to achieve victory over the opponents. Mahatma Gandhi defined Satyagraha as ‘satya’ means truth and ‘agraha’ means firmness. He said that if you are firm in the truth in the long run you are going to win.

During Gandhian times many others showed their way of protest. Rajguru, Chandrashekhar and Bhagat Singh took the path of violence and killed General Dyer. Most of the Indian movies including Rang De Basanti took inspiration from them. Jinnah way of protest was aimed in dividing the country and get Pakistan and Ambedkar’s way of protest was to get reservation for the backward people. Krishna way of protest was to hide himself, “rooth jana or to pretend as if he was upset” Strike is a modernized version of Satyagraha...................................more

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Emedinews : Time to awaken sleeping “Anna” in each one of us

Buddha represents the “enlightened one”. Buddha is a state of mind and not a person. So is Anna today. He represents the corruption-free state of mind. Anna represents the Satvik state of mind in each one of us, which is not under the influence of Tamas or Rajas.

Each one of us is controlled by the duality of mind and instead of taking the right actions we end up by taking the convenient action. The convenient action gives us the immediate gains while the right action is tough and may not give immediate results.

Indulging in corruption is the most convenient way of getting any work done. We tend to buy movie tickets in black, give money to electricians to get the electricity fixed up, buy goods in cash to save sales tax, bribe babus to get petty government works done and so on.

The time has come to waken up the sleeping “Anna” in each one of us. We should pledge that from today we will neither give bribes nor accept bribe from any one. As professionals, we will not give or accept commissions.

Let us become Satyugi living in Kalyuga and not Kalyugi living in Kalyuga. Even though we might be a minority, we as a group of Satyugi can make an impact in Kalyuga.

The awakened ‘Anna’ within us will give us the strength to fight with the corrupt in the society.

HCFI Update:The Science behind Anna Hazare Movement, Satyagraha & Gandhigiri

Gandhigiri always works, whether it was Mahatma Gandhi, the movie “Lage Raho Munnabhai” or the Gandhian Anna. The Gandhian principles were so framed that it always united the common man, said Padmashri and Dr B C Roy National Awardee Dr K K Aggarwal President Heart Care Foundation of India and MTNL Perfect Health Mela.

Dr Aggarwal said that four basic principles Gandhi taught are of Satya (truthfulness); Ahimsa (non violence); Sarvodaya (welfare for all) and Satyagraha. The word Dharma means to hold together. All the above four principles can hold people together and hence forms the backbone of dharma.

Yoga-shastras as well as the Yoga Sutras of Patanjali propagate truthfulness as one of the main components for living a disciplined life or to start yoga. Satya means oneness in your thoughts, speech and actions. Bapuji’s three monkeys also had truthfulness represented in one of the monkeys who talked about ‘bura mat bolo’. In fact, Gandhi believed that “there is no religion higher than truth”

Gandhi preached the concept of “experimenting with truth” — a phrase that formed the subtitle to his autobiography. He taught how to learn through trial and error, often admitting to mistakes and changing one’s behaviour accordingly. Non observance of truthfulness is the root cause of any corruption in the society.

Ahimsa is the next principle and teaches us the path of non violence. Again it has to be practiced not only in actions but in thoughts and speech also. It also forms the basis of Jainism and Hinduism as a religion.

Sarvodaya or welfare for all is the third Gandhian teaching. Vedic philosophy also emphasizes on the welfare for all. It talks about “bahujan hitay-bahujan sukhay” (‘the good of the masses, the benefit of the masses). Gandhi found in it a composite concept of social welfare & economic justice. Any action which is aimed and seems to be aimed at the welfare of the people will e accepted by every one in the society.

Satyagraha is the protest based on satya (path of truthfulness) and non violence and includes peaceful demonstrations, prolonged fasts etc. It’s a non violence based civil resistance. Satyagraha is formed by two Sanskrit words Satya (truth) and Agraha (holding firmly to or firmness). Gandhi said “Satyagraha is a weapon of the strong; it admits of no violence under any circumstance whatsoever; and it ever insists upon truth”. Gandhi said if you are firm in the truth in the long run you are going to win. It is base on the law of persistence.

The current Satyagraha by Anna Hazare is using all the principles of Gandhigiri and is already in its way to success.

Gandhigiri: the Path of Satya, Non violence, Sarvodaya and Satyagraha

The science behind Anna movement based on Gandhigiri Gandhigiri always works, weather it was Mahatma Gandhi, the movie “Lago Raho Munnabhi” or the Gandhian Anna. The Gandhian principles were so framed that it always united the common man.The four basic principles Gandhi taught were of Satya (truthfulness); Ahimsa (non violence); Sarvodaya (welfare.... more     http://www.itimes.com/users/iti475269/blogs

Anna is within us

Time to awaken sleeping “Anna” in each one of us
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Buddha represents the “enlightened one”. Buddha is a state of mind and not a person. So is Anna today. He represents the corruption free state of mind. Anna represents the Satvic state of mind in each one of us which is not under the influence of Tamas or Rajas.Each one of us is controlled by .... more

Can a person die after his prolonged fast is broken?

Nine days fast by Ramdev, death of another swami in Uttarakhand after 115 days fast and now a threat by Anna Hazare to go into fast again has opened a new chapter for one to revise the knowledge as to how to deal with such a person especially one is breaking the fast.

The 35 years old swami who died was protesting the Uttarakhand government's refusal to ban mining along a stretch of Ganga near Rishikesh. He had been on a fast since February 19 2011. On April 27, officials shifted him to Haridwar district hospital as his condition deteriorated but he still refused to touch food. When he slipped into coma on May 2, he was rushed to HIMS and put on life support system.  The president of Haridwar Citizen Council, alleged the seer suffered a heart attack at Haridwar district hospital after being injected poison by hospital staff. Did he die of refeeding syndrome or the starvation effects is the question in the mind of the medical fraternity?

The basic aim of breaking any fast is to prevent occurrence of re-feeding syndrome, a metabolic complication that occurs when nutritional support is given to severely malnourished patients or to someone recovering from prolonged fast or hunger strike.

Any individual who has had negligible nutrient intake for 5 consecutive days is at risk. It occurs within four days of starting to feed. Patients who weigh less than 70 percent of ideal body weight or lose weight rapidly are at greatest risk for the syndrome.

During prolonged fasting the body conserve muscle and protein breakdown by switching to ketone bodies derived from fatty acids as the main energy source. The liver decreases its rate of gluconeogenesis thus conserving muscle and protein. Many intracellular minerals become severely depleted during this period, although serum levels may remain normal. Insulin secretion is suppressed and glucagon secretion is increased.

During re-feeding the metabolism shifts from a catabolic to an anabolic state. Insulin is released on carbohydrate intake resulting in increased glycogen, fat and protein synthesis. Insulin release triggers cellular uptake of potassium, phosphate, and magnesium which are already depleted and the stores rapidly become used up. When the serum concentrations of these electrolytes are reduced, serious complications, such as irregular heart beat can occur. Patients can also develop fluid and electrolyte imbalance, low phosphate levels, neurologic, lung, heart, neuromuscular, and blood related complications.  

Irregular heart rhythm is the most common cause of death with other significant risks including confusion, coma and convulsions and cardiac failure. The diagnostic feature is presence of low phosphate, potassium, magnesium, vitamin B1 levels  and fluid overload with edema feet. Low phosphate levels is the essential criteria for diagnosis.

If the refeeding syndrome occurs, doctors should immediately slow nutritional replenishment and correct low levels of phosphates, potassium and  magnesium while monitoring the cardiovascular system.

In patients at risk of re-feeding syndrome, nutritional support is initially delivered at a maximum of 10 kcal/kg/day and raised gradually to full needs within a week. In extreme cases this energy intake is limited to 5 kcal/kg/day.

Before and during the first 10 days of feeding, it is important to give 200-300 mg oral thiamine a day, 1-2 vitamin B complex tablets three times a day or intravenous vitamin B, and a balanced multivitamin and mineral supplement each day.

One should monitor and supplement oral, enteral, or intravenous potassium, phosphate and magnesium in such patients.

On average, patients should receive 2-4 mmol/kg/day potassium, 0.3-0.6 mmol/kg/day phosphate, and 0.2 mmol/kg/day intravenous or 0.4 mmol/kg/day oral magnesium.

Moderately to severely ill patients with marked edema or a serum phosphorous < 2 mg/dL should be hospitalized to intravenously correct electrolyte deficiencies.

About the author

Padmashri & Dr. B.C. Roy National Awardee, Dr. KK Aggarwal is a Senior Consultant, Physician, Cardiologist at Delhi based Moolchand Medcity; President Heart Care Foundation of India; Chairman Ethical Committee Delhi Medical Council and has served as the Research and Academic Wing Heads of National Indian Medical Association.

Making of a good leader

One of the main reasons for any conflict is engaging in “violent communication” on a daily basis. A violent communication is based on judgment and not observations. A violent communication can be in thoughts, action, speech or writings. A non-violent communication, on the other hand, is either based on observations or on individualized opinions. These observations or opinions are always written or spoken as quote-unquote.

“Congress calls Anna Hazare 'unelected tyrant' (TOI)”

“Hazare team targets ‘arrogance of power’ (Calcutta Telegraph)”

“Threat to democracy is from unelected tyrants, says Congress (TOI)”

These are few of the latest headlines in the media that reflect a war of words and hence, violent communication between the Government and Anna Hazare team.

If we look at the current scenario, both Baba Ramdev earlier and now the Anna Hazare team are violently communicating through the media.

The three ‘Cs’ of violent communication are: Criticize, condemn and complaint.

Using violent communication is expected of a politician, in this age of Kalyuga, but for a Satyagrahi team or a saint to communicate in such a manner is beyond comprehension.

Most of the recent statements of Anna Hazare team, through media, press conferences and during their Satyagraha demonstrations, have used phrases that give an impression of violent communication.

A medical perspective on this is that reading a violent communication incites negative feelings in the heart of the readers, which can even produce a feeling of anger.

Any righteous fight, which is based on violent communication like criticism, condemning and complaining will soon lose its credibility.

When Anna Hazare started his movement, he began on a positive note based on the Gandhian philosophy of non violence. Here, one must bear in mind that violence does not only stand for riots; it also denotes violence in your speech and thoughts.

The general public joined Anna Hazare in large numbers, especially, the younger generation, in his non violence approach to anti corruption. His non violent approach won the attention of the general public, media and the government and a committee was soon constituted. But, since then, the communication to the public by the Anna Hazare team has not been based on the principles of non violence.

In Sat Yuga and Treta Yuga, when the majority of the people were truthful and there was Ram Rajya, there too were people like Ravana and his team, though in minority, still created hell for the society. Similarly, the Dwapar Yuga, the era of Lord Krishna, had people like Kansa. Likewise, in Kal Yuga, when we have majority of Ravanas and Kansas, we are bound to have Satyugi people, even though in minority. Just as Ravana and Kansa created havoc for the society in their respective eras, in Kal Yuga too, some Satyugi people, even if in minority, can create havoc for the Kalyugi people in majority. 

After the death of Bhagwan Sai Baba, many people began thinking that they have got another Avtar in the guise of Anna Hazare to lead this Satyugi minority population.

Whether a person is a Satyugi or Kalyugi is decided by presence of some or all the four characteristics as mentioned in Srimad Bhagwad: Truthfulness (Satya), Selfless hard work (Tap), positive thoughts (purity) and Daya & Daan (Charity).

1.      If all the four characteristics are present, the person is Satyugi.

2.       If truthfulness is absent, the person is Tretyugi

3.       if both truthfulness and hard work are absent, one is Dwaparyugi

4.       When only Daan & Daya are present, the person is Kalyugi.

 To become a Satyugi in today, one should follow the principles of communicating the non-violent way.

 If Anna Hazare group continues to communicate violently, they will lose their credibility in the public.

 Saam Daam Dand Bhed is taught and practiced as a fundamental principle in politics. It is understandable that politicians in power will try to instigate Anna Hazare so that he responds using violence in his speech and in this way lose his credibility in the public.

 And this is what has been happening over the last few days. Everyday we are witnessing members of his team attacking the government with violence in their speech. Anna Hazare should realize that public sympathy is with Anna Hazare; he is respected as a Gandhian and not his team mates. If they continue using violent communications, this movement will lose its importance and impact.

 Is somebody listening?

About the author: Padmashri & Dr. B.C. Roy National Awardee, Dr. K K Aggarwal is a Senior Consultant, Physician, Cardiologist at Delhi based Moolchand Medcity; President Heart Care Foundation of India; Chairman Ethical Committee Delhi Medical Council and has served as the Research and Academic Wing Heads of National Indian Medical Association.