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samedi 30 novembre 2013



Be careful not to become Ignorant!

My teacher at University of Miami, Dr Howard Lessner (olav ha shalom) once told me, noting my desire to devour medical information:
Do not trust medical information that comes free, read what you pay for.
Of course in 2014, we are inundated with FREE medical information, in the case of Medical Practitioners, bogus journals, just set up by Interest Groups to propagate the information they want to be known. They are very seldom written by Doctors but by journalists who report from various meetings and also summarize the articles.
This is where the manipulations begin
A notable headline in a Free “journal” touted:
Not Inferior to Placebo
And this morning, this arrived:
Diet beverages pose no greater harm than sugar sweetened
Do these journalists truly believe that doctors who spend 10-12 years at University level to educate themselves are that stupid?
What happens is as follows.
A journalist attends a meeting, in this case the Obesity week, November 11-15, 2013 in Atlanta.
The culpable or innocent researchers may have an abstract or oral presentation that allows them to twist the fact into something else altogether.
The title was
Role of non-nutritive sweeteners in the regulation of weight: Obesity facts and fiction
And they would interview the presenter who is happy with the free publicity he is getting.
He said: when you stop drinking sugar-sweetened beverages, you loose weight. Not a surprising remark!
People are better off drinking diet drinks when compared to sugary drinks, but he added, it is not a strong effect!
That was converted into the headlines of today:
Diet Beverages pose no greater harm than sugar sweetened beverages.

When you read the article, whether the original presenter meant it or not, it comes across as if he is employed by the Aspartame manufacturers to promote diet drinks!
Reading medical nuances from journalists is like taking a course in Pharmacology from the Drug Representatives.
You are what you read, so please make sure that you subscribe to your specialty journals and also journals or magazines which are peer reviewed and there are many of them making available excellent research.
This morning, yet another paid Professor Peon had this to write:
The SAVOR-TIMI 53 and EXAMINE trials were highlighted at the annual European Society of Cardiology (ESC) Congress and European Association for the Study of Diabetes (EASD) meeting and published inThe New England Journal of Medicine. In SAVOR-TIMI 53, saxagliptin (Onglyza, AstraZeneca/Bristol-Myers Squibb) added to standard care neither reduced nor increased risk for ischemic events as compared with placebo in patients with type 2 diabetes at high CV risk. In EXAMINE, alogliptin (Nesina, Takeda Pharmaceuticals) added to standard care did not increase major adverse CV event rates as compared with placebo in patients with type 2 diabetes and recent acute coronary syndrome.

And this, he touted, as an advance in the treatment of Diabetes! This is the Non Inferiority to Placebo they are talking about!

vendredi 29 novembre 2013


In the Medical Literature, there has been a lot of hullabaloo made about the importance of a Low HDL Cholesterol, the so called Good Cholesterol and millions of dollars spent by Pharmaceutical companies to find a drug to raise it, but to no avail. Also they sadly found out that manipulating the HDL cholesterol to a higher level does not actually benefit the Heart!
The Low HDL cholesterol levels among the group I work with, The Indians of North America have puzzled me.  Also had become aware of the fact that HDL cholesterol is lower among many groups. The only common link I could find was one of change in Lifestyle in conjunction with Oppression or Alienation.
Science offered no help until recently when I read an article from our colleagues from Mesoamerica. Mexican researchers studying various American Indian groups were able to make some observations about ABC A1, ATP binding Cassette Transporter A 1 gene associated with low HDL cholesterol. They also found an association between this gene and Obesity and Type 2 Diabetes.
ABC A1 plays a key role in the cholesterol efflux and transfer from peripheral cells to lipid poor Apo lipoprotein A1 (ApoA1) the first step in the HDL particle formation.
A variant of this gene, C230, has only been found in Native Americans. No other groups in the world, Africans, Melanesians or Chinese have this allele.
This finding has tremendous implications.
From Western Alaska (Aleutian Islands) to Tierra del Fuego (Chile and Argentina) there are millions of Native Americans and in countries like Mexico, Guatemala, Peru and Bolivia there are millions more descendants of Native Americans. It is present across language divides among the Native Americans, decreasing only in the colder climates, which they postulate to be climate related adaptive processes.
(C230 allele in various native american groups, absent in other groups from other countries)
Overall, HYPOALPHALIPOPROTEINEMIA (HA) was the most common form of dyslipidaemia in this study: 65 percept of Mexican and South American Natives had it.
This variant is also associated with Obesity (which may have been contributed by the Newcomers to the continent from Europe, who were not known for their kindness, by forcing lifestyle changes).  Most Native Americans in South America are not obese but most North American Native American groups are overweight or obese.
What is very interesting is that, this allele is exclusive to Native Americans and their descendants.
Mexican Americans as they are labelled in the USA are not Native Americans but they have a fair bit of Indian admixture, and this is blamed for the high rate of obesity and type 2 Diabetes among them in the USA and also in Mexico (much evident after the North American Free Trade Agreement),
In 1962, Dr JV Neel had hypothesized a “Thrifty Gene” theory. Working closely with American Indians and observing other indigenous people, I strongly believe in the presence of this “thrift” in the metabolism of Indigenous peoples.
In the hunter-gatherer populations such as the Native Americans, the R230 C carriers could have had a selective advantage. Its presence prevents cholesterol efflux; this could favour intracellular cholesterol and energy storage during the times of Famine.
This natural protection became a curse. During famine, it accommodated the fluctuations in energy, provided energy for important functions such as Reproduction and more importantly the Immune System. (Which costs a lot of energy to maintain!)
It is not this genetic variant cursed the American Indian to become overweight and obese, but this trait became a liability when contact with outsiders created a lifestyle change, with increasing Body Mass Index, Type 2 Diabetes etc.
So by itself low HDL-C in an Indian or Indian descendant is not a disease, but a hint, in the modern times, to look elsewhere: Lifestyle changes and an important signal to counsel them on a Lifestyle change to one that resemble their Ancestral Lifestyle. This may also be partially responsible for the Fatty Liver seen among Native Americans and Mexican Americans.
Just around the time I began working with American Indians, I was also running Free Clinics for the Rural Poor in Jamaica who had high rates of Hypertension and Diabetes. To run these clinics, one needed help from all sectors of that very divided society. A prominent family had consulted their Endocrinologist in Miami (rich Jamaicans to this day seek their medical care in Miami), he had told them, both the mother and daughter had high cholesterol levels and had prescribed treatment of the day, which were creating some complications. In those days, when requesting Cholesterol levels one got different Lipoprotein factions and unlike today, no calculated values are recorded. (That is why in most of today’s lab reports; the sum of the calculated cholesterol values may be higher than the total cholesterol reported). Some friends at the University of Miami Chemical Pathology department afforded me some free testing of blood; I tested all the family members. Even I, as a novice endocrinologist but very well interested in medicine outside the body, could see that all members of the family were healthy, without any evidence of heart related conditions or risk factors for such. I was gratified to present the report to the family that they had HYPERALPHA LIPOPROTEINEMIA, something quite opposite to what I had been discussing above.
How to tie it all together? To complete the circle so to speak?
Rescue arrived in the form of research from Sao Paolo endocrinologists (published on 22 November 2013). They had hypothesized that plasma HDL-C concentrations independent of Overweight and Obesity might be influenced by Insulin Sensitivity.
One is reminded of all the pharmaceutical attempts to raise the HDL-C, which has ended up in failure so far!
In their studies of measurements of various proteins, in lean, low HDL C and high HDLC (like our Jamaican friends in question) they demonstrated that the protection offered is related to Insulin Sensitivity!
This observation has tremendous implications for the non-European, non-African populations of this world and especially with the groups that I work with: The Indigenous peoples.
In a paper published in 1972, the mavens of the media, later the troubadours of tragedy, those epidemiologists studying the Pima Indians, trumpeted:
Unexplained Hyperinsuinaemia among the PIMA Indians compared to the Caucasians.
Diabetes 26: 827-840, 1972
Insulin Sensitivity, Insulin Resistance and Diabetes among the groups I work with have been in my thoughts for years, trying to make sense of it all, away from the pronouncements based on other races and other countries, irrelevant socially, economically to the tragic reality of the Indigenous peoples.
An erudite colleague of mine from University of Texas Medical Branch at Galveston, Dr Charlie S, had asked me to look for the prevalence of Acanthosis Nigricans (the dark velvety markings on the nape of the neck one can easily see) among the Native Americans. A casual survey was surprising. Up to 1/5 children and 1/3 adults had this marking. For the next five years, we systematically did anthropometric measurements on hundreds of Indian children and dutifully recorded them. We couldn't fully understand the significance of Acanthosis Nigricans in Indian children, until Dr Charlie S, found a way to measure insulin levels without being too intrusive.

 Antibodies to insulin were incorporated into circles in a blotting paper to which one drop of blood was applied, which later was mashed up and measured for insulin levels.
Imagine our surprise when we found out that almost all American Indian children had higher than normal levels of Insulin levels and those with Acanthosis Nigricans had higher Insulin levels.
(it was my pleasure to travel to Tsumkwe in Namibia and check the Insulin levels of Healthy San Hunter Gatherers and as expected it was higher than normal, no obesity or Diabetes known among them)
It also fitted into the Thrifty Gene theory, which necessitated a storage hormone to store the energy at times of plenty and to release it when there was a shortage of energy. Insulin was the strong contender
for it. And still is!
From this and an anthropological analysis, I was able to put forward a holistic explanation.
Indians were and some of them are still INSULIN SENSITIVE, which protected them against
Type 2 Diabetes
Non alcoholic Fatty Liver Disease.
The onslaught of outsiders with their peculiar lifestyle and eating habits, combined with oppression, powerlessness, alienation and marginalization became INSULIN RESISTANT.
It is this conversion that makes them overweight, obese, dyslipidaemic and Diabetic.

Here is where the Anthropological education comes in handy. It differs dramatically from the Biomedical Education such as we are given at Medical School in that it is
It asks the question WHY and not tries to answer it with WHAT which is what the biomedicine does
It takes into consideration the lived in life of the person rather than just the body as it happens in Biomedicine.

My erudite friend from Miami, has this capacity to ask WHY? And he can come up with searing answers that light up another pathway. He asked me, what if HDL-C is just a marker for something else. Here is your answer, my dear friend: It is.
We will ask some more WHY!
Studies like this help us alleviate the suffering of the Indigenous people of OUR AMERICA.
Thank you, dear researcher friends from Meso America and Brasil!
And to Brunel University for giving me such a wonderful Medical Anthropology education.
At a conference given at the Potawatomie Tribe of Kansas in 2006, I had suggested that social factors converted them from being Insulin Sensitive to Insulin Resistant.


This invitation arrived from Cochin, India today:

As the Jewish community is dwindling in Malabar, more and more interest is taken by sympathetic and kind Hindu and Christian souls. I was particularly gratified to see that the exhibition would be displayed at Ethnic Passage, a gallery, antique store, book store and café strategically located just in front of the Synagogue in Jew Town in Mattanchery in Cochin.
Yet another reason for my glee. The owner of Ethnic Passage, an erudite Christian from a prominent local family, opened a bookstore because he wanted to see his favourite books on display. Thus this bookstore is not as commercial as the other ones which cater to the tourists or those who want picture books of Kerala or Kathakali.
I entered the book store, at that time in various stages of construction, and talked to the man behind the counter. After an interesting conversation, when I was told that the bookstore is the pet project of the owner, I left a 5 peso Cuban currency, with a note to the owner that I had been impressed. Soon the counter clerk returned to say that the owner wished to see me. He kindly returned the 5 peso note and told me that if he accepted this gift that would infringe certain archaic tax laws of Indian government.
Thus began a long friendship with Mr RN, and wonderful evenings at various clubs in Ernakulam and long chats at his office over milky teas.
As soon as India institutes Visa on Arrival, you can expect me to fly into Cochin either via Doha on Qatar or via Kuala Lumpur on Malaysian Airways.
Tonight is the first night of Chanukkah, rather early by the usual standards. I had to make do with a hand drawn menorah but I had enough dreidls of all sorts to make a decoration. Thus I could remind myself that tonight, these very same rituals would be repeated from homes from Auckland to Asuncion and in remote communities such as Cochin, Yangon, La Habana, Kingston where I would actually know some of the participants!
Shalom Bear had travelled here from Miami as a gift of Auntie Greta, the Koala and Kangaroo came courtesy of Qantas from Auntie Sandra in Melbourne.

Then I remembered, there are Cochin Chanukkia lamps in the Blue House among the Indians, and I have to make sure that next year I should use it!

For a moment, the universal connection of my people becomes clear to me. A strong connection is felt all across this universe, and this connection is what American Indians would define as part of Spirituality. For a group of people not that well known for their religiousness, the connection to the history if palapable.
This celebration is not religious, it is not mentioned in the Bible but it did happen during the Hellenic occupation of Israel during the time of Antiochus Epiphanes. It is to be grateful for the victory of a small band of guerrilla fighters led by Yehuda Macabee against the might of Greek Empire in the East.
As I was writing this, I felt the winds from Yangon and Cochin, La Habana and Kingston, Melbourne and Buenos Aires, blowing my way. I even made up a ditty as I spun the dreidl…


jeudi 28 novembre 2013


Gratitude, Make someone Happy and Elixir of Love

The forecast for this morning was Rain, dreary skies and the pertinent cold of oncoming northern winter. But that was not to dampen my enthusiasm for the chain of events that led to my enjoying this exquisite tea, Elixir of Love
Gratitude to make others happy and make oneself happy was an idea planted in my head by the American Indians, especially by my Hocank Sister, GG.
As we were preparing to go into an Inipi ceremony, at dusk many winter moons ago, she said, Doctor, when did you see your mother last? I guiltily admitted that travels in that hemisphere had prevented me traveling to the East to see her.
Be grateful that you have a mother to go and see, my mother is no longer alive, GG lamented, for me to avail of her wisdom.
Within two weeks I had located my “birth” mother in a city in Asia and was knocking at the door.

Who couldn't be impressed with the happy smiling face of His Holiness Dalai Lama?
How good it was to hear him talk about Compassion and Gratitude?

Right around that time, a Chinese accountant entered my life, of all places in Cambodia, not to help me with my erratic finances but to tell me about Gratitude List!
Each morning when you wake up, you must greet the Sun with thanks, said Ohiyesa, the Indian who became the first ever of his race to become a Medical Doctor graduating from Dartmouth.

Gratitude for each moment that is a gift to you, and in that moment try to make someone else happy and that in a nutshell is the essence of our own happiness. Paradoxically enough Happiness does not derive from having Desires but it arises from the lack of Desires and especially the lack of cravings for those desires.
I woke up this morning feeling content; despite yesterday being a day involved in mundane paperwork that government bureaucrats revel in.
My Gratitude List, I prayed?
An innocent smile of a young girl embarking on a career that she hopes would lead to embrace more knowledge about this world.
Her Kind mother
My good friend, the Chinese Accountant of Malaysia, who was the first one to introduce me to Shanameh
And a good friend from Meshed, who is now in KL, having just been granted a PhD in English
A family member who deserves more attention hovered, completing the list.
If I were allowed to borrow a line from Pablo Neruda, who said
Love is so short, and the forgetting so long.
I would say,
Encounters are so short, and their fragrances persist for so long!
Four brief encounters within a matter of weeks, two in KL, both over dinners at a Malaysian Resto and another at an Iranian Resto.

Two breezy encounters in the shadow of the bare mountains of Salalah in Oman, like the Khareef and monsoon to come in May. Bringing us the promise of good tidings.
All had one thing in common, there was innocence, conversations without agenda, unselfishness fired by the desire for the other to be happy.

I said thank you to the five people who arrived on the canvas of my mind.
Be careful what you pray for, my UmonHon teacher Pierre had warned, it will come true. So make your prayers meaningful.
I felt grateful for being present in the smiles of an innocent girl in Salalah and her mother, in the heart of a Bakhtin scholar, in the thoughts of a genuine altruist from Seri Kembangan.
The Bakhtin scholar wrote to wish me a Happy Hanukkah. She is from Meshed in Iran
The schoolgirl innocence wrote to say that the first step on the ladder of her career seemed firmer this morning!
I thought to myself, imagine her little heart and the heart of her mother, how happy they would be this morning, dancing with joy. It is that pleasure they transmitted me across the Rub’ Al Khali, the empty quarter of Arabia, beginning just a few kilometres away from their residence.
The Bakhtin scholar send messages in which she tried to cool some flames of aversion I had in my head. It is only in the head, I told her. I thought of my other friend in KL, who had said: aversion is the other side of the coin of attachment. Both are structural defects of your mind.
It is time to get rid of any aversion, real or perceived towards any one in the circle of friends, which is growing each day.
I wanted to celebrate this morning, so full of joys of quotidian life of an International Traveller.
What else is better than to read a few pages of my companion, the history of my alter ego, Maqroll El Gaviero by my favourite Latin American prose writer, Alvaro Mutis and prepare a nice cup of delicious tea from?
The French company, Mariage Freres, Maison fondee en 1854
I chose, Elixir D’Amour, to reflect my mood.
It did not disappoint me!

It may be more than just a coincidence that I wrote this on the morning of THANKSGIVING DAY being celebrated in the USA !
My Thanksgiving breakfast was at my favourite Cafe at Rue Archimede, where the genial spanish/italian hosts greet me with latin familiarity of long term friends!