Month: February 2020

What every woman must know about a Mammogram!

/ Subash Rau / Leave a comment

Mammography is the preferred method of detecting early Breast Cancer or to evaluate a breast lump. In fact it is the most reliable method of detecting a breast mass before it can even be felt by the examining hand. Slow growing tumours can be detected nearly 2 yrs before they can be felt by the doctor’s hand. Therefore routine screening is widely advised. On the brighter side only one third of the abnormalities detected by screening mammography are found to be cancerous. (Sensitivity 60-90%). The pick up rate depends on the patients age, breast density, tumour location and size, histology on biopsy. The tumour may be detected late in young women with dense breasts as compared to older women with fatty breasts.Smaller tumours especially those that aren’t calcified may also be more difficult to spot on the mammogram.

When should you get a routine mammogram done?

Different medical agencies have slightly different recommendations regarding the timing and the frequency of the screening tests. For the sake of not causing any confusion to the reader, let me tell you that screening mammogram can be started from the age of 40 yrs onwards. It must be done every year and must continue until that age of 74 yrs or till the estimated life expectancy is shorter than 7-10 years. The frequency can be reduced to once in 2 years after the age of 55 yrs. The doctors are advised to help the patient make informed decisions regarding the risk of false positives and over diagnosis Vs the benefits of early diagnosis.

What are the indications for mammography?

The following are some of the indications for mammography:

1. Routine screening in asymptomatic women

2. Evaluating after a diagnosis of Cancer is made and at regular intervals thereafter to monitor disease (same and opposite side)and response to treatment.

3. Evaluation of a breast mass (before biopsy)

4. Search of an occult breast cancer in those with a lymph node enlargement in the arm pit

5. Screening before cosmetic breast surgery.

Who has a high risk for breast cancer and would benefit from Routine mammography?

1. Age : risk of breast cancer rises rapidly until the early 60s, peaks at 70 and declines after that.

2. Positive Family history of Breast cancer or Ovarian Cancer. If a woman has a family history of 2 first degree relatives diagnosed <50 yrs of age especially if they are pre-menapausal, bilateral breast cancer or male breast cancer, that portends a higher risk.

3. Certain races – Ashkennazi jews and caucasian women are at a higher risk. People of Afro-caribbean descent have worse prognosis when they have breast cancer.

4. Hormonal exposure: Nulliparous women or those who have had their first pregnancy after the age of 30, early menarche (<12 yrs) and late natural menopause (>55yrs) are at a higher risk for breast cancer. Women on combined Oral contraceptive pills and those who receive post menopausal HRT with both Estrogens and Progesterones.

5. Life style: Obesity and lack of exercise, Alcohol intake and high dietary fat intake and a higher socioeconomic status can increase the risk too.

6. History of cancer: Women who have already had a cancer of one breast or of Endometrial cancer are at a higher risk for breast cancer.

7. Germline mutations in the BRCA family tumour suppressor genes (accounts for 5-10% of all cases -BRCA1 and BRCA 2), p53 gene mutations and those with Ataxia telangiectasia.

How do you interpret a mammogram?

1. To note down the indication for the test. Routine screening, accidentally detected breast lump (self detected or by the doctor), painful breast lump or other causes.

2. The Overall composition of the breast including its density. Younger women have denser breasts which reduce the sensitivity of the mammogram test in identifying sinister pathologies. The mammogram is more sensitive to pick up lesions in older women with fatty breasts (with less glandular breast tissue).

A – almost entirely fatty

B – Scattered areas of fibroglandular density

C – heterogeneously dense

D -extremely dense

3. Description of abnormalities: Density of breasts and calcific spots. Finely granular, popcorn like, vascular calcification suggest benign disease where as spiculated lesions, lesions with pleomorphic calcifications ( varies shapes and sizes), V or Y shaped calcifications would suggest an underlying neoplastic process.

4. The latest mammogram must be compared with the previously done study to look for interim changes and worsening of abnormalities.

5. The opinion must be summarised with advice for further management.

In a mammogram both breasts are viewed simultaneously as mirror images.The upper half in the craniocaudal view (CC) represents the outer portions of the breast and the lower half represents the inner parts of the breast.

In the normal MLO (mediolateral Oblique) view of both breasts the pectoral shadow must be seen till the level of the nipple. The top portion would represent the upper part and the bottom part would represent the lower part of the breasts.

Correct positioning of the breasts would be very important in obtaining good pictures. In the MLO views the Pectoral muscle shadow must be seen and the breast must be adequately compressed to get the best pictures. Inadequate compression would cause superimposition of the tissues

Benign Breast lesions

Fibroadenoma- is referred to as the Breast mouse- most often is detected as a small lump that moves inside the breast. They may be single or multiple as on the picture on the right below! The lumps are smooth walled and well defined.

The picture to the left shows a “popcorn” calcified Fibroadenoma.

Fibroadenosis: refer to lumpy breasts often painful with a rope like texture to feel. This condition is also referred to as Fibrocystic disease of the breast.

Simple Breast cyst: cysts are fluid containing cavities and are very well seen on the Ultrasound of the breast. But this is how they would appear on a mammogram. This thin walled cyst is accompanied by small smooth round to oval calcifications suggesting a benign lump.

Breast Implants: Breast augmentation is one of the most common and popular cosmetic surgeries that women undergo. This is how they would appear on the mammogram.

Breast implants make mammography more difficult and can obscure small lesions. Mammography can also help detect implant related problems such as rupture, capsular contraction etc.

Benign Calcification of the breast:

A – vascular calcifications

B – popcorn calcification

C & D – benign secretory calcifications

E – cigar shaped calcifications.

Malignant lesions:

Spiculated lesions with greater density indicate malignancy. Certain patterns of calcification also suggest malignancy.

Clustered irregular microcacifications also suggest malignancy especially when there is distortion of the surrounding breast tissue. V and Y shaped calcifications also suggest malignancy.

What should you do after getting the mammogram report?

The first thing that you should do with the mammogram is to show it to your doctor and ask him for his interpretation and advice. He might suggest that nothing needs to be done or he may ask you to repeat the test after a few months or he may ask for a few additional test such as an Ultrasound scan or an MRI of the breast. He may even advice you regarding a needle biopsy or surgery.

To summarise

Mammography is more sensitive in picking up lesions in the breast compared to examination by a doctor.

Birads 0,4 &5 require further evaluation. Birads 1 is a normal study. Birads would mean a benign disease of the breast. Birad 3 would mean that the test would need to be repeated after 6 months. A report of Birads 4 and 5 will be followed by a biopsy.

An MRI may be done for women with a high risk for breast cancer in addition to a Digital Mammogram (women with BRCA mutations, history of childhood radiation to the chest, a higher lifetime risk for breast cancer 20% and previous history of breast cancer) An MRI breast would also be useful in women with breast implants especially to detect rupture of implant.

An USG of the breast might be useful to differentiate solid from cystic (fluid filled) lumps of the breast.

Anger and why you must control it!

/ Subash Rau / Leave a comment

Anger is a sudden maladaptive response to a variety of stimuli characterised by an aggression which could be verbal, physical or both. It is provoked more often in people with a certain personality types especially when subjected to stressful triggers or situations in specific contexts. It may even be provoked by minor stimuli in anyone depending on the circumstance. While it has been essential for the survival of our species, modern life (in overcrowded urban jungles) provides too many stressors that provoke unnecessary anger which then has long term health implications. This article attempts to throw some light as to the causes, effects and changes during and after an episode of Anger.

Civilisation and urbanisation forces people of all different personality types, of different interests and priorities to live together. In the hustle and bustle of daily living we are forced to deal with different situations and people who could make our lives difficult, with intention or otherwise. We are provoked into losing our tempers, get angry, explode (or implode) and suffer the consequences. Our personality type, our current mental state, our previous experiences, the people we have to deal with, all have a role in determining how we respond to a situation and how angry we get. Often we get irritated with what is happening and if this isn’t resolved, results in anger. I call Anger a maladaptive response because we get angry only with people we can get away with showing it and it rarely solves the issue that provoked it.

The Anger reaction begins in the Amygdala in the brain, it spread to the Hypothalamus and the Pituitary which releases ACTH hormone that stimulates Cortisol secretion from the Adrenal glands. Cortisol suppresses the immune system, increase sugar production and the conversion of Fatty acids to energy. The adrenals also produce Adrenaline which increase the Heart rate BP and the Cardiac output. Adrenaline also increases the release fo glucose from the Liver and increases the tension in the skeletal muscle and also increasing the rate and force of contraction of the skeletal muscles. The respiratory rate increases and visual fields constrict and pupils dilate allowing the angry person to focus on the person triggering the reaction. In short the body prepares for “fight or flight” when angry.

All these hormones increase the blood pressure, Heart rate and respiratory rates. Blood is shunted away from “nonessential” organs such as the intestine and kidneys in favour of the heart lung brain and skeletal muscles. It is quite common to feel like you want to empty your bladder or even vomit when very stressed.

Chronic and recurrent Anger depletes the body’s ability to fight inflammation that is triggered by the free radicals. This eventually causes disease.

Anger is known to cause frequent headaches, digestive problems and abdominal pain/gastritis, Insomnia, increased anxiety and depression, skin problems and eczema and even Heart attacks and Strokes.

Your Anger has not only implications for you, your mental and physical well being and productivity but also for that of your family, friends, work colleagues and everyone in your immediate surroundings. Your anger will have a domino effect on others. It is therefore very important to control or release your anger, not just for your own selfish reasons but also for the greater good of society.

The first step in Anger management would be to realise that Anger is harmful to you more than to anyone else. While there may be many ways to keep your anger in control, I personally believe that if you have an understanding nature, have empathy for others and make excuses (to yourself) for their inability to see or do things your way – you could control your anger. Being placid or timid or avoiding people or situations may not necessarily be the right way to deal with anger or a situation that could make you angry. Learning to meditate, attempting to resolve conflict by understanding the other person and seeking counselling (professional) could help you deal with your anger. Yoga, exercise, regular breaks from your work, having a supportive network of friends and family could also help you release your anger. Keeping a diary could help you understand your anger and could help you device strategies to cope with stressful situations when they happen the next time.

My very best wishes to you for staying cool always.

HOW TO LOSE WEIGHT

/ Subash Rau / 1 Comment

As a doctor I see many people who want to reduce their body weight for a variety of reasons including to improve their health, body image or personality. Unfortunately only a few actually achieve their weight goals and succeed in keeping their weight down for prolonged periods. Most have some early gains and then either stop losing weight further or put the lost weight back on despite everything that “they think” they may be doing. They then become frustrated or depressed and sometime totally give up the “battle of the bulge”! Many take solace in food and put on more weight on the rebound. I will put down in this article what I have seen successful weight losers do to achieve their target.

The first part includes some points for you to consider. The second part contains some strategies for weight loss.

Things to consider:

1. As someone said, “failing to plan is planning to fail”! You have got to have a written plan of action to achieve your body weight targets.

a. Set your body weight target (what do you want your body weight to be)- e.g., 10kg less-

   write it down!

b. When do you want to achieve this weight? E.g., in one year’s time 1st March 2021.

c. Put down interim goals – quarterly goals viz 2.5 kg weight loss every 3 months which would be 1 Kg weight loss every month.

Someone also said “the difference between working with a goal and without a goal is…………………….…result”. Consult your doctor and do the necessary tests to certify your cardiac fitness to begin your weight loss programme.

d. You have got to put up an exercise schedule and diet chart. You could consult a dietician to help you plan your meals and the low calorie in-between meal snacks too.

2. “Whatever gets measured, improves” {someone said 🙂 } . Buy a good digital weighing scale and check your weight every Sunday, early in the morning soon after waking, after evacuating your bladder and before you take anything by mouth. You want to definitely do this as half a litre of water taken, will definitely increase your weight by half a kilo! Record each measurement in a book against the date of measurement.

3. You have got to accept that what you have done in the past to reduce weight, just wasn’t enough. You have go to do something quite drastic and consistently to achieve your goals. You would need to cut the calories that you eat as well as increase the amount of exercise that you do (volume of exercise as well as Intensity). This also needs to be documented everyday. You can sum it all up at the end of the week to see how well you have stuck to your plan.

4. If you don’t achieve your weekly goal, be hard on yourself the following week and either go on a stricter/ lesser diet or exercise more or do more of both! Be brutally honest with yourself. Don’t accept excuses for your inability to reach your goal or to follow your own weight loss plan. Achieving these smaller weekly goals will ensure that the larger monthly goals, quarterly goals, half yearly goals and the final goal are all achieved (as planned).

5. Changing your thinking is a given. But you absolutely have to change your lifestyle and habits to achieve your weight loss goals.

a. Separate food from the good times. Don’t attend parties where food is the main draw.

Have a green tea party. Avoid junk food when having alcohol. Don’t sit in from of the TV with junk food to munch on.

b. Eat out less often and when you do, fill yourself up with low calorie salads before going onto the main course. Share your main course with someone else. Avoid eating deserts completely.

c. Don’t keep high calorie snacks at home and if you do take them, buy them one at a time (not an entire box full and a small portion too). A good example is chocolate.

d. Avoid all kinds of bakery foods (bagels/ white breads/ cakes/ pies etc)

e. Take twice as long to eat. Chew each mouthful 30 times before swallowing.

f. Have more of the food that you don’t like and completely avoid what you do! This way you would get all the nutrition without the craving to eat more!

6. Plan your snack and in-between meal foods. Salads, green tea, low calorie fizzy drinks and water will definitely reduce your hunger and help you get by till the next meal. A high protein shake is a good way to reduce your hunger without increasing the risk of weight gain. However you should make sure that you are using a pure protein powder drink rather than a balanced protein supplement drink (which would have less protein and is used as a post-exercise re-fueller).  

7. All habits take 3 weeks to form and 3 months to become permanent. Grit your teeth and stay strong for this period especially during the first 3 weeks. It should become easier after this.

8. Take an Antacid especially if you develop acidity when eating smaller quantities of food. Remember the food you enjoy is the one that is particularly harmful to your goals.

9. When all else fails, don’t hesitate too much to go under the knife. Bariatric surgery does wonders for many.

Strategies to lose weight

What is most important is to develop a daily calorie deficit. Food intake in terms of calories must be less than calories expended by exercise. If you can reduce your daily food intake by 300-400 KCals and increase the calories spent by another 300-400 KCals you could achieve a 700-800 Kcal deficit which over the week would amount to 3500-5000 Kcals and a weight loss of 1/2 a Kilo of weight per week and a 2 Kg weight loss per month! (if consistently done)

Exercise daily but vary the intensity and duration of exercise. Training is to be done in cycles of increasing volume and intensity of exercise. This not only keep the challenge up but makes exercising more interesting. Make exercise a part of your daily living – walk up the stairs, walk to the neighbourhood shop, take the train or the bus instead of using your car, cycle to work etc. Listen to your body and don’t push yourself when you are tired. Ensure that you get 7-9 hrs of sleep a night.

Eat everything but reduce the intake of carbohydrates (alone) by 25% at each meal. Compensate for the reduced volume of food by eating a lot more of salads and less calorie dense meals and snacks.

You could consult a professional dietician and take a very low calorie diet. (600-900 Kcal/day) Again taking plenty of salads would help a lot in reducing your hunger and keeping you sane.

Try a completely different diet – Keto/Paleo/Atkins etc

Try a 24 hr fast or fast for at least for 16 hrs a day for 2 days a week. There is some evidence that this is equally effective as eating less (dieting) every day. So you would get the pleasure of eating normally on most (except 2 days) of the week.

Reduce your meals to just 2 a day. Skipping dinner would probably be the best. The food that is taken at night gives calories that just stick to the body. Your metabolism is the slowest when you sleep and therefore the food eaten is  not consumed as it might be in the morning. Skipping dinner will therefore help in weight loss.

Essential supplements that you may need when you go on a weight loss diet are the following:

– Multivitamin mineral tablet

– B complex tablet

– Fish oil (omega 3) capsule

So to summarise

Write down your goals, targets and timelines.

Start your diet and stick to the plan.

Do your exercise 6 days a week.

Check and record your weight every week at the same time.

Reduce your food intake and increase your exercise volume if you haven’t reached your weekly target. Continue the same if you are satisfied with your weekly weight loss.

Have someone you should be answerable to – a weight loss coach!

Best wishes for your success!

Here is a interesting YouTube link

Gastro- esophageal Reflux Disease

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GERD Advice

Gastro Esophageal reflux disease  (GERD) is a condition where acid water from the stomach moves up the gullet (Oesophagus) and causes corrosion and irritation in the lower chest or throat.

While many people can develop this condition because of being overweight, often it flares up after a respiratory infection. Repeated coughing increases the pressure in the stomach, which then increases the upward flow of acid from the stomach to the oesophagus (food pipe/gullet). GERD refers to the the pain and burning that is felt in the lower chest. Laryngo-pharyngeal Reflux disease (LPRD) refers to the chronic throat irritation that prolongs the cough and delays the recovery form the cold. There are a few lifestyle changes that can be of great help to sufferers of this troublesome condition. The following are my suggestions:

1. To take small frequent meals rather than large ones.

2. To avoid heavy spicy dinners.

3. To avoid lying down within 2-3 hrs of a meal.

4. To avoid taking excessive fluids or water with meals.

5. To avoid taking liquids after 7PM. If you must, take a spoonful of water and gargle your mouth and throat. You will feel less thirsty once your mouth is moistened.

6. Avoid alcohol and fast food (oily/fatty food) consumption at night. (Alcohol and fatty food delay gastric emptying and predispose to reflux)

7. Elevate Head-end of the bed/cot at night or while lying down to sleep.

8. Take a Antacid/Prokinetic at 5PM in the evening.

9. Gargle and swallow an Antacid syrup at night just before sleep. It coats the throat and stops the acid from contact with the throat.

10. Take a Digestive supplement. This hastens digestion and the emptying of the stomach.

11. If overweight, make a serious and concerted attempt to reduce weight. Weight loss would really help in reducing symptoms.

Contact your doctor for a prescription.

All you wanted to know about Diabetic Diet

/ Subash Rau / 2 Comments

How to design a Diabetic diet

How do you design a Diabetic diet

1. First fix the number of Calories you will need per day. 20Kcal/Kg of Ideal Body weight (for sedentary life)

Add 5Kcal/Kg extra for underweight persons or if they lead a moderately active life.

Reduce Calories by 5 Kcal/Kg body weight if overweight.

2. Fix the Constituents of Diet:

Carbohydrates – 55-60%

Proteins – 20-30%

Fats – 20-30%

Fibre 25-35 fibre

        Take about half or a little more of the calculated calories as Carbohydrate (boiled or brown rice is preferred over white rice, whole wheat chappathi is preferred over maida rotis and Naans. Take all the

proteins that you would like, add oils to your food (1-2 tablespoons per meal. Take 300-400 gm of vegetable as salads daily. Remember to incorporate as many colours in the salad as possible.

Note: Carbs and Proteins give 4Kcal/gm and fats and oils give 9Kcal/ gm. Therefore if you are advised 1500Kcal of food per day, you will need to take 900 Kcals and 225 gm of Carbs (60% of 900).You can add about 30ml of oil to your meals (2 tbs) and take the remainder of calories as proteins (which would contain fat also).

   3. How are the calories divided between the meals?

Morning meal 40% (Breakfast 25% and 11 AM snack 15%)

Lunch 35% (Lunch 30% and Tea time snack 5%)

Dinner 25% (Dinner 20% and late night snack 5%)

Food is to be taken in 5-6 meals a day.

Roughly 2/3rd of the assigned calories should be taken at meal time

and 1/3rd as an In-between meal snack. If you are used to taking

        3 idlis for breakfast, take 2 at 8AM and 1 at 11AM.

Important terms explained

Simple carbohydrates: are those that are digested very quickly to yield glucose molecules such as fruits, milk and milk products, sugars, sweets, syrups and soft drinks.

Complex carbohydrates: are those that take a longer time to get digested and release glucose slower such as peas, beans, whole grain, vegetables and whole grain bread.

Glycaemic Index: refers to the ranking of food according to how they raise blood glucose levels. They are classified into

Low GI foods – <45

Mid GI foods – 46-59

High GI foods ->60

What are the determinants of Gylcaemic Index?

The following factors are important

how refined the carbohydrates are

how the food is cooked

how quickly it is digested and absorbed – like rice

how much simple carbohydrate it contains

how much of fibre it contains

how much of fat and proteins it contains – fats slow down gastric emptying and proteins stimulate Insulin secretion and reduce blood glucose levels.

So a Diabetic person must avoid or eat very sparingly High GI foods, eat moderately of Medium GI foods and eat plenty of Low GI foods.

4. Foods that don’t require Insulin for metabolism in the body are Fats and Proteins. So you could have a steak or add oil to your food without having to worry about your blood sugar levels. A diabetic person needs to reduce the intake of Rice, wheat and other cereals and tuberous vegetables such as Potatoes, Carrots, beetroot, Colacasia, tapioca etc (Onions and Radish are ok). Unlimited green vegetables of all types must be taken.

5. Getting into the habit of weighing the food would go long way in understanding how much and what type of foods affect the blood sugars. A simple kitchen scale can be bought for as less as Rs.350/-.

General Advice for Diabetic patients regarding their Diet and food intake!

2. Have small frequent meals, 5-6 meals per day.

3. Have a heavy breakfast, lighter lunch and a very light dinner. Fit in 2 low carbohydrate snacks at 11PM and 5PM. The snacks could have a high protein or fat content!

4. Know how much to eat (total calories per day) and how much of each food item to eat at each meal. (Count your Idlis and estimate the amount of rice eaten)

5. Never overeat and avoid deserts. Have a fixed helping of Rice and count of Chapattis.

6. Snack on nuts, sprouts and salads.

7. You don’t need to reduce your intake of Oil and meat unless you have high blood cholesterol levels.

8. Supplementing an optimal diet is “compulsory” for all Diabetic patients as the reduced food intake doesn’t allow adequate micronutrient intake. Please contact your doctor for a suitable vitamin supplement.

9. If you are eating out, have a large salad before starting your main course. Share your main course with someone else and avoid the desert completely if possible. You can have all the non-veg kebabs you want.

10. If you are a vegetarian, have just one helping rice or a limited number of breads (Chappatis/Rotis etc)

11. Always avoid Calorie dense foods e.g., a piece of cake has more calories than a Idli!

Useful tips:

1.Eat before you are hungry so you are not tempted to overeat.

2. One way to eat more without running the risk of increasing your blood sugars is to add your Rasam/Sambar to your Salad and to eat your salad before your main course.

3. You should increase your intake of salads especially if you are always feeling hungry. Metformin as advised by your doctor would also reduce your appetite.

4. Take veggies of as many different colours as possible every day.

5. Your fruit intake should be limited especially if your blood sugars are elevated. Fruits must be taken as an in between meal snack and not as desert after a meal.

Food that are bad for an Diabetic

While I might have touched upon this topic, I think that it would be worthwhile to reinforce it to you. The food that must be avoided are:

Sweets – chocolates, Indian sweets, ice creams etc

Sugar and sugar containing foods

Beverages – all juices, fizzy drinks (unless zero calorie)

Tubers – Potato, Beet root, Carrots, Tapioca and others

High GI foods

Calorie dense foods – Cakes, pies, tarts, pastries or anything nice by any other name!  

How do you adjust your meals according to your blood sugar values?

Your doctor may ask you to check your sugars before a meal and 2 hrs after. You will also need to measure the exact amount of food that you consume in terms of (katori/cup) or pieces of bread. If your post meal sugars are high, you may have to reduce the helpings of rice/bread and increase intake of vegetables or fats with your meal. In time, you will know exactly how much or how little you can take to keep your post meal sugar values under control.

Common targets for Diabetics

Fasting Blood Sugars – 90-110mg/dL

Post prandial Sugars – 140-160 mg/dL for those under 60.

160-180 mg/dL for those between 60-75 yrs

                 180-200 mg/dL for those >75 yrs of age.

200-250 mg/dL for those with frequent hypoglycaemia

HBa1c values – <7% for those <65 yrs of age

7-7.5% for those 65-70 yrs of age

7.5-8% for those 70-80 yrs of age

8-8.5% for those >80 yrs of age.

Useful Links:

Food exchange list –https://www.iitk.ac.in/hc/food-exchange-listhttp://A Dieter’s manual – ouricc.org/wp-content/uploads/2014/06/Indian-Food-Calorie-Chart.pdf