M. P. Ravindra Nathan

When I stepped out during the intermission of a popular recent release in a movie theater in India last month, the lounge appeared crowded. The air was hazy from a cloud of smoke with its overpowering smell. Almost everyone who was standing there was smoking a cigarette while indulging in animated conversations. The few non-smokers, including school children, were on their cell phones. So this was a �smoke break,� not an intermission, I surmised and decided to get back inside the cool theatre before I collapsed from the acrid secondhand smoke.

Coincidentally, the next day�s news paper contained a short article about �the rampant increase in heart disease in India,� in which smoking was cited as a risk factor. I wonder if anybody paid much attention to that. While walking along the roads, it was easy to spot the empty cartons of Gold Flake, other common brands and an occasional American blend, sticking out of the garbage heaps. The obituary columns sadly reflected the trend in India, many youngsters in their 40s and 50s having untimely, often sudden, deaths from heart attacks.

Later, my sister gave me an update: �Ravi, three people who are dear to us departed recently, Dr. N J, the thriving homoeopathic doctor died suddenly; he was just 48. Yes, he was a chain smoker,� she said anticipating my next question. In spite of all the warning �Smoking is harmful to your health� on every carton of cigarettes sold in any corner of the world, this terrible habit continues. While the old smokers die away, new smokers are born. As I have repeatedly mentioned in this column, heart disease has become the bane of all of us who are of South Asian heritage. And Indians who smoke have a quadruple jeopardy, the other three being genetic lipid abnormalities, diabetes/ pre-diabetes and high incidence of metabolic syndrome.

Tobacco, in this discussion, is meant to include the various commonly used products besides cigarettes, such as cigars, �beedis� (the small Indian cigarette with tobacco in a rolled up leaf,) smokeless chewing tobacco, �pan,� snuff, etc.

Ravages of tobacco abuse: If you want to see a quick demonstration of the deleterious effects of smoking, take the pulse rate of a smoker before and after smoking just one cigarette. You will find the heart rate increases after smoking. With every additional heart beat, extra work load is imposed on the heart. And the lungs suffer as well. Here is another 10 second test. Ask the smoker to pull just one puff and without inhaling blow into a white blotting paper and you will see dark patches on the paper. Now, let him inhale the smoke like all smokers do and see the difference. The blotting paper is cleaner, suggesting the extra tar and other alkaloids from the smoke have gone into the lungs! Are you surprised that chronic smokers get emphysema and cancer of the lungs so frequently?

�Do you know how it feels like having lung cancer?� asked one of my patients, Todd, during an office visit. There was an edge of despair in his words. A heavy smoker in the past, he was now undergoing various treatments for his cancer.

�I know, Todd,� I tried to sympathize with him.

�I live from CAT scan to CAT scan and run from one doctor�s office to another. Then there is this dreadful chemotherapy,� he said disgustedly. He knew what was coming to him when he lit up every cigarette in spite of all my admonitions, but couldn�t prevent it. Nor could I. Such latitude even toward one�s own health? All I could do now was to offer a few kind words to help him cope better and live a few more days.

In general, a smoker dies 20 years earlier than a non-smoker. The relative risk of getting a heart attack is much higher in younger age groups, almost five-fold if you are under 40! The litany of diseases is not just confined to heart and lungs. Cancers of the stomach, kidney, bladder, tongue and cheek, the last two especially in those who chew tobacco, occur frequently in this population. Also, peripheral vascular disease, abdominal aortic aneurysm, stroke, peptic ulcers and hypertension. Diabetic patients who smoke have a higher incidence of heart attacks and strokes; even their blood sugar control becomes difficult. Early signs of aging such as those unwanted wrinkles on the face can be seen in smokers. Now, you know why chronic smokers look a tad older and weather-beaten.

Tobacco smoke is a deadly cocktail containing more than a 1,000 chemicals, many known poisons and carcinogens � nicotine, tar, benzene, carbon monoxide (the deadly odorless gas which results from incomplete combustion and reduces blood�s ability to carry oxygen), even cyanide (I am not kidding), just to mention a few. The nicotine is a powerful �vasoconstrictor� reducing the blood flow in smaller vessels, thus affecting nearly every organ in the body. And it is responsible for the pharmacologic dependence on cigarettes.

Women and smoking: The overall smoking rate is still low among Indian women, but recent studies show an 18 percent increase in the past decade, especially in the urban high-earning sophisticated group who are vulnerable to the aggressive marketing strategies of tobacco companies. �The women who smoke two packs of cigarettes a day have a 21 percent greater risk of developing high blood pressure and heart disease," according to research reported in the a recent issue of the Journal of the American College of Cardiology. �Although only 8 percent of women in Asian countries smoke, more than 60 percent of the men do, exposing vast numbers of women and children to the harmful effects of second hand smoke,� according to physician E. A. Enas, who has done extensive research on heart disease among South Asians. �Smoking is catching up with the school going children as well, a recent survey showing nearly 50 percent Indian school children � boys and girls, regularly or sometimes use tobacco particularly chewing tobacco (gutka),� said Enas recently.

(To be concluded)

Cardiologist Dr. M. P. Ravindra Nathan, director of Hernando Heart Clinic in Brooksville, lives in Brooksville.

	Payal Patel

In this article, I would like to stress the importance of prevention of obesity since it is much easier than treating it. Prevention is the key to protection against many diseases that go hand in hand with obesity such as hypertension, diabetes, etc.

Prevention should begin from early stages of life as a newborn. Breast feeding is essential along with delay in introduction of solid foods at six months of life instead of four months. The American Association of Pediatrics (AAP) recommends that breastfeeding be continued for one year or longer for substantial benefits along with availing weight gain. Introducing the right foods also is important such as introducing vegetables before fruits as a way of introducing taste development to less sugar, and less calorie-rich foods. Avoiding processed and junk food through toddler hood also helps develop healthy eating habits that will last lifelong. In this day and age, processed foods as well as food coloring are leading cause of increased attraction to such foods, which are related to obesity, diabetes, Attention Deficit Hyperactivity Disorder (ADHD), etc, in kids.

As parents, we are responsible for making choices for our kids. Offering them a banana as a snack, instead of a cookie is a matter of choice that we should make. This does bring changing our own habits into account. As I had mentioned in Part I of my article, don�t expect your child to eat a salad if you are eating French fries. Moderation is the key. None of us can completely eliminate high calorie, processed food completely, but having them occasionally is the alright. It is not easy to ask a child to give up candy when his friends are having the same, but limiting it to no more than one is important.

Children are often picky eaters in their toddler years, but making healthy food part of the household has to be a repeated effort. Some foods have to be introduced to kids about 10-15 times before they develop a taste for it. It can be frustrating but knowing you are doing the right thing should be a reward in itself. Involving the kids in food choices from early on also is essential. Giving them a choice between a banana and an apple is correct, but giving them a choice between banana and a cookie will result in failure to comply. Involving the kids via taking them for grocery shopping and asking them to help pick the right foods will give them a sense of control and understanding about a healthy lifestyle.

When preparing a meal, asking them to get a tomato from the refrigerator or pretend play in making roti also is helpful. Eating together as a family stresses the importance of everyone eating the same type of food in the family as well as cultivates positive thinking. Eating at home vs. outside also gives control over food choices and eliminates the possibility of having calorie-rich foods. When eating outside, making choices such as grilled foods vs. fried, and a glass of water vs. soda stresses healthy eating habits inside and outside the home. Food should not be used as a reward. For example, putting his shoes in the right place should not warrant the child to have candy but instead offering a star sticker or a penny for his piggy bank is okay.

Exercise also is important for the family starting from early ages. Children should play for one hour a day or do an activity as a family such as walking after dinner, or bike riding, or just playing catch. Parents should stress the importance of exercise by discussing with their children why they chose to join a gym or run on a treadmill to be role models for their childrens' future. Limiting TV watching or videogames to no more than one hour a day also decreases chances of inactivity.

Overall, Prevention plays a huge role in a family. Children should never be punished for making the wrong choices, because they are influenced by myriad of family and friends. Instead, parents need to be patient, and build self-esteem in a positive fashion via explanation of why right choices such as healthy food and exercise are important. Children may not get it completely, but they will learn from their parents and value their choices eventually. In my next article, with the help of a board-certified dietician and a close friend Bhavi Patel, I will talk in depth about detailed food choices that will benefit children as well as adults.

Happy holidays and best wishes for the New Year.

Payal Patel, a board-certified pediatrician, is at Sunshine Pediatrics, 18928 N. Dale Mabry Highway, Suite 102, Lutz, FL 33548. She also can be reached at (813) 948-2679.