Change the way you live and eat to prevent stroke

A study has found that people at high genetic risk of stroke can still reduce their chance of getting it by sticking to a healthy lifestyle. This includes quitting smoking and maintaining an ideal weight. The need of the hour is to raise awareness on the importance of adopting a balanced lifestyle right from a young age and for elders in the family to set precedence for kids on these lines.

This proves the age old Vedic expression that you can change your destiny and sanchit karmas by following a proper lifestyle.

The acronym FAST can be used to recognize the warning signs of stroke.

Face — Ask the person to smile. Does one side of the face droop?

Arms — Ask the person to raise both arms. Does one arm drift downward?

Speech — Ask the person to repeat a simple sentence. Are the words slurred? Does he or she fail to repeat the sentence correctly? and

Time — If the answer to any of these questions is yes, time is important.

Neurological disorders are the most complex among all health problems. People should therefore exercise regularly, maintain a healthy weight, keep their sugar, blood pressure and cholesterol under control, and most importantly quit smoking and alcohol consumption.

Stroke is an emergency and getting timely help and treatment is extremely important. Hence, it is very important to act fast to identify these patients. Early treatment improves the chances of recovery.

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA

Emedinews : In what direction would Anna’s fast end?

Most Satyagraha should end up in a win-win situation. No party should seem to look that they have won. What can happen during a Satyagraha?

1. The fast is broken after demands are met.
2. The demands are not met but the fast is broken on the promises made.
3. The demands are not met but the fast is broken after a committee is constituted to look into the demands.
4. The fast is broken on the mediation by a religious or an important person in the society.
5. The fast is broken after the President of the country intervenes.
6. The fast is broken on medical grounds.
7. The fast is broken by the order of a court.
8. The fast is broken on the intervention of local administration or the local police.
9. The fast is broken on the request of the followers.
10. Some shift from complete fast to a relay fast.

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.

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.

Baba Ramdev Special: How to medically face a patient of Satyagraha with signs of starvation?

I recall days of my joining in MBBS in 1975 when I met Vinoba Bhave ji for the first time and when I was an intern, I was a part of the medical team who looked after him when he undertook  a fast unto death. It was a willful decision taken by Vinoba ji after he was diagnosed to be suffering from LBBB heart rhythm and a pacemaker was advised to be put on him. Instead of going for an artificial machine, he decided to call it a day and quit the world. It became a debate of the nation whether a person can decide to fast unto death or not. A case was also filed in the local court that Vinobaji is trying to commit suicide but before the date of hearing, Vinobaji left his body on the day of Amavasya, 10 am on Diwali day. Ever since that subject has been hitting my mind and the memories of Vinoba Bhave ji became afresh with the recent episodes  of Anna Hazare going on Satyagraha and later Baba Ram Dev sitting on fast unto death.

I also recall my days in 1986 when I was doing my Fellowship in Non-invasive Cardiology in Birmingham Alabama USA when I came across article in US media about physician assisted suicide, a term not defined by Medical Council of India.

Physician assisted suicide was an unethical act in American dictionary at that time. From medical point of view, if we see a patient sitting on Satyagraha with a vow to fast unto death for practical purposes, he or she is committing suicide and if we as doctors are silent witness to the same, we are liable to be charged as an unethical act of assisting in that physician assisted suicide.

We should refuse to attend to any such patient and if we attend then it becomes our duty to forcibly treat that patient even if it amounts to calling Police or the local administrative authorities. As medical fraternity, we should refuse to attend to such patients if we are not allowed to act and treat them medically.

I know in Vinoba Bhaveji’s time doctors from MGIMS, Nagpur and many invited from Bombay behaved like a near spectators and were unable to offer any help to the dying saint.  We are seeing the same phenomenon happening with Baba Ram Dev and the local treating doctors showing their helplessness.

How long Ramdev can take on fast

Rough formula of 3 is that one can not 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.

Minus points with Ramdev are that he is slim, his muscle mass is low, his body fat content is low and he is fasting in summer.

Plus Points with him are that he has n access to AC environment and he is a Yogi who are known to fast for long by reducing their body metabolic needs.

People who are inb extremes of ages or are suffering from a chronic ilment, prewgnnt ldies, diabetics should not fst without a doctors clernce.


Here are some facts
1. Fasting is willingly abstaining from some or all food, drink, or both, for a period of time.

2. An absolute fast is abstinence from all food and liquid for a defined period.

3. Partially restrictive fast is limited to particular foods or substance.

4. The fast may also be intermittent in nature

5. Fasting may refer to the metabolic status of a person who has not eaten overnight, and to the metabolic state achieved after complete digestion and absorption of a meal.

6. A person is assumed to be fasting after 8–12 hours.

7. Metabolic changes toward the fasting state begin after absorption of a meal (typically 3–5 hours after a meal); "post-absorptive state" is synonymous with this usage, in contrast to the "post-prandial" state of ongoing digestion.

8. A diagnostic fast refers to prolonged fasting (from 8–72 hours depending on age)

9. The longest known fast for a human is 132 days (without food).

10. Glucose is the body's primary fuel source and is essential for the brain's functioning. When denied glucose for more than 4–8 hours, the body turns to the liver for glycogen, a storage form of glucose, to be used for fuel.

11. A process called glycogenolysis converts glycogen into a usable form of fuel. At this point, the body also uses small amounts of protein to supplement this fuel. This fuel will last for up to 12 hours before the body needs to turn to glycogen stored in muscles, lasting for a few more days.

12. If glucose is still denied at this point, muscle wasting is prevented by temporarily switching to fat as the fuel source, meaning fat is converted into ketone through catabolism. Ketones, while not sugars, can be used by the brain as a fuel source as long as glucose is denied.

13. The body continues to use fat for as long as there is fat to consume.

14. 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.

15. 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.

16. Hypovolemia refers to any condition in which the extracellular fluid volume is reduced.

17. It can be produced by salt and water loss (as with vomiting, diarrhea, diuretics, bleeding, or third space sequestration) or by water loss alone (ie, dehydration).

18. Salt and water loss comes primarily from the extracellular fluid whereas pure water loss (ie, dehydration) comes from the total body water, only about 40 percent of which is extracellular.

19. For dehydration to produce the same degree of extracellular volume depletion as salt and water loss, 2.5 times as much fluid would have to be lost.

20. Patients with dehydration are always hypernatremic whereas those with salt and water loss typically have a plasma sodium concentration that is normal or even reduced (due to free water replacement of part of the deficit).