Khaas Baat : A Publication for Indian Americans in Florida
Health & Wellness

It’s the Cholesterol, my friend!
Some New Insights - Part 1

Dr. M. P. Ravindra Nathan

By M. P. Ravindra Nathan,

Three persons of Indian origin whom I personally knew died recently from acute heart attack, one was 62, the other two in the young 70s. One was obese, another diabetic and the third one believed only in ‘naturopathy’ and hardly ever saw an allopathic physician. The common factor in all three was their poorly controlled cholesterol levels in the blood – hyperlipidemia in scientific terminology.
Why am I talking about cholesterol now? Haven’t we discussed this subject before? Yes, genuine questions. There are many modifiable risk factors for coronary artery disease (CAD) leading to heart attacks. And all of us know ‘high cholesterol’ plays a major role in producing heart disease. However, even experts didn’t know how important it is till recently. There are, of course, some naysayers who would say, “Oh, cholesterol is needed for our body.” Yes, its main function is to maintain the integrity of cell membranes and is necessary for the synthesis of some vital substances in the body like steroid hormones, bile acids and vitamin D. However, what most people don’t realize is that only little cholesterol is required for these functions and that is generally synthesized in your liver.

You probably already know the basics about the lipid measurements in the blood. Total Cholesterol (TC), Low Density Lipoproteins (LDL), High Density Lipoproteins (HDL) and Triglycerides (Trig) are the basic fractions we measure. Of these, LDL, the so-called bad cholesterol, is the main culprit that promotes atherosclerosis or plaque formation in the arteries leading to heart attacks. A sub fraction of LDL called LDL(a) is also highly atherogenic and is separately measured. HDL, the good cholesterol, on the other hand, fights LDL, snatching the LDL particles from the circulating blood and also from the plaques and, carries them to the liver for disposal. However, many new studies show that its protective effects are over exaggerated and artificially increasing its level by drugs would not confer this protection as well. So, currently all eyes are turned toward LDL, the true culprit, and how to reduce it drastically. The new dictum is “the lower the LDL, the better.” It can even be brought down to single digits and nothing adverse will happen to the body like cancer, etc., as once thought. And there are wonderful new drugs like PCSK-9 inhibitors that can drastically reduce the LDL, which can be given once a month or even less often as an injection.

Risk Factors for Heart Disease
We discuss often the various risk factors for heart disease such as Diabetes Mellitus, smoking, lack of exercise, high cholesterol, obesity, especially abdominal obesity, high blood pressure, alcohol, etc. Which one among these is the most important cause? Cholesterol, of course. Generally, we measure all the lipoprotein fractions as mentioned above in the fasting state.  The ideal normal range for these is TC <200, Trig <150, LDL<70 and HDL >50 and Lp(a) <50 mg/dl. In the past for those who have no risk factors whatsoever, especially Caucasians, an LDL of <100 has been acceptable but even for them a lower LDL is better.

Now, on to the problem in our hand. In spite of the recent advances in the management of coronary heart disease, it still remains one of the main causes of morbidity and mortality throughout the world. A global epidemic of CAD has evolved and more and more developing countries are being affected now. Among these, South Asians, especially Indians, seem to have a high incidence of the disease. Indian newspapers always report in the obituary columns, “The person collapsed and died while talking” or “He died in his sleep.” They are all from sudden heart attacks or fatal cardiac arrhythmias and one wonders if these could have been prevented. It appears South Asians in general and immigrant south Asian Indians (that’s all of us) especially appear to experience a disproportionately larger burden of CAD and show a three-fold higher risk of mortality as compared with native population, according to one researcher. Initially, many were skeptical about this observation but now the problem has been universally accepted. Even the American College of Cardiology has listed ‘South Asian heritage’ as a risk factor for CAD!
So, it’s time for us to take this problem seriously, understand the causes and treat them appropriately. 

To be continued …

M.P. Ravindra Nathan, M.D., is a cardiologist and Emeritus Editor of AAPI Journal. For further reading, “Second Chance - A Sister’s Act of Love” by Dr. Nathan from Outskirts Press, can be found at


100 Years of ‘Better 1 or Better 2?

Dr. M. P. Ravindra Nathan


Every patient who has been to an eye doctor remembers the “better 1 or better 2?” test. While many enjoy this exam, some are daunted by the fact that their response will decide their glasses prescription and or surgery outcomes.

Invented in 1853, the phoropter was the start of determining refraction for the eyes and using patient responses to determine the endpoint, which would then translate into a prescription for glasses or contact lenses, and even surgery.

This equipment, which is essential in every eye doctor’s office, is now 100 years old and was granted the U.S. patent in 1922. For those who need more in-depth knowledge, the “better 1 or better 2?” aspect of the phoropter was introduced in 1934 when “Jackson Cross Cylinder” was added to flip between the two options that the patient could confidently differentiate.

The phoropter is used for “refraction”; a test that results in determining a patient’s prescription (which translates into glasses or contact lens powers and even surgery endpoints). Therefore, Lasik, cataract and ICL surgeries (procedure to treat nearsightedness and astigmatism) are termed refractive and specialist eye doctors are called refractive surgeons.

Despite having some of the most advanced diagnostic technologies in the world at my institute, I still use the phoropter as my personal one-on-one examination with the patient and their brain potential of vision. That is especially because given many patients have had previous unsuccessful surgeries or complications elsewhere and I am repairing their vision or enhancing previous surgeries. Their own perceptive input becomes an important radar in my direction of how to correct poor vision and what surgery or technology to apply.

Using this personal information and perception from the patient, one can then apply over 40 different techniques to make people see without glasses or contact lenses after checking each patient’s vision optics for that eye, and then also compare the binocular vision aspect, which is finally controlled neurologically to their best vision potential.
This personal endeavor (which I encourage surgeons to do themselves) of custom-designing leads to successful vision outcomes for patients not only with Lasik, but also premium cataract surgery.

Unfortunately, the art of using the phoropter has declined steadily over time as this technology has advanced into automated versions. The talent of using this amazing device is an art and I don’t want that to disappear from the diagnostic realm of eye surgeons since this is one diagnostic equipment that allows the “patient” to be a part of the testing process and guide the measuring technician or surgeon to the correct surgical technique and expected vision potential.

I am involved in the evolution of these technologies, including automated phoropters that I’m collaborating with manufacturers worldwide wherein patients would be able to do this test by themselves. Thus, they would regain their power of deciding on what’s best vision potential in their own mind, as compared to a perceived 20/20 outcome, which may not be satisfactory to their surgery goals. I am also working on a concept of artificial intelligence-based feedback with the automated systems for patients, not only those with routine glasses and contact lens prescriptions that need refractive surgeries like Lasik or cataract surgery, but also complex cases like Keratoconus, irregular astigmatism, complications of Lasik, radial keratotomy, cross-linking and transplant surgeries. This would enable doctors to move forward with high confidence and patients to gain independence by being part of the process rather than a summative test result based on automation only.

Though I am involved constantly with innovation and progress of diagnostic technology in the field of eyecare and surgery, I personally do not want this equipment to land in the museum. I would like the phoropter to continue to be the foundation of any eye surgeon who dedicatedly wants to take each patient to the best vision potential.

As I share my passion with eye surgeons globally, to help patients see beyond 20/20, my statement on worldwide podiums resonates as I say it loud and clear, “A refractive surgeon must know how to refract!”

Here’s to another 100 years of everyday familiar music in every eye doctor’s office; “better 1 or better 2?”

Arun C. Gulani, M.D., M.S., is director and chief surgeon of Gulani Vision Institute in Jacksonville. He can be reached at [email protected] or visit


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