Homocysteine and adverse pregnancy outcomes

Thrombophilia and the associated risk of preclampsia, abruptio placentae, intrauterine growth retardation (IUGR) and still birth has been studied extensively in the last few years. There is emerging evidence that the formation of thrombi in the placental blood circulation could cause impaired nutrition of the fetus, in turn leading to adverse pregnancy outcomes1.


Homocysteine, a sulphur containing amino acid, derived from the demthylation of methionine is thought to be an independent risk factor for vascular disease. Several studies conducted in pregnant women have reported a direct linkage between elevated levels of homocysteine and pre-eclampsia, placental abruption, and IUGR.

In a study comparing 30 pre-eclamptic women with 30 normotensive women of the same gestational age, the mean levels of homocysteine was significantly higher in the pre-eclamptic group than in the normotensive group. Additionally women in the pre-eclamptic group with elevated homocysteine levels showed an increased incidence of IUGR, IUD, still birth, and abruptio placentae2. In another study of 137 women it was noted that women who developed IUGR had reduced levels of RBC and increased levels of plasma homocysteine concentrations3. Studies have also shown that supplementation with Vitamins B-6, B-12, and Folic acid significantly reduces homocysteine levels in these women. Supplementation with these “homocysteine lowering vitamins” appears to be an effective, inexpensive, and safe way to not only reduce homocysteine levels but also to reduce the incidence of pregnancy related complications including IUGR, IUD, still birth, and abruption placentae4.


1. Editorial. Clinical Chemistry. 2003;49(9):1432-1433.
2. Ghike S, et al. JSAFOG. 2011;3(2):71-74.
3. Furness D, et al. Matern Child Nutr. 2011; Abs[Epub ahead of print].
4. Khatre P, et al. Asia Pac J Clin Nutr. 2012;19(3):335-343.

Planning a heart healthy diet

General Principles:

1.       Preferred diet is lacto-vegetarian

2.       Low in sodium, sugar, and calories

3.       Natural foods rich in high-quality fibre and nutrients - preferably organic  foods

4.       Emphasis on whole grains, seeds (including nuts), fresh fruits, and vegetables

5.       Foods to be eliminated from the diet include white-flour products, sweets, canned foods, syrupy juices, soft drinks, squashes, hard-fats from animal sources – butter and cream in particular

6.       Yoghurt/curds, and skimmed milk is OK and can be consumed within prescribed limits

7.       Tea and Coffee should be severely limited (1 cup a day max) or avoided totally. Those addicted to these beverages should be weaned away gradually

8.       Garlic and onions are excellent for the heart

9.       Nuts in general and walnuts, almonds, pistachios, pecans, and peanuts in particular, are good for the heart as they reduce LDL and help raise the levels of HDL. However do not consume more than a handful a day. You could even use them to garnish your oat porridge. Importantly, all nuts that you consume should be unsalted.

10.   Among grains Oats and barley are the gold standard as they contain soluble fibre. Other foods that contain soluble fibre include apples, pears, kidney beans, and prunes

11.   Among oils, olive oil and sesame (gingely) oil are heart healthy. Cold-pressed oils are preferable to heat-processed oils. Again oil should be limited to about 2 tablespoons a day

12.   Among fruits - fresh grapes, pineapples, oranges, apples, custard apples, pomegranates, and pears are heart healthy

13.   Tender-coconut water is a good heart tonic

14.   Amla (Indian gooseberry) is an excellent heart tonic

15.   Vegetables in general are rich in fibre and should be part of a heart healthy diet

16.   Important thumb rule: 75-85% of a day’s food should come from whole-grains, vegetables, and fruits

Table 1: Foods to be avoided or severely limited

Food substance	Remarks	What it means
Sodium (Salt)	Limit intake to < 1,500 mg per day – roughly 1 teaspoon or lesser	1.       No “added” salt 2.       No biscuits, pastries, cakes, canned foods, savouries, chips, dips, sauces, ketchups, and processed foods 3.       Check food labels for sodium content – several processed, commercially available food substances contain hidden salt
Sugar	Cut recommended sugar intake by 50-60% Recommended max sugar intake is 6 teaspoons/day, so aim for 2 teaspoons of sugar a day	1.       No chocolates, sweets, toffees, and added refined sugar 2.       Substitute honey for sugar (again limit to no more than teaspoon/day) – honey is better than refined sugar
Drugs	Avoid all NSAIDS* (In general and particularly in Heart failure)	1.       Paracetamol/Acetaminophen, Ibuprofen should be avoided by heart patients. If you have a headache use a balm or if you must consume a pain-killer, choose aspirin
Trans fats	Avoid completely	1.       Hydrogenated fats (Vanaspathi/Dalda) to be avoided completely 2.       Packaged cookies, crackers, commercially prepared fried foods, chips, savouries, sweetmeats, potato crispies, finger-chips
Triglycerides	Avoid or limit intake to negligible quantities	1.       Includes all of the above and rice (can be consumed in limited quantities), potatoes, pizzas, burgers, white bread, rolls, and all refined starches 2.       Whole milk, butter, and fried foods

*Non-steroidal anti-inflammatory drugs

Table 2: Natural foods that are "heart-healthy"

Food substance	Benefits
Grapes and grape juice	1.       Contain resveratrol known to preserve heart muscle flexibility 2.       Reduces heart pain and palpitations 3.       Helpful in reducing platelet aggregation and clots 4.       Oxidises LDL (bad cholesterol)
Apples	1.       Contain quercetin that is a natural anti-inflammatory which helps prevent blood clots 2.        Rich in soluble fibre
Amla (Indian gooseberry)	1.       Richest natural source of Vitamin-C 2.       Heart tonic that tones up the heart muscle
Tomatoes	1.       Contain Lycopene a potent antioxidant and free radical scavenger 2.       Promotes heart health
Almonds, walnuts, pistachios, pecans	1.       Contain “good-fat” (monounsaturated and polyunsaturated fats) 2.       Enhance HDL (good cholesterol), reduce LDL 3.       Reduce inflammation and blood clots
Onions and garlic	1.       Reduces LDL 2.       Onions like apples contain quercetin that is a natural anti-inflammatory which helps prevent blood clots 3.       Allicin in garlic is broken down into sulphur compounds which then react with RBC in blood to produce hydrogen sulphide which helps relax the blood vessels, thus keeping blood flowing freely in arteries
Pineapples	1.       Rich source of vitamin-C 2.       Improves blood flow to heart 3.       Prevents pain due to angina 4.       Beneficial in patients with ischaemic heart disease
Pomegranates	1.       Rich in polyphenol antioxidants 2.       Reduce LDL, enhance HDL Caution: Pomegranate juice can (in some patients) interact with certain medicines such as warfarin, ACE-inhibitors – check with your doctor before including it in your diet
Oranges	1.       Rich source of Vitamin-C and phytochemicals 2.       Prevents LDL and enhances HDL 3.       The phytochemical Hesperidin, a flavanone, improves blood vessel function and also lowers high blood pressure level

A sample meal plan:

On rising (optional)	Fresh fruit juice of grapes, orange, or pineapple (without sugar, a teaspoon of honey may be added for taste) alternatively: warm water with a few drops lemon juice squeezed- in and a teaspoon of honey
Breakfast	2 slices of brown/whole-wheat bread or a bowl of oats, or 3 steamed idlies, or a bowl of vegetable upma or poha One apple, or a pear, a cup of grapes, or 5-6 slices of pineapple A cup of unsalted yoghurt or buttermilk or skimmed cow’s milk or soy milk
Mid-morning	A glass of coconut water
Lunch	Mixed salad of vegetables such as cabbage, carrots, tomatoes, onions, garlic and cucumber - seasoned with olive or sesame oil (1 teaspoon) Two whole-wheat phulkas 1 bowl of vegetables 1 bowl of rice – preferably fibre-rich red rice with sambar/rasam/vegetable stew (kootu) One cup of yoghurt/curd
Mid-afternoon/evening	1 cup herbal or green tea without milk and sugar – a teaspoon of honey can be added for taste
Dinner	2 whole wheat phulkas, or 3 steamed  idlies, or a bowl of vegetable upma  or poha One fruit A glass of unsalted butter milk

Halitosis: Bad breath/malodor - causes, diagnosis and treatment

Posted by Ramesh Venkatraman

Halitosis more commonly known as bad breath, is a term derived from the combination of the latin prefix - "halitus" (breath) and the greek suffix "osis" (condition). Halitosis is very common with almost everyone having suffered from it at least transiently. For example all of us suffer from oral malodor on awakening which is very common and is generally not regarded as halitosis. It becomes a problem only when it is long standing, and is a cause for societal embarrassment.

Poor oral hygiene is the single most common cause of oral malodor - most likely due to the accumulation of food debris and bacterial accumulation on the tongue surface and between teeth. Additional factors (that will require more aggressive treatment interventions) include infection/inflammation of the gums gingivitis/periodontitis. Xerostomia, a condition characterized by a lack of saliva in the mouth and dryness can also cause malodor - most people would have experienced a transient form of xerostomia during illnesses or when they have suffered from mouth ulcers.

Broadly, oral malodor can be categorized under 3 main causes:

1. Oral malodor due to oral disease, respiratory disease, and volatile foodstuffs (the last being transient in nature).
2. Systemic causes i.e. an internal disease/disorder whose symptoms manifest as oral malodor
3. Certain drugs (including alcohol) that may be the cause of oral malodor. 

Let us examine each of these categories in greater detail:

Oral disease and malodor:

1. Food impaction, i.e. food particles stuck between teeth that can putrefy, decompose and cause malodor
2. Acute gingivitis - infection of the gums
3. Periodontitis
4. Xerostomia - dryness of the mouth due to a lack of saliva
5. Oral ulceration
6. Oral malignancy

Respiratory disease and oral malodor:

1. Sinusitis
2. Tonsilitis
3. Malignancy
4. Bronchiectasis
5. Presence of foreign body in the respiratory passage

Volatile foodstuffs and malodor:

1. Garlic
2. Onions
3. Spiced foods

In addition to the above causes, certain systemic diseases (infections/diseases in other organs systems of the body) can also cause oral malodor and can in fact be an early warning of a more serious underlying disease condition. These include diseases such as acute febrile (fever) illness, respiratory tract infections, gatro-esophageal reflux disease, hepatic (liver) failure, renal failure, diabetic ketoacidosis, leukemias (blood cancer), menstruation.

In the absence of any systemic disease, the most common cause of oral malodor is poor oral hygiene. In some people, oral malodor may persist in spite of good oral habits, then the most likely source is the tongue and a lack of tongue cleaning.

Diagnosis and assessment of malodor: Clinical assessment of oral malodor is usually subjective and is basically arrived at by smelling the exhaled air from the mouth and nose and then comparing the two:

1. Odor coming from the nose but not from the mouth could likely indicate a problem with either the nasal passage or the sinuses
2. Odor detected from the mouth but not from the nose could be of oral or pharyngeal origin
3. In rare case when the oral and nasal odor are of similar intensity it could indicate a systemic cause that calls for more detailed analysis and diagnosis of underlying problems, if any.

 Managing Oral malodor:

1. Brushing and Inter-dental cleaning: Effective brushing and interdental cleaning (flossing) can significantly reduce malodor particularly in people with oral malodor due to poor oral hygiene and any related oral diseases
2. Tongue scraping and cleaning: If oral malodor persists even when oral hygiene is good, then the most likely source could be the tongue. Gentle, regular tongue scraping and cleaning can significantly reduce malodor.
3. Mouthwashes and mouth rinsing: Although a variety of mouthwashes are available in the market, a plan oil-water mouth rinse should suffice in most cases. Commercial mouth washes containing chlorhexidine while effective cannot be used too frequently as they tend to cause a burning sensation of the oral mucosa. Mouthwashes containing Triclosan may be a better alternative but Triclosan is effective only in the presence of a suitable delivery agent.
4. Chewing gum: Studies have shown that 70% of people with oral malodor choose to use chewing gum to reduce odor. However, chewing gums only mask the odor and and they have only a short-term effect on malodor.
5. Gum massage: Regular massage of the gums also helps in improving blood circulation to the gums, and in squeezing out any residual bacteria - You can do this by gently pressing the gums between forefinger and thumb - ensure that your fingernails are clean and cut cleanly and evenly.
6. Oil pulling: Regular oil pulling or gargling with gingely oil - also called sesame oil or til oil is recommended in Ayurveda for strong teeth and gums - simply pour 15 ml of sesame oil into your mouth and swish it around, pulling the oil between your teeth for a bout 5 minutes and then spit it out - rinse and clean your mouth with warm water.

Women at higher risk of death due to heart attack

Posted by: Ramesh Venkatraman

Results of a new study reveal that women (particularly younger women) are more likely than men to present without chest pain following a heart attack. Hospitalized women also show higher mortality (death) rates than men within the same age group. Excerpts (Table) from a new observational study from the National Registry of Myocardial Infarction, 1994-2006, of 1,143,513 registry patients (481,581 women and 661,932 men):

 Ref: Canto JG, et al. JAMA. 2012;307(8):813-822.

MI = Myocardial Infarction (Heart Attack)

The dark side of Paracetamol/Acetaminophen: Liver Toxicity and Death

Posted by: Ramesh Venkatraman

Paracetamol known as Acetaminophen in the US, is arguably the commonest drug used for treating pain and fever. It is today an over-the-counter (OTC) medication across the world. Sold under popular brand names such as Crocin, Calpol, Dolopar, and Tylenol, paracetamol is probably the first drug that the common man pops the moment he/she experiences a headache or feels even slightly warm.

Now stop for just a moment and consider the facts below:

1. In England and Wales, alone it is estimated that  150 to 200 deaths and 15 to 20 liver transplants occur each year due to paracetamol overdose [http://en.wikipedia.org/wiki/Paracetamol_toxicity]
2. In the US paracetamol/acetaminophen toxicity is the one of the leading causes of serious liver damage accounting for more than 56,000 emergency visits, 2,600 hospitalizations, and an estimated 450 deaths annually [Highleyman L, Franciscus A. HCSP Fact Sheet, ver 2.2;2009.].

These statistics fly in the face of the commonly held belief that paracetamol/acetaminophen is completely safe and can be used by anyone to get quick relief from pain/fever.

Is it unsafe at any dose?
The quick answer is NO. However it is quite easy for the uninformed to risk popping in more than the recommended daily dose of paracetamol. This is because the "window" between a therapeutic dose and a toxic/lethal dose in the case of paracetamol is very narrow. Paracetamol tablets in India are available as 500mg and sometimes even as 650mg tablets. The maximum recommended dose of paracetamol is 4 grams a day, which means that a person taking 3 or 4 tablets during a day could easily be consuming 50 to 60% of a potentially lethal dose of paracetamol!

A bigger danger comes from a little snippet of information featured in the US FDA fact-sheet on acetaminophen which points out that some people may be more susceptible to acetaminophen/paracetamol toxicity than others - these people may suffer from liver toxicity with paracetamol doses of as low as 2.5 grams/day - approximately 4 tablets! Studies have shown that about 20% of people with acetaminophen-related liver toxicity had actually consumed less than even the recommended daily dose of acetaminophen.

Alcohol and paracetamol make a lethal cocktail - Paracetamol/acetaminophen is more likely to cause liver toxicity at normal and near-normal doses in people who consume alcohol regularly. The current packing of Tylenol (the US brand of acetaminophen) contains a warning which states that people who consume 3 or more alcoholic drinks everyday must consult their doctor before taking acetaminophen/paracetamol. In fact Tylenol has been carrying a more generic version of this warning since the mid-1990s. Interestingly Crocin the most popular brand of paracetamol/acetaminophen in India does not contain this warning with regard to alcohol consumption and paracetamol use.

How acetaminophen/paracetamol harms the liver:
When you swallow a pill of acetaminophen/paracetamol it is absorbed into your blood stream and then reaches the liver where it is metabolized. If a large dose of the drug enters the liver system then the normal pathway can become overwhelmed and the liver pushes the drug into a new/different metabolic pathway called the Cytochrome P450 enzyme system. When this meatabolic pathway kicks in, a toxic metabolic byproduct is produced called NAPQI (N-acetyl-p-benzoquinone imine) which has the potential to kill the liver cells. Alcohol and many other drugs also use this same Cytochrome P450 processing system and the risk of a "bottleneck traffic" jam is significantly greater if the liver is asked to process acetaminophen along with other substances such as alcohol at the same time.

Acetaminophen/Paracetamol poisoning usually happens in 3 stages:

1. Stage-1 (12-24 hours) - the person usually complains of nausea/vomiting
2. Stage-2 (24-48 hours) - the person may feel better
3. Stage-3 (48-72 hours) - Blood tests however may reveal elevated levels of liver enzymes (ALT and AST) a clear marker of liver injury. In severe poisoning, the patient may slip into coma and only a liver transplant can prevent death.

The key is to go to a doctor as soon as you feel nauseous and any gastrointestinal discomfort following a dose of paracetamol/acetaminophen. Antidotes such as glutathione and/or N-acetylcysteine (NAC) work best when taken within 16 hours of poisoning - However most people do not recognize the signs and symptoms of paracetamol/acetaminophen poisoning early enough to initiate treatment. 

Does this mean that we shun paracetamol altogether? No. However, caution and understanding the risks involved is extremely important - More so because paracetamol/acetaminophen is not only available as plain paracetamol/acetaminophen tablets/syrups but also comes as a combination with over 200 other medications - small doses of acetaminophen/paracetamol in combination remedies can add up and cause serious trouble.

What is Holistic Health?

Posted by Ramesh Venkatraman

I have often been asked this question in addition to being told that while the title of my blog says Holistic Health, the articles are not "Truly Holistic" meaning that I discuss and even recommend certain allopathic (Western/English) medicines/therapies.

The misconception that Holistic Health is actually synonymous with alternative therapy is widespread. The fact is, Holistic Health is based on the premise that the "WHOLE" is MORE than the SUM OF ITS PARTS" Let me explain this using a very crude example - take your index finger. As long as your index finger remains associated with your palm/hand it can take part in several activites - writing for example, typing on a keyboard, scratching your head and so on. However assume for a moment that the finger is severed from your palm, what happens? - on its own the finger is practically and functionally useless and can do nothing, in other words as long as it remains a "PART OF A WHOLE" it can perform several activities but ceases to be functional the moment it loses this association.

This is true of several diseases/disorders - severe arthritis and the associated pain can cause depression - a problem in the physical affecting the mental, similarly depression can manifest itself in the form of pain and/or several unexplained disorders in the physical. What this tells us is that almost all diseases/disorders are psychosomatic in nature i.e. affecting both the psyche (mind/mental) and the soma (body) and therefore logic demands that we treat both the mind and the body.

Allopathy or the Western system of medicine is a reductionist system of medicine - this is not meant in a derogatory sense and only means that in the case of allopathy the human body (and the associated organs/diseases/disorders) are reduced to their smallest functional components and the component and the associated symptom/disorder is treated/managed at a granular level. This system has great value in the treatment and management of acute illnesses and has also been responsible for the eradication of several life-treatening diseases through the use of vaccines. For example if you were to suffer from a bacterial infection of the lungs, you will need to use broad spectrum antibiotics than can kill and eradicate the pathogens - it is allopathic medicine that first classified and categorized pathogens and the diseases they cause, and specific medications that can treat these diseases - without this knowledge people would still be dying from infections that we have come to think of as routine. Then again if you fracture a limb you have to go to an orthopedic surgeon to set it right. Therefore new age pundits who dismiss allopathic medicine and promote only the so called "alternative-therapies" do so at their own peril.

At the same time exclusive promotion of allopathic medicine at the cost of other systems of medicine is also a no-brainer. Ayurveda, Homoeopathy, Siddha, Unani, Chinese Herbal medicine, music therapy etc. that take a more Holistic view of diseases/disorders have an important role to play in the mainteneace of optimum health and specifically in the treatment and management of chronic disorders/diseases - studies have shown that in the management of chronic diseases like cancer, cardiovascular diseases, arthritis etc., the so-called alternative therapy has a key role to play in not only managing the symptoms but also in the treatment and eradication.

Ayurveda arguably the most ancient system of medicine, is much more than just a "medical-system" - in the ancient days it was conceived as a "way-of-life" with the core principle being the achievement of "BALANCE". This balance is to be achieved through proper Aahara (diet), Vihara (lifestyle), Acharya (spirituality), and Aushadha (medicine). Siddha medicine once very popular in South India dates back several thousand years and has the Sage Agastya as its preceptor and originator - it is closely aligned to the ayurvedic system of medicine. Unani medicine originally pioneered by the Greeks (Hippocrates) and Romans (Galen) and further refined by the persians (Hakim Ibn Sina) remains popular in parts of South Asia including India.

All of these medical systems have their value and cannot be junked and neither can anyone of them be an exclusive replacement for allopathy or vice versa. Holistic Health therefore is a concept in medical practice upholding that all aspects of people's needs - psychological, physical and social should be taken into account and seen as a whole and therefore treatment modalities should be designed with this principle in mind. If this be true, then it stands to reason that medical systems will need to glean the best concepts, principles, and treatment modalities from each of these systems in treating disease. I intend to write brief summaries about each of these medical systems because it is important for people to know in order to make an informed choice.

Mobile/Cell Phones may be potentially carcinogenic (cancer-causing) - WHO new classification

Posted by: Ramesh Venkatraman

Mobile/Cell phone use has become ubiquitous. Global estimates put the number of mobile users at 5 billion. Cell phones emit radio-frequency (RF) waves, a type of  non-ionizing electromagnetic radiation which can be absorbed by human tissue when in close proximity to the source of radiation. The amount of RF energy absorbed by a cell-phone user depends on (1) phone technology, (2) extent and type of use (3) distance between the device and the user. This post highlights the WHO and US-FDA recommendations on the use of mobile phones and the potential risk of cancer.

The International Agency for Cancer Research (IARC) a key compnent of the World Health Organization (WHO) recently classified radiofrequency fields such as those emmitted by mobile/cell phones under GROUP-2B thereby placing it along with substances such as lead, engine exhaust, and chloroform - What this means is that the WHO now believes that mobile/cell phones are "possibly carcinogenic to humans".

The National Cancer Institue (NCI) of the USA also says that although studies have so far not confirmed a direct link between mobile/cell phone use and cancer, there is evidence to show that prolonged cell-phone use heats-up brain tissue, and more specifically increases glucose meatobolism on the side of the brain closest to the phone antenna/receiver. It is important to note here that a meta-analysis of 10 published studies on "long-term cell phone use and cancer risk" concluded that there is an association between mobile/cell-phone use and development of glioma and acoustic neuroma on long term use ( > 10 years) (Hardell L, et al. International Journal of Oncology, 2008;32:1097-1103.)

The US FDA has recommended that cell phone users (1) reserve the use of cell phones for shorter conversations or for times when a landline phone is not available and (2) Use a hands-free device which increases the distance between the phone and the users head.

Important studies that have also confirmed the possible link between mobile phone use and increased cancer risk include a 2009 study published in the Journal of clinical Oncology involving 37,916 participants (Myung Kwon S, et al. J clin Oncol, 2009;27:5565-5572.), and Michel Kundi's article in the Environmental Health Perspectives Journal published in 2000 (Kundi M. Environ Health Perspect. 2009;117:316-324.).

Most of these studies and recommendations have come and continue to come from researchers and Government action in the Western Countries. In India where cell phone use has become ubiquitous, precious little is being done by the Government, media, or research agencies to at least highlight the concerns that are slowly but steadily building up about the risks associated with long-term cell phone use.

For a start we can at least do the following (Adapted from the US FDA recommendations on cell phone use):

1. Avoid using cell phones for long conversations
2. Choose texting over talking
3. Use a landline whenever you have a landline phone close at hand
4. Use a hands-free device (not a Bluetooth) or the loudspeaker option where feasible