Vitamin D reduces heart risk

Datuk DR RAJEN M. is a pharmacist with a doctorate in holistic medicine.
Email him at health@po.jaring.my

VITAMIN D is a fat-soluble vitamin that is naturally present in very few foods, added to others, and available as a dietary supplement. It is also produced by the body when ultraviolet rays from sunlight strike the skin and trigger vitamin D synthesis.

However, vitamin D obtained from sun exposure, food, and supplements is biologically inert and must undergo two hydroxylations in the body for activation.

The first occurs in the liver and converts vitamin D to 25-hydroxy vitamin D, also known as calcidiol. The second occurs primarily in the kidney and forms the physiologically active 1,25-dihydroxyvitamin D also known as calcitriol.

Vitamin D is essential for promoting calcium absorption in the intestines and maintaining adequate serum calcium and phosphate concentrations to enable normal mineralisation of bone and prevent hypocalcemic tetany.

It is also needed for bone growth and bone remodelling by osteoblasts and osteoclasts. Without sufficient vitamin D, bones can become thin, brittle, or misshapen. Vitamin D sufficiency prevents rickets in children and osteomalacia in adults.

Together with calcium, vitamin D also helps protect older adults from osteoporosis.

We are now going beyond the skeletal system and going into the cardiovascular system. Vitamin D it appears, is good for the heart.

A new study presented on Nov 16 at the American Heart Association's Scientific Conference in Orlando, Florida, confirmed a strong association between the presence of reduced vitamin D levels and a greater risk of coronary artery disease, stroke, heart failure and dying among men and women 50 years of age and older.

This is both new and exciting. We seldom talk about vitamin D in association with heart disease.

Dr Brent Muhlestein and his colleagues at Intermountain Medical Centre in Salt Lake City followed 27,686 subjects with no history of heart disease for an average of 1.2 years. Serum 25-hydroxyvitamin D levels obtained during routine clinical care were classified as normal at over 30 nanogrammes per milliliter (ng/mL), low at between 15 to 30 ng/mL or very low at less than 15 ng/mL.

Over the follow-up period, 2,614 participants developed coronary artery disease, 1,742 developed heart failure, 314 experienced a stroke and 1,193 deaths occurred.

Those with very low vitamin D levels were 45 per cent likelier to develop heart disease, twice as likely to develop heart failure, 78 per cent more likely to experience a stroke, and 77 per cent likelier to die than those with normal levels.

It was notable that subjects whose vitamin D levels were classified as "low" as opposed to "very low" also had greater risks of these conditions, however, the increase compared to those with normal levels was not as great as the very low group.

"This was a unique study because the association between Vitamin D deficiency and cardiovascular disease has not been well-established," commented Dr Muhlestein, who is the director of cardiovascular research of Intermountain Medical Centre's Heart Institute.

"Utah's population gave us a unique pool of patients whose health histories are different than patients in previous studies," he said.


"For example, because of Utah's low use of tobacco and alcohol, we were able to narrow the focus of the study to the effects of vitamin D on the cardiovascular system.

Co-author Heidi May, PhD, who is an epidemiologist with the Intermountain Medical Centre research team noted: "We concluded that among patients 50 years of age or older, even a moderate deficiency of Vitamin D levels was associated with developing coronary artery disease, heart failure, stroke, and death."

"I think that this study is important because vitamin D deficiency is easily treated. Vitamin D is also somewhat inexpensive and widely available."

When you consider that cardiovascular disease is the leading cause of death in much of the industrialised world, you could understand how this research can help improve the length and quality of people's lives.

Very few foods in nature contain vitamin D. Fish meat (particularly salmon, tuna, and mackerel) and fish liver oils are among the best sources.

Small amounts of vitamin D are found in beef liver, cheese and egg yolks. Vitamin D in these foods is primarily in the form of vitamin D3 (cholecalciferol) and its metabolite 25(OH)D3.



Fortified foods provide most of the vitamin D in the American diet. For example, almost all of the US milk supply is fortified with 100 IU/cup of vitamin D.

In the 1930s, a milk fortification programme was implemented in the United States to combat rickets, then a major public health problem. This programme virtually eliminated the disorder at that time.

Other dairy products made from milk, such as cheese and ice cream, are generally not fortified.

Ready-to-eat breakfast cereals often contain added vitamin D, as do some brands of orange juice, yogurt, and margarine. In the US, foods allowed to be fortified with vitamin D include cereal flours and related products, milk and products made from milk, and calcium-fortified fruit juices and drinks.

- NEW STRAITS TIMES

All about anaemia

By Dr MILTON LUM

While the causes of anaemia may be varied, the condition can be treated easily with proper diagnosis.

BLOOD is made up of fluid (plasma) and cells, that is, red blood cells which transport oxygen; white blood cells which help protect the body against infection; and platelets which help the blood to clot. Most blood cells, including the red blood cells, are produced from the stem cells in the bone marrow which is the red spongy material found in the cavities of the long bones of the body.

Red blood cells contain haemoglobin which is a red, iron-rich protein that gives the red colour to blood. Haemoglobin, which is made up of two proteins called alpha and beta chain globins, enables the red blood cells to transport oxygen from the lungs to all parts of the body and to transport carbon dioxide from other parts of the body to the lungs where it is got rid off during exhalation.

The body uses iron, folate and vitamin B12 found in the food we eat, to produce red blood cells. The number of red blood cells in circulation is maintained through the control of their formation and not their life-span. A feedback mechanism controls the production. It is not until the cells have been removed from the marrow that new cells will develop to replace them.

Erythropoietin, a hormone produced in the kidneys, plays an important role in the development of new red blood cells and the production of haemoglobin.

The red blood cells circulate in the bloodstream for about 120 days before they are broken down in the spleen. If the haemoglobin or number of red blood cells is low, the oxygen-carrying capacity of the blood is reduced and anaemia develops. Anaemia is a general name given to a variety of disorders affecting the red blood cells.

Haemoglobin is measured in grams per 100 millilitres (1 decilitre or dl). The normal level in females is between 11.5 and 15.5gm per dl. A woman is considered to be anaemic if the haemoglobin is below 11.5gm per dl.

Types of anaemia

Iron deficiency anaemia is the most common type of anaemia. It affects about 30% of the world’s population. It is due to a shortage of iron, which is needed by the bone marrow to produce haemoglobin. Without enough iron, the body cannot produce enough haemoglobin for the red blood cells. This results in iron deficiency anaemia. Apart from food, the body can get iron from the red blood cells that die.

The iron in the dead cells is recycled to produce new cells. If blood is lost, iron is also lost. This occurs if women have heavy periods or when there is a chronic blood loss from some part of the body.

Vitamin deficiency anaemia occurs when there is a shortage of folate and/or vitamin B12. The dietary requirements of folate are much more than that of vitamin B12. When the diet is short of these and other important nutrients, there is a decrease in the production of red blood cells. This can also occur if absorption of nutrients is affected by a variety of gut conditions. The bone marrow produces large, abnormal red blood cells called megaloblasts.

Hemolytic anaemia occurs as a result of an inherited or acquired condition in which the red blood cells are destroyed faster than their replacement by the bone marrow. Haemolysis is a term used to describe the breaking up of red blood cells and results in the release of haemoglobin into the plasma.

Aplastic anaemia is a life-threatening condition. It is due to a decrease or failure of the bone marrow to produce sufficient numbers of red blood cells, white blood cells and platelets. Sometimes the cause is unknown but at other times, it could be due to chemotherapy, radiotherapy, toxins and lupus.

Anaemia can also be caused by liver disease, cancer, HIV/AIDS and chronic inflammatory conditions like rheumatoid arthritis which interfere with the production of red blood cells, resulting in chronic anaemia. Kidney failure and chemotherapy can cause a shortage of erythropoietin, resulting in anaemia.

On rare occasions, no cause of anaemia can be identified.

Anaemia in pregnancy

Many women are anaemic during pregnancy. A recent study by the Anaemia Working Group found that about one-third of pregnant Malaysian women are anaemic.

Anaemia occurs because there is increased demand for iron and vitamins in pregnancy. The mother has to produce more red blood cells for herself and the foetus. More plasma is also produced.

The blood volume increases by about 50% during pregnancy with a disproportionate increase in plasma. This leads to a dilution of the blood with the haemoglobin falling. The haemoglobin is at its lowest level between 24 and 30 weeks of pregnancy.

Other causes of anaemia include:

> Poor diet: If the diet is low in iron and vitamins, especially folic acid, there is a risk of anaemia as these are the raw materials needed to produce sufficient numbers of red blood cells.

> Family history: Some women whose family members have anaemia because of inherited genes are at increased risk.

> Alcoholism: Chronic drinking increases the risk because alcohol interferes with the absorption of folic acid.

> Vegetarians who have a strict diet may not get enough iron or vitamin B12 in their food.

> Chronic conditions like kidney or liver failure, and cancer increases the risk. Chronic blood loss from some parts of the body due to ulcers, haemorrhoids, etc, may lead to iron deficiency anaemia.

> Intestinal conditions like Crohn’s disease: Intestinal polyps and even intestinal surgery can result in nutritional deficiencies because of poorer absorption.

> Other conditions: Infections, blood disorders, autoimmune disorders, exposure to toxins, and the use and abuse of certain medicines can affect red blood cell production.

If the anaemia is severe, it may interfere with the ability to carry out daily activities. One may be too tired or even exhausted to work or play. If untreated or inadequately treated, anaemia can lead to rapid or irregular heartbeat. The heart has to pump more blood to compensate for the shortage of oxygen. This can result in a heart attack or stroke.

The rapid loss of a large volume of blood can result in acute anaemia and may be potentially fatal, unless there is blood transfusion. This can happen during childbirth.

If anaemia caused by vitamin B12 deficiency is not treated, it can result in nerve damage and decreased mental function because vitamin B12 is important not only for healthy red blood cells but also optimal nerve and brain function.

The symptoms of anaemia include tiredness, breathlessness, rapid heartbeat (palpitations), dizziness, and headache and chest pain if the anaemia is severe. Apart from these symptoms, anaemia is usually diagnosed during ante-natal blood tests which are usually done at the initial consultation and, if necessary, in the second half of pregnancy. A full blood count measures the haemoglobin level and the levels of the different cells in the blood. Some of the blood may be examined under the microscope to evaluate the size, shape and colour of the red blood cells. This evaluation may indicate a diagnosis.

Blood estimations of iron, folate and vitamin B12 will help confirm deficiencies of these compounds. If inherited conditions are suspected, tests like haemoglobin electrophoresis will be carried out.

Additional tests may be done to determine the underlying cause of the anaemia. For example, iron deficiency can be due to peptic ulcers, benign colon polyps, haemorrhoids or other conditions, in which case, appropriate tests will need to be carried out.

If there is a family history of inherited anaemia, a discussion with the doctor and possibly a medical geneticist would be helpful as they can help advise on your risk and the risk of transmitting the condition to your children.

Management and prevention

The treatment depends on the cause. With adequate treatment, most anaemias can be cured. Iron deficiency anaemia will be gone once the iron stores are replenished and any source of blood loss stopped. Folate and vitamin B12 deficiencies are often successfully treated with supplements. Anaemia caused by chronic conditions, hemolytic anaemia and aplastic anaemia can be managed, if not corrected. Inherited anaemias are not curable but the symptoms can be relieved with treatment.

Many types of anaemia can be prevented. Iron deficiency and vitamin deficiency anaemia can be avoided by eating adequate amounts of a healthy diet.

It is important to eat plenty of iron-rich foods. Adequate iron is also important for vegetarians. Food rich in iron include lamb, beef, pork, beans, peas, whole grain breads, dark green leafy vegetables, dried fruit, nuts and seeds.

Food that contains vitamin C helps increase iron absorption. They include raw vegetables, potatoes, lime and oranges. Foods rich in folic acid includes fresh fruits and vegetables, citrus fruits, meat, dairy products and beans.

Vitamin B12 is found abundantly in meat and diary products.

The diet can be supplemented with iron, vitamins and folic acid.

Influenza A(H1N1) : Protect yourselves

With the number of reported Influenza A(H1N1) cases and deaths on the rise, it is normal for us to feel anxious about the spread of the disease, and our chances of getting it. However, there are a few things we should keep in mind:

I. Panic and fear do not help. If you have flu-like symptoms, avoid:

·We are right to be concerned, and we should practise good personal hygiene and social distancing to prevent ourselves from getting Influenza A(H1N1). But there is no reason for us to panic because we can prevent ourselves from getting it, and treatment is available.

·If we have influenza-like symptoms, we should check with a doctor and take appropriate measures.

II. But should we all get anti-viral medication?

·Oseltamivir and zanamivir are anti-viral medications that can stop the virus from replicating in the body. It works best if taken within two days after symptoms appear, but it is not necessary for healthy people as the disease is usually mild and self-limiting.

·Currently, the following groups will be given anti-viral medications if they have symptoms of influenza-like illness:

i) People who are in the high-risk groups (see IV).

ii) People who are not in the high-risk groups but have had persistent, high fever, for more than two days.

·However, regardless of whether anti-viral medications are prescribed, it is important for everyone who has influenza-like illness to monitor their own symptoms and seek medical help immediately if symptoms worsen.

III. What should we do then?

·We should keep ourselves as healthy as possible – eat well, rest well and exercise regularly.

· Those of us who have influenza-like illness should take responsibility for our own health. We should ask doctors about steps we should take to recover and avoid spreading the infection.

·Those of us who are caring for people with influenza-like illness should always take extra precautions to make sure we ourselves are not infected. Be on the lookout for early flu symptoms and seek medical advice promptly.

·Doctors and healthcare workers should be vigilant and take all influenza-like illnesses seriously. All patients should be reminded to monitor their own symptoms and take precautionary measures to avoid spreading the infection.

IV. As for people who are at high risk...

People who are at risk of severe illness or complications from Influenza A(H1N1) infections must SEEK IMMEDIATE TREATMENT. Individuals at risk for severe illness or complications are as follows:

> Children less than 5 years old

> Persons aged 65 years and older

> Children and adolescents (less than 19 years old) on long term aspirin therapy

> Pregnant women

> Adults and children with asthma, chronic obstructive pulmonary disease, organ failure, cardiovascular diseases, hepatic, haematologic, neurologic, neuromuscular, or metabolic disorders such as diabetes mellitus.

> Adults and children who have suppressed immune systems (including that caused by medications or by HIV infection)

> Residents of nursing homes and other chronic care facilities

> Individuals who are obese

V. Are we doing enough to stop A(H1N1)?



·The Ministry of Health has made efforts to increase hospitals’ and clinics’ access to anti-virals.

·Confirmatory testing is only done for severe cases that require hospital admission.

·Anti-viral medication may be prescribed by all government and private hospitals and clinics based on the doctors’ clinical judgement.

·Nevertheless, to achieve effective infection control within the community, there is still a need for the public to cooperate with the health authorities by practising cough etiquette, good hand hygiene and social distancing.

- THE STAR

Power up

Get the right vitamins and minerals to keep you energised all day long.

You can’t hear, see, touch or smell it, but when you don’t have it, your body feels it immediately. You’re tired, listless and weak. If you’re still guessing what it is, the answer is energy.

Nobel laureate Albert V. Szent-Gyorgyi once described energy as the “currency” of life. He couldn’t be more right.

From eating, walking, exercising, working and to everything you do, you need energy. Even at a cellular level, energy is needed to fight off infections and break down toxins in the body. Your body also needs energy to produce hormones, enzymes and other molecules that are essential for survival.

Energy is basically obtained from the carbohydrate, protein and fat we consume. Your body converts or metabolises energy from these dietary sources through a complex process.

Excess energy is converted into adipose tissue (fat) and is stored for later use. A small amount of carbohydrate is stored in the liver and muscles as glycogen for quick release when needed. This energy is normally released when needed for, say, physical activity.

How much energy a person needs depends on their level of physical activity, gender, age and body size.

Intake also varies if someone has special requirements such as being pregnant, recovering from cancer or even surgery. Everyone has his own energy requirement and all of us want to be sufficiently energised so we can be productive throughout the day.

“Energy is very important when you’re leading a physically active lifestyle. Having high energy levels allows you to be more productive, do and achieve more, and get the most of out life,” says Teresa Chian of the Dance Space studio in Kuala Lumpur.

Surech Kuppusamy, an Alpine and Himalayan climber who has climbed several peaks including Everest, Ama Dablam and aiguille des Pélerins, shares: “When you know you have the energy to conquer a task, you’re more motivated and confident to go on. Apart from rest and training, nutrition is important in giving you the energy to perform well. Vitamins also constitute essential regulative and protective substances that your body needs. So, it’s not just about calories but also vitamins and minerals.”

The answer could be as simple as getting more calories from your food. But many times, energy intake is not the problem. After all, too much energy-rich foods could lead to other problems such as weight gain.

Another factor is your body’s ability to convert energy from your food intake. Consuming the right vitamins and minerals in the right quantities is vital.

Power boosters

Studies have indicated that there is a relationship between micro-nutrients, energy metabolism and an individual’s well-being. Further research also shows that vitamin and mineral supplements can alleviate the risk of inadequate micro-nutrient intake. However, nutrient deficiencies can only be addressed if the supplements are taken for an adequate period of time.

So, what vitamins and minerals can boost your energy levels?

They are the Vitamins B group and C as well as iron, magnesium and potassium. A well-balanced diet should give you sufficient quantities of these, but even in developed countries, people often fail to eat healthily due to poor food choices, improper eating habits such as skipping meals, and following faddish diets.

Smoking and excessive alcohol consumption are also culprits. But sometimes, you may just need more nutrition if you’re pregnant, breastfeeding or an elderly person.

A good health supplement can make a difference. The B Vitamins support energy metabolism from protein, carbohydrate and fat. They help in the release of energy from foods. Except for Vitamin B12, the others cannot be stored in the body and need to be replenished daily. So getting adequate quantities daily is very important. Specifically, Vitamin B1 (thiamine) is directly linked to carbohydrate intake and the metabolic rate.

Vitamin B2 (riboflavin) is also needed for the utilisation of energy from food. It also aids in the utilisation of protein, fat and carbohydrate for energy.

Iron is needed for the formation of haemoglobin, which is a substance in our blood that carries oxygen to tissues. If you are constantly fatigued, lack of iron could be the reason. Severe lack of iron can lead to anaemia. Magnesium and potassium are required to break down glucose into energy in our bodies. When magnesium is low, our body produces more lactic acid which makes us tired. In fact, magnesium is a co-factor in over 300 enzyme reactions, particularly those involving metabolism of food components. Potassium is also necessary to convert sugar in the blood into energy.

Rounding it off is Vitamin C, which is needed as it increases iron absorption; this means it needs to work in tandem with iron.

There are probably times when we all want to feel a little more energetic to get us through the day. Well, besides looking at your caloric intake, do also look at the quantities of vitamins and mineral in your diet. Follow this formula (calories + vitamins + minerals = energy) and fatigue and lethargy would be a thing of the past. – Article courtesy of Wyeth Consumer Healthcare

Diabetis - Who is at risk?

AMONG the general population, those who:

·Have Type 2 diabetes mellitus (T2DM) symptoms

·Have a parent, brother, or sister (first-degree relative) with T2DM

·Have had heart disease

·Have abnormal blood cholesterol levels (HDL, or “good” cholesterol, level below 0.9mmol/L or triglyceride level above 1.7mmol/L)

·Have high blood pressure (above 140/90mm Hg; on therapy for hypertension)

·Have a clinical condition associated with insulin resistance

·Are overweight (BMI over 23; or waist wider than 80cm for women and 90cm for men)

·Do not exercise regularly (less than three times a week, 20 minutes at a time)

·Are women with polycystic ovarian syndrome

Pregnant women who:

·Have a BMI over 27

·Have delivered a baby weighing 4kg or more

·Have a bad obstetric history and/or current obstetric problems

·Have gestational diabetes mellitus

·Have glucose in their urine at the first prenatal visit

·Are over 25

TAKE ACTION: If you have any of the risk factors above, ask your doctor to screen you immediately. If you do not have any of them, ask your doctor to screen you annually from age 30 and up.

Overweight children and teenagers (over 120% of ideal weight) who have:

·A first- or second-degree relative (aunt, uncle, grandparent, nephew, niece, half-sibling) with T2DM

·A mother who has had gestational diabetes mellitus

·An Indian ethnic background

·Signs of insulin resistance or conditions associated with it

TAKE ACTION: If your child or teen meets any two of the criteria above, make sure he or she is screened for T2DM at least every two years from age 10 onwards, or at the onset of puberty if puberty occurs before then

Mythbusting

As a private hospital diabetes centre manager, nurse Yong Lai Mee is charged with educating patients, nurses, and the public on diabetes management. Here, she clears up some common misconceptions.

Myth #1: Diabetic drugs cause complications

Drug therapy doesn’t lead to complications - it prevents them, stresses Yong. Unfortunately, many of her patients think oral diabetes medication causes renal failure, so they try to reduce the amount they take and then get discouraged when they have to take more. “They don’t know that diabetes is a progressive disease,” she says.

Myth #2: Insulin is the end of the line

Nowadays, patients whose diabetes is newly diagnosed can be put on any available treatments straightaway - diet and exercise control, drug monotherapy, or insulin therapy - whichever efficiently achieves blood sugar control.

Yong explains: “Treatment no longer goes ‘stage by stage’. Patients can pick up any of these treatments. (But) today in our society, insulin therapy acceptance is very low. People think that if a person is on insulin, his diabetes is very severe and he is going to die soon. So we have patients who insist to the end they don’t want it, even though the benefit is greater (than their current therapy).”

Myth #3: Once my blood sugar is stable, I can self-medicate

Proper diabetes management requires periodic reviewing with a doctor so your treatment can be tweaked from time to time for optimal effect. Patients who self-medicate miss out on this vital process.

Such patients, says Yong, “take the prescription, purchase the medication over the counter, and continue taking it without coming back for review. But they don’t know how to monitor their blood sugar and take it based on their feelings - ‘When it is high, I take, when it is low, I don’t take.’ That causes a lot of poorly controlled blood sugar.”

Myth #4: This special diet will cure my diabetes forever

Often, patients will try to wean themselves off their diabetes drugs, notes Yong. The usual pattern is to follow the diet strictly and progressively omit taking their medication. So no drugs for one day in the first week, then two days in the next, then three, and so on, until they are no longer taking any.

“This is a myth,” says Yong. “But patients would rather buy this than the doctor’s recommendation because they do not want to have diabetes. They want to be cured, and will explore all kinds of ways to get cured. These patients are exposing themselves to higher blood sugar levels and much damage can be done by the time they come back to the hospital to see a doctor.

“Diabetes is incurable,” Yong drives home. “It is controlled by diet, exercise, and medication. You’re talking about beta cell failure (beta cells in the pancreas produce insulin). You need these drugs to stimulate insulin production. By controlling diet alone, you can only limit a certain amount of blood sugar.” — LEE TSE LING

- THE STAR

Juicy goodness

Pasteurised 100% juices are a delicious way to help meet your daily fruit and vegetable requirements.

Remember being told to “eat your fruits and vegetables”? Well, thanks to advancements in food technology, you can now conveniently drink them up in the form of 100% juice, too.

Whether you eat drink them, fruits and vegetables are essential to proper nutrition and good health. Both are important in their own right, and neither one can substitute the other. This is why we need to eat both fruits and vegetables everyday – and in different colours – to receive the wide range of vitamins, minerals, fibre and phytonutrients that the foods can offer.

Phytonutrients are naturally occurring bio-active compounds. Besides giving off the marvellous hues that make fruits and vegetables look so appetising, most phytonutrients act as antioxidants. They work together with other nutrients to help prevent oxidative damage to body cells.

Some of the more well-known phytonutrients include carotenoids (beta-carotene in mangoes, lutein in spinach and lycopene in tomatoes), flavanoids (resveratrol in grapes, quercetins in apples, and anthocyanins in red dragon fruit), and glucosinolates/indoles (found in cauliflower, broccoli, cabbage and kai lan).

Hundreds of other phytonutrients are actively being studied.

It’s good to know that we can all enjoy fruits and vegetables in their unrivalled combination of great taste, nutrition, abundant variety, and various product forms (fresh, frozen, canned, dried and juiced). All these help increase consumption.

Indeed, it is definitely better to eat more fruit and vegetables than less. This is the message of the 5M national campaign, organised by the Health Ministry. In encouraging healthy eating habits, it advocates reducing the intake of fat, sugars and salt while increasing the intake of fruits and vegetables.

5M is based on scientific evidence which shows that increased daily consumption of fruits and vegetables may help reduce risk of many chronic diseases. Going by the Malaysian Dietary Guidelines, as well as prevailing expert opinion elsewhere, people should ideally eat five servings of fruits and vegetables each day.

Examples of one serving of fruit is half a medium-sized guava, a slice of papaya or a slice of watermelon. One serving of vegetables is half a cup of cooked dark green leafy vegetables (spinach or sawi) or half a cup of a root (carrot) or fruit (tomato) vegetable. Choose at least one Vitamin C-rich and one beta carotene-rich fruits or vegetables every day.

All in, five servings really aren’t very much for an entire day. Yet, some people fall short of this amount and are not receiving the full benefit of fruits and vegetables. If you happen to be one of them, you can up your intake by applying these simple tips:

· Have fruits and vegetables as part of every meal. It’s easy if you serve up salads or other fruit and vegetable-rich fare. Try out recipes where vegetables take centrestage.

· Snack on them. Bonus points if you can get some fruits and vegetables should you feel hungry in between meals.

· Go for something new. Variety spices up a healthy diet. So start exploring fruits and vegetables that you do not usually eat.

· Keep fruits in sight, since you’ll be more likely to eat fruits that you can see, whether fresh or dried, whole or sliced. Keep them out on the counter or in the front of the fridge.

· Drink pure fruit and vegetable juices. This is a convenient and fuss-free way to enjoy their natural goodness.

Fruits and vegetables are always best consumed whole but when they are not available, you can down a glass of 100% juice and, in effect, get two (out of your five) servings for the day.

Please be advised, this equation does not apply to “Juice Drinks” or “Fruit Drinks”. As defined by the Malaysian Food Act 1983, these products will only deliver a minimum juice content of 35% and 5%, respectively. Products labelled as “100% Juice”, however, give you pure juice with nothing else added. This is why 100% juice can be considered nutritionally rich and able to offer multiple nutrients (vitamins, minerals and naturally occurring phytonutrients). It also does not contain added sugar, preservatives or colouring. The process of pasteurisation (heating the product to a critical temperature for a specified amount of time before chilling) reduces the number of harmful microorganisms while retaining the fresh taste and nutritional goodness.

Amid the hustle and bustle of every day life, great tasting 100% fruit and vegetable juices never fail to provide a boost of natural goodness. Serve chilled by themselves, or mixed into a refreshing mocktail, smoothie or cold dessert, they’re ideal and convenient for completing a balanced and varied diet for optimal nutrition.

Health enhancers

Ongoing research reaffirms the power of fruits and vegetables in enhancing health. Here’s a quick take:

Heart health: People with high levels of cholesterol in the blood should ensure a daily intake of 20 to 30g of dietary fibre to improve their condition. This target can be achieved by eating three servings of vegetables, two servings of fruits and one serving of whole grain products.

Blood pressure: Even if on medication, people with high blood pressure are advised to continue eating diets rich in fruits and vegetables, and low in saturated and total fat.

Cancer: Certain phytonutrients (such as flavonoids and lycopene) are compounds that act as antioxidants which may help reduce the risk of developing some cancers.

Gastrointestinal health: The fibre in fruits and vegetables absorbs water and expands, like a sponge, as it passes through the intestines. This help promotes regular bowel movement, thereby reducing the risk of constipation.

Vision: Besides the well-known benefit of carrots in aiding night vision, fruits and vegetables also help reduce the risk of two common ageing-related eye diseases – cataract (gradual clouding of the lens) and macular degeneration (cumulative damage to the macula, the centre of the retina). Dark green leafy vegetables, such as spinach and kale, also contain pigments that appear to be able to snuff out free radicals before they can harm the eye’s sensitive tissues.

Increased intake of a good variety of fruits and vegetables go a long way in keeping us healthy and well. So, get their full benefit by making these foods, in whole and in the form of 100% juice, a part of your daily diet.

- THE STAR

My immunity

How to keep the immune system strong to cope with the daily stresses of life.

The times, they appear to be rather harrowing. Witness the recent spate of “troubles” that have arrived on our shores, not least H1N1. It is such times that reinforces the belief that health is truly wealth.

When it comes to infections, the body’s main defence against these is its immune system.

This consists of a network of cells, tissues and organs that are entrusted with the task of preventing foreign micro-organisms from proliferating and wreaking havoc in the body.

Staying strong

Much like the military arm of any country, the body’s immune system has its own troops to detect, fight and contain these foreign invaders. Through a series of steps called the immune response, the immune system attacks organisms and substances that invade the body and cause disease. When a person falls sick, it’s an indication that the immune system has failed. In essence, the body has been “invaded”.

The various cells (or troops) of the immune system that help fight infections are white blood cells, or leukocytes and various others. These combine to seek out and destroy the organisms or substances that cause disease.

In general, any disease that can compromise the immune system can be regarded as the initial invasion force – in essence, the disease “softens” up the body and makes it more susceptible to other infections. A flagging immune system may result in fatigue, lethargy, repeated infections, slow wound healing, allergies, thrush, colds, and flu.

The mantra that is oft repeated by dietitians and nutritionists all over the world goes something like this: A healthy diet helps keep you healthy and strong. The basis for this statement is the fact that a varied and healthy diet provides the body with various vitamins and minerals that help the functioning of the body, amongst other things.

When it comes specifically to the immune system, there are certain vitamins and minerals that can help optimise the functioning of this system, as demonstrated by the many studies that have been carried out examining the link between nutrients and immune system function.

Supporting the immune system

Studies have shown that a deficiency of vitamins A, B1, B2, B6, B12, folic acid, C and E suppresses immunity, as does a deficiency of iron, zinc, magnesium and selenium.

How specifically do these nutrients help the immune system? Lets’ dissect the studies and take a general look at each of these nutrients:

·Vitamin C increases the production of infection-fighting white blood cells and antibodies.

·Vitamin E stimulates the production of cells that search and destroy harmful cells. It also enhances the production of B-cells that destroy bacteria. Vitamin E can also slowdown or reverse the effects commonly associated with ageing on the immune system.

·Beta carotene, the precursor to vitamin A, helps stimulate growth of infection-fighting cells and natural killer cells as well as supporting T cells.

·Selenium is a trace mineral that is essential for proper functioning of the immune system.

·Manganese possesses antioxidant properties and is a key component of an immune related enzyme.

·Zinc and copper are also important factors in the development and maintenance of immune function.

The right balance

All successful military campaigns throughout history have one thing in common: the right balance of air, sea and ground forces. Similarly, supporting the body’s immune defences require the right balance of nutrients. It’s not enough to consume large doses of these nutrients, but to consume them in the right combinations.

Various clinical studies have shown that nutrients work best in combination with each other rather than individually in keeping the immune system operating at its best. One particular study conducted in the US revealed that older people who consumed multivitamins consistently for six to 12 months showed substantial improvements in cellular immunity. This was followed by other clinical studies that showed that those who consumed supplements which had combined nutrients rather than individual nutrients saw an increase in the number of immunity cells in their body.

In addition, consumption of antioxidants, either through foods or nutrient supplements, offered further benefit to the immune system.

So we need a varied and healthy diet to help support our immune systems. But how many of us can confidently say that we keep to optimal diets?

This is where a complete multivitamin/mineral supplement makes a positive difference, as illustrated by the above studis. Consuming a supplement on a regular basis will boost our nutrient consumption from sub-optimal to optimal levels to ensure that the immune system stays strong.

Apart from supplements, you can also keep your immune system as its best with these simple tips:

·Exercise: Regular, moderate exercise five times a week can help the immune system.

·Sleep: Ensure you get sufficient sleep so the body may rest which is crucial to staying well.

·Don’t smoke: Smoking suppresses immune cells. Quit smoking if you’re a smoker.

·Limit alcohol consumption: Limit alcohol to no more than one drink per day.

How often do most of us actually think about our immune systems? Only after we’ve caught the flu bug?

We live our lives with multiple roles – a parent, a lover, a colleague, a son, a daughter, a father, a mother. We try to fulfill the expectations of those roles as best we can. To do so, we need to be healthy, otherwise, we will be the ones needing to be looked after.

A strong immune system can only help, not hinder us, in the fulfillment of such duties.

- THE STAR

Influenza A (H1N1) - Not just a common cold

By Dr MILTON LUM

Watchful vigilance is needed to handle Influenza A (H1N1).

THE Director General of the World Health Organization (WHO), Dr Margaret Chan, announced on June 11, 2009 that the flu pandemic level was to be raised to level 6, which is the highest possible. This means that there is sustained human to human transmission of influenza A (H1N1) with community outbreaks in at least one country in two WHO regions. It meant that it was no longer possible to contain the virus to a particular geographical area.

During previous pandemics, the influenza virus took more than six months to spread as widely as the influenza A (H1N1) has spread in less than six weeks since the detection of the initial cases in Mexico and the United States.

International travel has contributed very significantly to the spread of the virus, seeding urban areas with an increased intensity of transmission.

As at July 1, 2009, health authorities in 116 countries have reported 77,201 cases and 332 deaths to WHO. As at July 2, 244 cases were reported in Malaysia, with no deaths. 206 patients had returned from abroad and 38 were due to local transmission.

This article was written with the objective of getting all readers on board the prevention train as everyone can take individual preventive measures that would collectively contribute significantly to controlling the spread of the disease.

Influenza

Influenza is a common infection that affects many people. It is caused by RNA viruses of the orthomyxoviridae family. The influenza viruses are classified into types A, B and C based on their core proteins.

Type A viruses infect humans and many other mammals, eg pigs and horses, as well as birds. Type B and C viruses usually affect humans.

Types A and B viruses are common causes of acute respiratory infections.

The virus often mutates. Minor mutations (antigenic drift) are frequent and cause repeated outbreaks. Major mutations (antigenic shift) are rare and are due to reassortment of genetic material from different A sub-types. When they occur, pandemics may arise, causing many deaths. The type B virus does not exhibit antigenic shifts.

The frequent viral mutations lead to outbreaks annually. This is because the immunity from an infection does not provide full protection against another infection by an antigenic or genetic variant of the same sub-type A virus or type B virus.

Influenza is spread by droplets and aerosols from the respiratory secretions of infected persons. The virus usually infects the upper respiratory tract, ie the nose, throat and bronchi. It rarely infects the lungs. If an infected person coughs or sneezes and does not cover it, the droplets containing the virus can spread to about a metre (three feet) distance. This can be inhaled by anyone very close to the infected person.

If the infected person coughs or sneezes into his hands, the droplets containing the virus are easily transferred to surfaces touched by the person. Traces of the viruses may be found on items at home and work, eg door handles, hand rails, computer keyboards etc as they can survive for several hours on these surfaces. Should anyone touch these surfaces and then the face, the person can get the infection.

Symptoms develop between one to five days. A person can be infectious from the day before symptoms develop until seven days afterwards. The infection spreads rapidly, especially among those who are in crowded areas. The virus survives longer outside the body in cold and dry weather. As a result, epidemics in temperate countries usually occur in winter.

The clinical features of influenza include a sudden onset of high fever, muscle ache (myalgia), headache, non-productive cough, sore throat, and running nose. Most people recover within a week or two without requiring any treatment.

It is difficult to distinguish influenza from other respiratory infections. Laboratory tests will help in confirming the diagnosis. The collection of specimens for viral culture is critical to the provision of information about the circulating influenza subtypes and strains. This is needed for decisions on treatment and the formulation of vaccines for the subsequent year.

Secondary bacterial pneumonias are a common complication, especially in children below two years, senior citizens and those with medical conditions, eg lung diseases, diabetes, cancer, kidney or heart problems. Infections can also lead to death.

Influenza is an upper respiratory tract infection that lasts a few days in most people, and is usually treated symptomatically. The body gets rid of the virus in a few days. Antibiotics have no role in the treatment of people who are otherwise healthy. However, they are used to treat secondary bacterial complications.

Influenza A (H1N1)

Influenza A (H1N1) contain some elements of a virus found in pigs. There is no evidence of it circulating in local pigs and scientists are investigating its origins. It has spread from humans to humans worldwide, leading to the declaration of a pandemic flu outbreak.

The novel influenza A(H1N1) virus spreads in exactly the same way as ordinary seasonal colds and influenza. The symptoms are the same as the ordinary seasonal flu although it may be more severe with more serious complications. The typical symptoms are sudden fever and cough. Other symptoms include headache, myalgia, pain in the joints and limbs, sore throat, running nose, sneezing, tiredness and loss of appetite.

It is different from the ordinary seasonal influenza because it is a new virus that appeared in humans and spread globally very rapidly. Since it a new virus, no one will have immunity to it and everyone is at risk of getting the infection. This includes healthy adults as well as older people, young children and those with existing medical conditions. It is likely that the current pandemic will affect more people and lead to more deaths than the ordinary seasonal flu.

Dr Margaret Chan of WHO states concisely: “Thanks to close monitoring, thorough investigations, and frank reporting from countries, we have some early snapshots depicting spread of the virus and the range of illness it can cause ... We know, too, that this early, patchy picture can change very quickly. The virus writes the rules and this one, like all influenza viruses, can change the rules, without rhyme or reason, at any time ... Finally, and perhaps of greatest concern, we do not know how this virus will behave under conditions typically found in the developing world. To date, the vast majority of cases have been detected and investigated in comparatively well-off countries.”

Pandemics

During an influenza epidemic in the developed world, between 5% and 15% of the population will be affected. Hospitalisation and deaths usually occur in senior citizens and those with medical conditions. It is estimated there are three to five million cases of severe illness and between 250,000 to 500,000 deaths annually worldwide. Most deaths associated with influenza in the developed world occur in those aged 65 years and above.

The type A virus is the main cause of epidemics and pandemics, eg the Spanish flu in 1918 which resulted in estimated deaths of 40 million worldwide. The accuracy of this figure is being debated as there was no laboratory confirmation simply because the influenza virus was discovered in 1933, years after the event. More recent pandemics, which occurred in 1957 (“Asian influenza”) and 1968 (“Hong Kong influenza”), caused significant morbidity and mortality worldwide.

All the pandemics in the 20th century were characterised by a series of multiple waves, each of which caused increased mortality for two to five years. There was a mild first wave during the summer in the 1918 pandemic, followed by two severe waves the following winter. The 1957 pandemic had three winter waves during the first five years. The 1968 pandemic had a mild first wave in Britain, followed by a severe second wave the following winter

WHO currently categorises the severity of the influenza A (H1N1) pandemic as moderate. This means that:

·Most people recover from infection without the need for medical care;

·The incidence of severe illness is similar to that seen during local ordinary seasonal influenza outbreaks, although higher levels have occurred in some local areas and institutions; and

·Most countries have been able to cope with the numbers seeking care, although there are stresses in some localities.

There is concern about the occurrence of serious cases and deaths in young people, including those who have been previously healthy and those with pre-existing medical conditions or pregnancy. There are still many gaps in knowledge about the virus.

As the pandemic has mainly affected the more developed countries to date, WHO anticipates that a bleaker picture will emerge as the virus spreads to areas with limited resources, poor healthcare, and a high prevalence of underlying medical problems.

There is increasing evidence in many countries that sporadic cases are arising without any apparent link to travel abroad or to other cases in the country. The possibility of the local epidemiology of the infection mirroring that of these countries cannot be discounted.

Many health authorities have used mathematical models in their planning. For example, the Department of Health of the United Kingdom, after taking into consideration that the total illness levels in previous pandemics was 25 to 35%, have based their plans on illness rates of 50%.

What every person can and should do

The most effective way of stopping or slowing the spread of many infectious diseases, including influenza A (H1N1), is the prevention of the spread of germs. There are several inexpensive practical measures that can be taken for protection of individuals and their families.

·Good hand hygiene – Regular washing of the hands with soap and water or the use of anti-germ hand rubs will help in protection against many germs, including influenza A (H1N1).

·Avoid touching the nose, mouth and eyes – When one touches anything that is contaminated with germs and follows that by touching of the nose, mouth or eyes, infections may be contracted.

·Practise respiratory etiquette – Covering the nose and mouth with tissues when sneezing or coughing can prevent the spread of infection to others. One should always carry tissues as sneezing or coughing is unpredictable. Used tissues should be disposed promptly and carefully, eg putting in a bin or flushing it away in the toilet.

·Avoid close contact – This reduces the chances of catching an infection from the sick who, in turn, will also protect others from getting infections.

·Stay home when sick – This will prevent the spread of infections to others. The sick should be cared for by designated caregivers with appropriate instructions from a healthcare provider.

·Social distancing refers to keeping an arm’s length distance from others and minimising social gatherings, eg closing of schools etc. The former is a useful habit to have. Compliance with the latter is vital if advised by the health authorities.

·Improve general health with physical activity, nutritious food, adequate sleep, cigarette smoking cessation and substance abuse avoidance. Healthy people have better immune systems and can withstand infections better.

·Clean household and office surfaces, eg door handles or knobs, tables etc regularly with soap and water or disinfectant as germs can survive for some time outside the human body and are spread when a contaminated surface is touched.

·Household ventilation – Keeping windows open allow sunlight to get in and air to circulate, both of which will reduce the survival times of germs outside the body.

Medical attention

It is advisable for anyone who is sick to seek medical attention as soon as possible. Immediate medical attention should be sought by anyone with:

·Fever; and

·One or more of the following respiratory symptoms: cough, sore throat, myalgia, difficulty in breathing; and

·One or more of following: close contact with a person diagnosed as probable or confirmed case of influenza A (H1N1) or recent travel to an area or country reporting cases of confirmed influenza A (H1N1).

This will facilitate early diagnosis, treatment and implementation of preventive measures. Whenever there is doubt, it is prudent to seek medical attention early than to feel sorry later.

Sometimes a definitive diagnosis is not immediately possible. However, it is vital that medical advice be followed. There is no place for self medication.

Facemasks

Queries have been raised about the use of face masks. Surgical facemasks used by surgeons, nurses and other healthcare professionals reduce the risk of the transmission of viruses or bacteria from surgeons, nurses and other healthcare professionals to patients undergoing procedures, eg an operation.

Facemasks are also used by doctors, nurses and other healthcare professionals to reduce their risk of getting infections from patients when there is a risk of droplet transmission.

As far as the public is concerned, there are certain situations when facemasks may be of benefit i.e.

·Reduction of the risk of transmission of respiratory infections to others, eg people with colds or influenza when in contact with others; or

·Reduction of the risk of caregivers getting an infection from persons with cold or influenza.

The use of facemasks by healthy people not involved in the care of sick people is not recommended. There is no scientific evidence available currently to suggest that this is an effective preventive measure. Furthermore, there are many practical issues that need to be considered, viz:

·The choice of facemask is important as the quality and effectiveness is variable;

·Improperly worn facemasks may not provide any protection;

·Prolonged wearing of facemasks may be necessary as exposure to infectious persons is random and unpredictable;

·Facemask users may not pay attention to good hand hygiene practices which are effective in reducing the spread of respiratory infections like influenza;

·Failure to wash the hands after removal of a facemask or its reuse will render it ineffective and increase the risk of self-contamination;

·Those with respiratory infections may use a facemask to hide their symptoms and go out when they should be staying at home; and

·Proper disposal of the facemasks is important in order that others are not exposed to risk of infection.

Summary

The novel influenza A (H1N1) virus is in the early stages of a pandemic. The scale of the problems it can pose is uncertain. Yet action is required now when the severity of the threat is still moderate.

Any intervention will involve trade-offs between the social and economic costs and the uncertain probability of greater harm of a widespread outbreak. The uncertainty, urgency and the costs of intervention make the efforts to control this pandemic very challenging.

There is need for vigilance, not complacency or panic. Everyone has to play their part in the efforts to control the spread of the disease. Individual efforts may not be significant by themselves but the collective contributions will be substantial. The understanding and active participation of the public is crucial to controlling the spread of this new disease.

Dr Margaret Chan of WHO summarises it succinctly: “Influenza pandemics, whether moderate or severe, are remarkable events because of the almost universal susceptibility of the world’s population to infection. We are all in this together, and we will all get through this, together.”

- THE STAR

Influenza A (H1N1) - Better safe than sorry

By CHOI TUCK WO

Students returning from abroad for the holidays should self-quarantine.

The balik kampung exodus has started.

No, this is not the traditional Hari Raya festive rush. Rather, it’s the great summer holiday getaway as Malaysian students in Britain head home to be with their families.

With the term break in full swing, there’s never been a better time to hop over to Europe for a short vacation before returning to Malaysia.

For the moment, the economic squeeze seems to have taken a back seat. After all, nothing beats going back to the warmth and love of parents. With reports of swine flu escalating to more than 4,300 cases in Britain, there’s all the more reason to leave the worries behind.

Then again, those arriving at KLIA might have been a little taken aback at the sight of intensive health screenings at the airport to curb the spread of influenza A (H1N1).

But the inconvenience to travellers is understandable. The rise in the number of imported cases involving those returning from overseas makes for grim reading.

Hence, the health authorities’ call to students travelling back from the United States, Britain, Australia and the Philippines to practise self-quarantine for seven days is to be commended.

As the total number of cases climbed to more than 120 in Malaysia, it’s high time those returning home limit their contact with others as a precautionary measure.

Both the Malaysian Students Department (MSD) in London and the United Kingdom & Eire Council (Ukec) for Malaysian Students have issued travel advisories for students to take the necessary precautions before travelling home.

As Ukec chairman Amir Fareed Abdul Rahim aptly puts it: “It’s better to be safe than sorry.”

He estimated that at least 2,000 out of the 11,000 Malaysian students in Britain had started returning to Malaysia for their summer holidays over the last two weeks.

“We expect the trend to continue until the first week of July,” he said, adding many of them usually travelled to Europe before heading home.

He said those returning might be unwittingly carrying the virus either through their travels in Europe or having come in contact with an infected person.

Whatever the scenario, he said that they don’t want to be caught in a situation where they could be guilty of helping to spread the virus in Malaysia.

“Our advice is that you must make sure you’re in good health before catching the flight home.

“Should you have high fever and flu-like symptoms, go to the nearest NHS for a full check-up,” he said, adding that he took a friend to University College London Hospital last weekend when she felt unwell.

Amir said his friend was screened and found to be suffering from a normal flu.

More importantly, the student had attained peace of mind when she travelled home to be with her family.

Run for your life!

You don’t need to finish a marathon to benefit from running. Twenty minutes, three times a week, are enough for a healthier, happier you.

Putting one foot in front of the other on a regular basis is an easy, affordable form of exercise that will get you far, in more ways than one.

Regular exercise improves mood, controls weight, and strengthens muscles and bones. It helps prevent chronic diseases by keeping blood pressure, cholesterol, and sugar in check.

Regular exercise can even improve your sex life by boosting energy and promoting blood circulation. (According to the Mayo Foundation for Medical Education and Research, men who exercise regularly are less likely to have problems with erectile dysfunction than men who don’t, especially as they age.)

Too tired to exercise? Pity, because it’ll help you sleep better. Especially if you’re someone who comes home exhausted from the office, yet takes ages to wind down enough to fall asleep.

Running is a particularly flexible. You can indulge in it at any time in peaceful solitude, with a fun group of friends, or competitively in events like today’s KL Marathon.

Whatever your preference, the important thing is to start on the right foot, advises 10-time marathon runner, Jamie Pang.

“Running is not sprinting”

Pang, 39, has been running since his dad dared him to complete the Penang Bridge Run when he was 15. Most recently, he completed the 2008 US New York Marathon in four hours and three minutes - a personal best that’s miles away from his early days.

Like most first-timers, the teenaged Pang would be off like a shot from the get-go, or try to chase other runners down, only to have to slow to a panting, gasping walk minutes later. Today, his first piece of advice to beginners is: “Don’t run too hard. Running is not sprinting.”

These beginners are those who attend the free classes he conducts through Runners Malaysia. Every Saturday morning, Pang and his Runners Malaysia partner bring them through an easy route at the Lake Gardens in KL, instructing them on technique along the way.

“We always advise them to take it slow,” he says. “New runners tend to get very enthusiastic because they see their fitness improve very, very quickly. The first session is tough - they get sore etc - but after a couple of weeks, when their bodies adjust to the stress, they get very encouraged. Then they sign up for a 10km run, or, even better, a 15 or 20km run. Herd mentality kicks in and everybody signs up. It’s too much too soon.

“When they’re overenthusiastic, they don’t get enough recovery time, and their bodies start to break down. They’ll find something doesn’t feel normal, their knees or feet start to hurt. And when they injure themselves, they stop.”

To get you started, and avoid these pitfalls, Pang presents these pointers:

BEFORE

·Get shoes that fit well, with the correct support for your foot shape, and which are meant for running. Using other shoes can lead to injury.

·Eat and drink something before, but not too soon before, you run. Avoid foods that are difficult to digest, because they will reroute oxygen-carrying blood from your running muscles to your gut.

·Stre...tch. Stretching properly can prevent cramps and reduce soreness. Find out what works for you - holding stretches for longer (20 seconds) or shorter (three seconds), static stretching (where you stay stationary) or dynamic stretching (where you’re in motion).

DURING

·Don’t count distance, count time spent on your feet. The first 20 minutes will give you the highest spike in aerobic benefit, so go for 20-minute sessions more often, rather than longer sessions less often.

·Warm up. A warm body is a flexible body, and a flexible body gets injured less easily (in the same way a green twig bends, and a dry twig snaps). Walk, jump, or jog around a bit before you run.

·Run-walk. Measure your progress against visible markers eg lampposts. Run five lampposts, walk three lampposts, run five more. Increase running and decrease walking until you’re running the whole route.

·Go slow. If you can’t talk comfortably while running, you’re going too fast.

·Mix it up slowly. Running on varied terrains builds strength and adaptability, but should be approached gradually. Start running on level ground.

AFTER

·Cool down. Don’t jumpstart your heart and don’t “jumpstop” it either. Slow your pace down from a run, to a jog, then a walk before stopping completely.

·Stre...tch again.

·Recover. Let your body rest in between runs. Measure your heart rate when you wake up - that’s your resting heart rate. If your resting heart rate is higher than normal the day after a run, rest another day before running again.

Moderation is key

You may have come across some alarmist articles about runners dropping dead in long distance races. These rare cases have typically been those of marathon runners who experience sudden cardiac death as a result of excessive heart stress.

But stress, Pang asserts, is the whole point of exercise: “It’s all about stressing your body, recovering, and repetition. To get fit, you have to stress your body, then recover, then you’ll be stronger.”

Besides, studies have shown the relative risk of sudden cardiac death in marathons to be infinitesimally low. As low as 0.8 per 100,000 runners, according to a 2007 University of Ontario study that retrospectively reviewed over three million marathon runners.

The study concluded: “Organised marathons are not associated with an increase in sudden deaths from a societal perspective, contrary to anecdotal impressions fostered by news media.”

Furthermore, the long-term benefits of regular, moderate exercise, as highlighted at the beginning of this article, far outweigh the risk of dying, says sports medicine doctor Dr William Chan (see Love your legs for more advice on SF11.)

If, however, you remain alarmed regarding the risk, just listen to your heart. Any of the methods below will help you keep your level of exertion moderate, and therefore safe.

·Take the talk test. Moderate exertion is when you can talk while running, but not hold a tune.

·Take your pulse. Count your pulse for six seconds and times it by 10 to get your heart rate. Moderate exertion is 60-75% of your maximum heart rate (HRmax). How HRmax is calculated can vary - some formulas take your resting heart rate, age, or gender into account, some don’t. Visit health.discovery.com/tools/calculators/hrc/hrc.html for a simple calculator.

·Buy an electronic heart monitor. It will do all the calculations for you, and even, depending on how much you pay for it, tell you when to take it easy.

To find out more about the Runners Malaysia beginner’s programme, visit www.runnersmalaysia.com.my or contact Jamie Pang 012-3080752 ; jamiepang@runnersmalaysia.com.my

Getting some sleep

A look at ways to manage insomnia.

The body rests and recovers from previous activities during sleep. Normal sleep comprises cycles of non-rapid eye movement (NREM) and rapid eye movement (REM). NREM sleep is followed by REM sleep, which occurs four to five times during the usual eight-hour sleep period.

The first REM period of the night may be last less than 10 minutes, while the last may exceed an hour. The NREM and REM cycles vary in length from 70 to 100 minutes initially, to 90 to 120 minutes later in the night.

During the first third of the night, deep NREM sleep predominates, while REM sleep predominates in the last third of the night. REM sleep takes up 20% to 25% of total sleep time.

Insomnia

Insomnia refers to the disturbance of a normal sleep pattern. The different types of insomnia are:

·Difficulty getting to sleep (sleep onset insomnia) which is most common in young people.

·Waking up in the night which is most common in older people.

·Waking up early in the morning, which is least common.

·Not feeling refreshed after sleeping, leading to irritability, tiredness and difficulty concentrating during the day.

·Waking up due to disturbances such as noise or pain.

The duration of insomnia varies. It may be:

·Transient, lasting two to three days

·Short-term, lasting more than a few days, but less than three weeks

·Chronic, that is, it occurs on most nights for three weeks or more.

Everyone has experienced insomnia. It is generally accepted that about one-third of the population has insomnia.

How much sleep?

The need for sleep varies with age. A newborn may sleep 16 to 20 hours, and an infant 12 to 14 hours. Toddlers may sleep 10 hours or more. Primary schoolchildren need nine to 10 hours of sleep, while normal adults need six to 10 hours of sleep.

It takes an adult about 10 to 20 minutes to fall asleep. Most of those who have less than five to six hours of sleep are probably not getting enough sleep.

After a good sleep, a person would feel refreshed on waking and can stay alert throughout the day, without the need for naps or sleeping in on weekends.

Symptoms and causes

The symptoms of insomnia vary. They include lying awake for a long period at night prior to sleeping, waking up several times at night, waking up early in the morning and not being able to go back to sleep, feeling tired and not refreshed, inability to function properly during the day, and feeling irritable.

The causes of insomnia:

·Physiological: working at night, light, noise, snoring, partner’s movements, and jet lag.

·Medical: pain or discomfort caused by arthritis, headaches, back pain, menopausal hot flushes, gastrointestinal disorders and pruritus (excessive itching).

·Psychological and psychiatric: examination stress, work worries, relationship problems, anxiety, depression, bereavement and dementia.

·Sleep disorders: sleep apnoea and sleep walking.

·Medicines: antidepressants, appetite suppressants, beta-blockers, corticosteroids and decongestants.

·Alcohol.

Management

Consult a doctor. He will look into the history of your condition and conduct a physical examination. The doctor will enquire about your sleeping routines, previous and current medical conditions, psychological or psychiatric conditions, if any, consumption of caffeine, medicines and alcohol, substance abuse including narcotic drugs, diet and exercise. The cause may be detected through this approach in many instances.

If the cause is not obvious, the doctor will ask for a sleep diary to be kept. This involves recording the time when one goes to sleep, when one wakes up in the morning and when one wakes up at night.

A referral to a specialist may be necessary if the cause is still not obvious. Laboratory tests and polysomnography may be carried out. The latter is used in the diagnosis of sleep apnoea and sleep disorders. This involves recording many parameters when one is asleep, including brain electrical activity; movements of the eye, jaw and leg muscles; and heart and lung functions. The doctor will discuss with the patient prior to any videotaping which may be considered necessary.

Once a diagnosis of the underlying condition has been made, the cause will be treated. For example, if the cause is anxiety or depression, the problem will go away once it is treated.

General measures which do not involve the use of medicines are preferred. It may involve counselling if the insomnia is due to stress or bereavement. Cognitive behavioural therapy which involves changes in thinking and behavioural patterns is useful. Measures like limiting caffeine or alcohol intake, exercise and keeping to a regular sleep routine are helpful.

Sleeping pills may be considered by the doctor for severe or short-term insomnia if general measures do not work. Doctors are usually reluctant to prescribe sleeping pills as they relieve the symptoms but do not address the underlying cause. An individual can also become dependent on sleeping pills, which are not without side effects.

Many of the sleeping pills available belong to a group of medicines called benzodiazepines which require a doctor’s prescription. Benzodiazepines are anxiolytics and hypnotics, that is, they reduce anxiety and promote calmness and sleep. Benzodiazepines can lead to dependence and side effects like a hangover and drowsiness during the day. This can lead to accidents when driving. Examples of benzodiazepines include lormetazepam and temazepam.

The short-acting “Z-pills” that is, zopiclone and zolpidem, act on the same receptors as benzodiazepines but are not classified as such because their molecular structures are different. They were initially thought to be less addictive and habit forming than benzodiazepines but this view has changed with reports of addiction in the past few years. The side effects are similar to benzodiazepines.

The lowest possible dose of sleeping pills should be taken for the shortest possible time. One should only take them under medical supervision. There is no place for self-medication. Do not stop intake abruptly as this may cause withdrawal effects. The doctor’s advice is crucial here.

Melatonin is a hormone that is involved in the regulation of the sleep cycle or circadian rhythm. It is a short-term medicine for insomnia and cannot be consumed for more than three weeks. Although side effects are uncommon, they include dizziness, migraines, irritability, constipation and abdominal discomfort.

Getting good sleep

Getting a good night’s sleep is vital. This can be achieved by various means:

·Having a routine facilitates sound sleep. This means going to bed and getting up at about the same time every day. It is important to relax before getting into bed as activity just before bedtime may keep one awake.

·Having an early dinner helps. The digestive system goes to sleep at about 7 o’clock. A light dinner is helpful.

·Avoid caffeine after lunch as caffeine keeps one awake.

·Avoid alcohol as its breakdown produces chemicals that stimulate the individual. It also increases the likelihood of snoring as it relaxes the muscles. This leads to lighter and less refreshing sleep.

·Avoid naps. The afternoon nap may keep one awake at night.

·Avoid light. This is because melatonin, the hormone that helps a person sleep, is produced in the dark.

Dr Milton Lum is a member of the board of Medical Defence Malaysia. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organisation the writer is associated with.

- THE STAR

Flu in human civilisation

By DR Y.L.M

A look at the history of flu pandemics.

I am curious about how many influenza pandemics there have been in history, because this is the first time I have ever been in a WHO Pandemic Level 6 situation. Then again, I am only 15 years old! What is a pandemic anyway?

A pandemic (pan = all; demos = people or population) is defined as an epidemic (or sudden outbreak of a certain disease) that becomes very widespread and goes on to affect a whole region, or continent, or even the world.

A WHO definition of Pandemic Level 6, the highest level, is when a disease is widespread and sustaining rapid human-to-human transmission in two or more regions around the world. The H1N1 flu pandemic is the first global flu pandemic in over 41 years since the 1968 Hong Kong flu!

Note that the term “Pandemic Level 6”, which is scary-sounding in itself, denotes the spread of the disease, but not its severity. Being in a Pandemic Level 6 does not necessarily mean that a lot of people will die from the disease that is spreading.

Seasonal influenza, the type you get in certain months like winter, is not considered a pandemic.

Have all the flu pandemics been recorded only from the 20th century?

The first major influenza epidemic (not pandemic) was recorded by Hippocrates, the father of medicine, in 412 BC, though it wasn’t called “influenza” then. Only in 1357 AD was the term “influenza” coined, from the Italian word “influence”. At that time, it was thought that flu was “influenced” by the stars in the sky!

The first ever pandemic was recorded in 1580 – and you guessed it, it involved influenza. It originated in Asia Minor (the Middle East) and Northern Africa and swept into Europe within six weeks. It entered Europe by way of Malta into Italy, then propagated rapidly north through the Italian peninsula. It also entered Spain because at that time, Spain ruled several North African ports.

At least 10% of all Rome’s population (then numbering 81,000 people) died within the first week of contracting it. Some Spanish cities were almost completely depopulated.

Then for a long, long time, there was no further pandemics until the 18th century.

How do you explain that?

This historical fact has also baffled many scientists. This is called a period of pandemic stability. Many questions arise as to whether a pandemic comes by chance. Because during the period between 1580 and 1729, there were plenty of epidemics. And the question remains to be answered whether epidemic situations prevent pandemics, or at least help delay them.

So when was the next pandemic and what happened?

There were three pandemics in succession then, the first from 1729 to 1730, the second from 1732 to 1733 and the third from 1781 to 1782. You must remember that in the 18th century, doctors didn’t know influenza was caused by a virus. They blamed it an unknown poison in the air and wind/temperature and meteorological phenomena. So their documents on pandemics are filled with these theories!

The 1729-1730 pandemic was a flu, and it is believed to have originated from Russia. There were two outbreaks in Moscow and Astrakhan on the Caspian Sea in April. Surprisingly, the summer of 1729 was a quiet one, Then suddenly there were influenza reports in Sweden in Sept 1729, and in Vienna come October. By November 1729, the flu had swept through Hungary, Poland, Germany and England.

But this particular pandemic, although virulent, caused relatively few deaths. Flu was unknown in North America until 1732 (yes, the American Indians never had flu before that!), because of the settlers in New England.

The 1781-82 pandemic on the other hand was not only virulent but deadly. This one started in China, involved then British-occupied India and then spread to the Western hemisphere. There were tens of millions of cases, spreading through all transport modes available then.

I heard that the worst flu pandemic occurred in the 20th century.

Yes. There were major pandemics from 1830 to 1834. Then in 1918, the Spanish flu began. (Though researchers think it actually started in the US.) It was also caused by a H1N1 flu virus, and is the worst flu pandemic to date. It was very dangerous to young adults, especially those from age 20 to 40.

The Spanish flu was memorable because it killed millions of people and it killed those in the prime of their lives. At first, it attracted little attention as people thought it was the “normal” flu. Then when a second killer wave descended and young adults began to be affected, people panicked.

This pandemic was extremely deadly as well as virulent. From North America, it spread to Europe and the rest of the world. In Switzerland in July 1918, 53,000 people alone died in that one month.

By August 1918, the flu had morphed into a 3rd deadly strain. World War 1 occured, and the spread of troops and disruption of the world’s population then helped transmit the virus. What’s worse, this particular pandemic came before treatment was available, so people succumbed easily.

At the end of it, it was estimated that 20 million to 100 million people worldwide had died. In the US alone, half a million people died. It is difficult to say today whether this 1918 flu would have the same impact on us with the advent of antibiotics to treat secondary pneumonia.

Ageless surgeries

By DR CHA KAR HUEI

Can anyone be ever too old for ‘key-hole’ surgery?

More and more surgical operations are being performed using minimally-invasive methods. In layman terms, they are commonly known as “key-hole” surgeries.

Such surgical methods are also called “laparoscopic surgery” when applied to the abdomen, “thoracoscopic surgery” in the chest, or simply “endoscopic surgery” in other parts of body.

“Key-hole” surgery has revolutionised the way surgeons treat diseases and benefited patients in terms of post-operative complications, pain, and discomfort. Today, “key-hole” surgery can be done on almost any organ, such as the gallbladder, appendix, stomach, large and small intestines, uterus, ovary, liver, pancreas, spleen, kidney and adrenal glands, abdominal wall hernias, and even thyroid glands in the neck!

The question is: does this type of surgery suit all patients?

When “key-hole” surgery was first introduced, there was a lot of criticism regarding its longer procedural time, putting patients at unnecessary risk, especially elderly patients. Besides, there was also concern that the gases surgeons use to create space in the abdomen in order to do this type of surgery would put extra pressure on patients’ cardiovascular systems (ie straining their hearts). There was a case where a physician actually wanted the surgeon to do open surgery on his “fit” old patient because of these concerns despite knowing the clear advantages of laparoscopic surgery.

The notion that laparoscopic surgery takes a longer time to complete is no longer true. In Malaysia, more surgeons are using this method. The learning curve is steep, but many have scaled it competently, and are able to complete common operations such as appendix and gallbladder removals in the same amount of time taken by open surgery.

Therefore, older patients are not subjected to “prolonged surgery” as claimed. On the contrary, older patients will benefit from faster recovery time and less post-operative discomfort. For example, removal of the gallbladder through the open method will set a patient back three days in the hospital compared to one day if done laparoscopically. The pain associated with a bigger incision will require more pain medications and increases the risks of post-operative delirium (confusion) in older patients.

Furthermore, higher lung infection rates have been reported in open surgeries because patients were too worried to take deeper breaths due secondary to pain. Lung infection or pneumonia represents one of the most costly and dangerous complications.

After all these potential ordeals in the first few days post-operation, surgeons also have to worry about the higher risks of wound infection rate simply because the incision is bigger.

The second notion that laparoscopic surgery increases risk of cardiovascular complications also does not hold well in today’s practice of surgery and anesthesia. The increased abdominal pressure during surgery is negligible in otherwise old fit patients. It has been shown that an additional abdominal pressure of 12 to 15cm H2O does not cause clinically significant distress to an otherwise normal body.

If the marginal increase in pressure causes unwanted side-effects, such as respiratory embarrassment during surgery, then the patients probably are not fit for open surgery either. It just means that the patient’s health or reserve is so poor that general anesthesia may be contraindicated. In this type of patients, the risks and benefits of doing or not doing the operation will have to be discussed in detail between the attending surgeon and the patient.

Let’s take abdominal or groin hernia as another example. If a patient is too frail to undergo general anaesthesia, the better option will be an open operation under local anaesthesia. The main point here is general versus local anaesthesia for the patient rather than laparoscopic versus open surgery.

More often than not, the decision to do or not to do “key-hole” surgery depends on the extent of the disease, ie large or small tumour, and the skill and experience of the attending surgeon. It is very rare to have absolute contraindication for “key-hole” surgery anymore. A case too complicated for one surgeon may be a “routine” operation for another. Patients should always seek second opinions if in doubt.

When we age, the possibility that we need surgical intervention increases significantly. Apart from appendix, gallbladder and hernia operations, other common diseases such as cancers in the colon, stomach, kidney, etc, start to appear in our golden years. Fortunately, “key-hole” surgery has been proven feasible in the colon, stomach and kidney as well. The results are not inferior to standard open surgery in terms of oncologic (cancer) control and risks of recurrence. The added benefits are less pain, smaller incision, faster recovery, less blood transfusion, and shorter length of hospital stay.

There have been studies carried out that show older patients are less likely to receive surgical intervention compared to younger patients in cancer cases. This is despite the fact that doctors know the end results after surgery are the same for older and younger patients. Older patients have the same chance of achieving as good a result as the younger group. Hopefully more patients and doctors will be more receptive to surgical intervention in curable cancer cases with “key-hole” surgery.

One major obstacle to further popularising “key-hole” surgery in Malaysia is cost. It costs significantly more compared to open surgery, anywhere between 50 and 100% more. This includes the use of special instruments and higher technology set-up required by the hospital. For fee-paying patients, this added cost does burden the patient and family. For insured patients, insurance companies have so far had no problems with the use of such high technology procedures as long as it brings benefits to their clients.

Age alone should not be the reason not to do “key-hole” surgery. There are other more important issues to consider for older patients, such as, pre-existing medical problems, patients’ nutritional status, hydration status, and others. It is paramount for the surgeon to review all the available data before deciding what is the best for his patients.

Fortunately for us, the advancements of surgical techniques and anaesthesia care that have occurred in the past decade have minimised the risks of peri-operative death for most operations. While we are talking about “key-hole” surgery now, there are more exciting innovations in progress to minimise insults to our body in the name of curing diseases, such as the “natural orifice transluminal endoscopic surgery”, ie surgery through the mouth or other natural openings!

- THE STAR

Hidden danger in plastics

A chemical commonly found in plastic can affect heart cells and worsen heart attacks.

Hormone experts are worried by a chemical called bisphenol A, which some politicians want taken out of products and which consumers are increasingly shunning.

They said they have gathered a growing body evidence to show the compound, also known as BPA, might damage human health. The Endocrine Society issued a scientific statement last week calling for better studies into its effects.

Studies presented at the group’s annual meeting show BPA can affect the hearts of women, permanently damage the DNA of mice, and appear to be pouring into the human body from a variety of unknown sources.

BPA, used to stiffen plastic bottles, line cans and make smooth paper receipts, belongs to a broad class of compounds called endocrine disruptors.The United States Food and Drug Administration is examining their safety but there has not been much evidence to show that they are any threat to human health.

“We present evidence that endocrine disruptors do have effects on male and female development, prostate cancer, thyroid disease, cardiovascular disease,” said Dr Robert Carey of the University of Virginia, who is president of the Endocrine Society.

The society issued a lengthy scientific statement about the chemicals in general that admits the evidence is not yet overwhelming, but is worrying.

Dr Hugh Taylor of Yale University in Connecticut found evidence in mice that the compounds could affect unborn pups. “We exposed some mice to bisphenol A and then we looked at their offspring,” Taylorsaid. “We found that even when they had a brief exposure during pregnancy, mice exposed to these chemicals as a foetus carried these changes throughout their lives.”

The BPA did not directly change DNA through mutations, but rather through a process called epigenetics – when chemicals attach to the DNA and change its function.

Taylor noted studies have shown that most people have some BPA in their blood, although the effects of these levels are not clear. Dr Frede­rick Vom Saal of the University of Missouri, who has long studied endocrine disruptors, said tests on monkeys showed the body quickly clears BPA – which may at first sound reassuring. But he said when tests show most people have high levels, this suggests they are being repeatedly exposed to BPA.

“We are really concerned that there is a very large amount of bisphenol A that must be coming from other sources,” Vom Saal said.

Dr Scott Belcher of the University of Cincinnati in Ohio and colleagues found that BPA could affect the heart cells of female mice, sending them into an uneven beating pattern called an arrhythmia.

“These effects are specific on the female heart. The male heart does not respond in this way and we understand why,” Belcher said. He said BPA interacts with estrogen and said the findings may help explain why young women are more likely to die when they have a heart attack than men of the same age.

US government toxicologists at the US National Institute of Environmental Health Sciences expressed concern last year that BPA may hurt development of the prostate and brain. A 2008 study by British researchers linked high levels of BPA to heart disease, diabetes and liver-enzyme abnormalities.

- REUTERS

Storing health records electronically

By Dr MILTON LUM

Electronic health records aid clinicians’ decision-making by providing access to patient information when they need it to incorporate evidence-based medical decisions. However, the implementation and use of such systems can bring certain risks.

Good medical practice requires the keeping of records about patients, as the medical record is essential to healthcare provision. The first medical records were developed by Hippocrates in the fifth century B.C. with two objectives, ie to accurately reflect the course of disease and to indicate the probable cause of disease.

Medical records assist in a patient’s healthcare by enabling the attending doctor(s) to structure his or her thoughts to make appropriate decisions; providing an aide memoire during subsequent consultations; providing information to other health professionals in patient care; providing information for inclusion in other documents, eg laboratory requests, referrals, medical reports; keeping patient information received from others, eg laboratory and imaging reports, correspondence and the transfer of the records when the patient changes care.

Good quality medical records contribute considerably towards raising the standards of care. They assist in the care of the population by assessing their health needs; identifying target groups for healthcare programmes; and supporting medical audit and clinical governance. Medical records also assist in meeting administrative, contractual and legal obligations.

The majority of medical records are paper records. However, there is an increasingly growing trend towards computerised records, which have been facilitated by information technology applications like computerised databases, electronic networks and smart cards. Unfortunately, many purchase decisions have not been based on well considered rationale but rather on keeping up with the Joneses.

Various definitions

Although there are various definitions of electronic health records (EHR), they are not mutually exclusive. The variation is in the emphasis, eg EHR as a source of information, clinical application, research or policy making; and representation of the clinical and chronological scope and the stakeholders involvement. EHR is also used to describe the systems holding the records as well as its management.

The Healthcare Information and Management Systems Society’s (HIMSS) definition is “a secure, real-time, point-of-care, patient-centric information resource for clinicians. The EHR aids clinicians’ decision-making by providing access to patient health record information when they need it and incorporating evidence-based decision support. The EHR automates and streamlines the clinician’s workflow, ensuring all clinical information is communicated, and ameliorates delays in response that result in delays or gaps in care. The EHR also supports the collection of data for uses other than clinical care, such as billing, quality management, outcomes reporting and public health disease surveillance and reporting.”

The International Organization for Standardization’s (ISO) definition is “a repository of information regarding the health of a subject of care, in computer-processible form.”

Personal health records (PHR) have been made available in the past two years by Google and Microsoft, ie Google Health and Healthvault respectively.

Google Health has defined PHR as a “patient-directed information tool that allows the patient to enter and gather information from a variety of healthcare information systems such as hospitals, physicians, health insurance plans, and retail pharmacies. PHRs allow people to access and coordinate their health information and share it with those who need it.” The challenge is obtaining the appropriate information, not too much and not too little, without any loss of integrity.

Benefits

EHR have the potential of creating a new paradigm in which all healthcare stakeholders have the potential to benefit from the information available. Electronic systems that link, integrate and aggregate individual records hold the promise of more co-ordinated and holistic healthcare from health professionals. Patient data can be extracted and transferred with greater ease and effectiveness, unlike paper-based systems.

The quality of care provided, its effectiveness, and incidences of specific events, particularly in relation to patient safety, eg medication errors, can be monitored and evaluated. There is potential for advances in public health using such systems as epidemiological studies have always been hampered by difficulties with data collection, which is laborious, time-consuming, poorly representative and simplistic. The development of new applications can facilitate analyses and improve knowledge of individual and population health.

There are also uses for EHR outside the health sector. It can influence employment, life insurance and a host of other activities.

However, no benefits come without risks. The risks of EHR are crucial for its uptake by patients, doctors, other healthcare professionals, employers and regulators. These are discussed below:

Confidentiality

The doctor’s duty of confidentiality is time honoured and dates from Hippocrates (400 BC), who stated: “Whatever, in connection with my professional practice or not, in connection with it, I see or hear, in the life of men, which ought not to be spoken of abroad, I will not divulge, as reckoning that all such should be kept secret.”

This duty is enshrined in the ethics codes of medical regulatory bodies worldwide. The Malaysian Medical Council’s Code of Professional Conduct states: “A practitioner may not improperly disclose information which he obtained in confidence from or about a patient.” This is elaborated in its document, Confidentiality, which states: “Patients have the right to expect that there will be no disclosure of any personal information, which is obtained during the course of a practitioner’s professional duties, unless they give consent. The justification for this information being kept confidential is that it enhances the patient-doctor relationship. Without assurances about confidentiality, patients may be reluctant to give doctors the information they need in order to provide good care. The professional duty of confidentiality covers not only what a patient may reveal to the practitioner, but also what the practitioner may independently conclude or form an opinion about.”

Compliance with this duty was not difficult in yesteryears when the relationship between patient and doctor was a direct one. However, the mode of healthcare delivery has changed in the past 50 years. It is now delivered by teams of healthcare professionals which include doctors, nurses, pharmacists, physiotherapists, occupational health therapists, etc. Others are also involved, eg hospital administrators, employers, insurance companies, managed care companies.

In general, doctors and other healthcare professionals who have direct contact with patients comply with the duty of confidentiality as it is inculcated into them during their training and practice. However, the more remote a person is from contact with patients, the more likely confidentiality will be breached, as many of those involved do not appreciate the significance of this duty.

The advent of EHR poses severe challenges to confidentiality. An analysis of patient information data will require going through numerous paper records. However, the situation with EHR is very different as a few clicks of the mouse can provide access to thousands or even millions of patient information data, notwithstanding usernames and passwords.

Privacy

Privacy is a much wider concept than confidentiality as it concerns a person’s right to control information about oneself and the right to exclude others from accessing it. One has the right to limit disclosure of personal information, its use by third parties and place limits on what doctors and other healthcare professionals can do with such information.

However, external factors like public interest may impinge upon this right. The balance of individual interests and external factors makes privacy a critical consideration in electronic health records.

Many countries have legislation that protects personal data, eg Privacy Act in Australia and Data Protection Act in the UK. The legislation came about because of increased threats to confidentiality and privacy resulting from the rapid expansion of computerised data systems, especially in healthcare. These laws have been amended with the ever increasing sophistication of computer technology.

Although there has been mention in the media from time to time of similar legislation, there is yet to be enacted in Malaysia legislation that protects personal data, let alone health data.

Security

The security of electronic information is an escalating concern with the increasing effectiveness of data retrieval engines and data mining techniques, which is reflected in the ever increasing theft of bank and credit cards.

Once health information is stored electronically, it is exposed to unauthorised access, misuse and abuse by “data thieves, blackmailers, and others with less than altruistic motives” (Anderson R. NHS-Wide Networking and Patient Confidentiality (1995) 311 British Medical Journal 5).

Medical identity theft is an issue that is of increasing concern as its victims may suffer great harm. Although the Federal Trade Commission estimated that its incidence comprised 3% of all identity thefts in 2005 in the US, its true incidence is unknown as it is under-researched and under-documented.

It is difficult to imagine how one could take a million pages of paper records out of a healthcare facility, but it is not at all difficult to remove the same in a thumb drive.

The harm to the affected individual may be medical or financial, or both. False entries in medical records are characteristic of medical identity theft.

The medical records of victims are altered without their knowledge and consent. The alterations may be minor or substantial. Harm can result from these false entries, which can lead to medical errors that may be life-threatening.

All levels of the healthcare system may be involved in medical identity theft, including healthcare providers, administrative staff, suppliers and information and communication technology vendors and service providers. The theft of a doctor’s username and password is often the beginning of medical identity theft.

The victims are often unaware of the medical identity theft as they do not usually have access to the entries in their medical records.

They are made aware of the theft in other ways, eg bill for services not received, receipt of another person’s bill, denial of medical insurance coverage, and so on.

Operability

One of the basic requirements of EHR systems is that they must be interoperable, ie clinical information about an individual must be always be meaningful even when transferred, both between various EHR systems and between versions of the same software. There has to be consistent recording of information so that effective comparisons can be made, if required.

The history of EHR is replete with examples of acquisition of different EHR systems and software only to find that they are not inter-operable, resulting in additional expenditure to correct a basic requirement. Integration is a nice word used to describe getting the EHR systems and software to “talk” to each other!

The structure and content of EHR is influenced by cultural, stakeholder and various other factors.

The attitudes of patients and doctors about the sensitivity of specific medical conditions influence their coding in the EHR systems and software. This has implications for integration between clinics and hospitals in the public and private sector.

The concept of a paperless hospital is everyone’s dream but it is only beneficial to the patient if the EHR is available whenever they are needed 24 hours a day and 365 days a year. On the day this article was written, the computer system in the hospital, where the writer was having a clinic session, failed (the system was “down”). Patients had to wait as they could not be registered; neither could their prescriptions be filled.

One shudders to think what would have happened had the hospital been paperless. Patients’ lives could have been put at risk and harm.

Going forward

Patients must have a central role in the introduction of EHR. A system acceptable to all is only possible if there is an understanding of patients’ and healthcare providers’ perceptions of EHR.

Patients and healthcare providers must be certain that:

● the EHR systems will be available whenever they are needed 24 hours a day, 365 days a year, and every year

● there is no change in the integrity of the information as it flows between healthcare providers

● there is proper and secure data storage in every part of the EHR system

● there are mechanisms that protect the storage and communication systems from intrusion

● the data will be properly managed and handled by each healthcare provider

Patients must also be certain that only authorised individuals will have access to the data, and that the data will only be used for legitimate purposes.

The factors that impact on the use of EHR were addressed succinctly in the document Critical issues for Electronic Health Records,which was the outcome of an expert workshop hosted by the Nuffield and Wellcome Trusts in November 2007 (Authors: P Singleton, C Pagliari and D E Detmer 2009).

Seven key requirements were identified for successful systems implementation, integration and maintenance of EHR. The authors stated: “For progress to be assured, regions, nations and the global health community must be engaged intelligently and iteratively.”

The requirements included:

1. A clear “vision” of the role of EHR and related information and communications technology (ICT)-aided healthcare interventions, supported by sub-component plans capable of assuring engagement of five key stakeholder groups:

a. patients, including informal caregivers

b. the public, including citizens, the media and public representatives

c. professionals, including clinical practitioners and allied health professionals, health informaticians, ICT technologists and technicians

d. managers/administrators/regulators/private payers

e. suppliers (application vendors, systems integrators, etc).

2. Clear and consistent communication (relevant messaging) of EHR content and meaning. This includes terminologies, classifications and standards to assure interoperability without loss of meaning, including relevant contextual content.

3. Systems that are able to aggregate, assess and manage the current base of knowledge and then …

4. Deliver that knowledge through decision support in a timely manner at the point of care. This is seen as critically important for both clinicians and patients (including their informal care-givers).

5. Systems that develop and support relevant workforce education and training.

6. Systems that support innovation in healthcare by enabling access to reliable data for research in the core sciences, as well as facilitating continuous improvements in healthcare quality.

7. Strategies for harnessing both experiential learning and opportunities to obtain evidence of the impact on quality, efficiency and safety.”

The workshop concluded that “All of the above assume that an information and communications infrastructure will be there to offer secure delivery of relevant information and knowledge on a right- and need-to-know basis. It is likely that this agenda will require another 20 years to reach maturity in a number of nations or regions of the world.”

Where does that leave us now?

Although medical records may have undergone changes with the advent of EHR, the underlying principles remain unchanged. Whilst there are potential benefits from EHR, there are also risks that have to be addressed. Patients and healthcare providers have to be assured and confident that confidentiality, privacy, security and operability issues are not compromised in any way before EHR can be accepted as the way forward.

● Dr Milton Lum is a member of the board of Medical Defence Malaysia. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organization the writer is associated with.