Heart disease and strokes are the most common cardiovascular diseases (CVD). In United States, they are the 1^st and 3^rd leading cost of death in both men and women. Forty percent of all annul deaths are a result of CVD. In 2006, it is projected that heart disease and stroke will cause the US tax payer 403 million dollars! The Centers for Disease Control and Prevention of USA (CDC) web article on CVD mentions that high blood pressure (or hypertension) and high blood cholesterol level are the two major independent risk factors for CVD. During 1999 – 2002, approximately 29% of US adults were diagnosed with hypertension. A 12-13 point reduction in blood pressure can reduce heart attacks by 21%, strokes by 37% and all deaths from CVD by 25%. In the same period, approximately 25% of US adults were diagnosed with high blood cholesterol levels. A 10 % decrease in total blood cholesterol levels may reduce the incidence of coronary heart disease by as much as 30%.

CVD as a public health menace is not unique to the people in United States of America. It is a menace to all people in the world. Why? The reasons are myriad and include dietary indiscretion, lack of exercise and genetic predisposition to name a few. It was indeed quite intriguing to me when I laid eyes on the article with the title “Early nutrition and long-term cardiovascular health.” (Nutrition Reviews 2006; 64: S44 – S49).

There is growing evidence to show that nutrition during critical windows in early life can programme the individual’s long-term risk for CVD. As early as 1960s, McCance showed that rat litters which had been overfed early in post-natal life were programmed for greater size as adults. In another 1984 study, rats overfed in the brief suckling period were found to have permanently higher insulin and cholesterol levels in later life. These observations were not limited to rats alone. Research on baboons showed that pre-weaning food intake in new born baboons had a major impact on later obesity and atherosclerosis (hardening of the blood vessel). These effects only emerged after the adolescent period.

A recent analysis of all available data showed that breast-fed children, when compared to non-breast fed children, had a 12% reduction in their risk of developing childhood obesity. Compared with formula feeding, breast feeding is also associated with a lower total cholesterol concentration. Breast feeding is also associated with a lower risk of insulin resistance later on in life. Overall, there is strong evidence that breast feeding does afford an advantage against the metabolic syndrome and therefore CVD risk.

A causal association between non-breast feeding and later CVD risk was studied in pre-term infants whose mothers decided not to breast feed them. These infants were randomly assigned to receive breast milk donated by unrelated lactating mother or formula milk. Infants assigned to breast milk for an average of 4 weeks were found to have marked benefits up to 16 years later. They had better cholesterol profiles, less insulin resistance, better blood pressure profiles and less probability of future obesity than those formula fed infants. For the cholesterol profile, breast fed infants had a 14% lower LDL (‘bad cholesterol’) to HDL (‘good cholesterol’) ratio than formula fed infants. Breast fed infants had a greater than 3 mm Hg lowering of diastolic blood pressure when compared to formula fed infants. If this lowering effect were to be maintained into adult life, this breast feeding effect on diastolic blood pressure would represent an effect greater than all other non-pharmacological means of reducing population blood pressure (e.g weight loss, salt restriction or exercise). If the population-wide diastolic blood pressure could be lowered by only 2 mm Hg, it has been estimated that this would reduce the prevalence of hypertension by 17%, the risk of coronary heart disease by 6% and the incidence of stroke / transient ischaemic attacks by 15%. Similarly, the 10% reduction in cholesterol concentration in breast fed infants would translate into a 25% reduction in the incidence of CVD and a 13 – 14% reduction in CVD deaths.

Breast feeding is not a practice embraced by all. The usual reasons given for not breast feeding include ‘I don’t have enough milk’, ‘The baby is not having enough milk from me’, ‘It is painful to breast feed’, ‘It is inconvenient’, ‘I can’t keep going because of my work’. Social attitudes can certainly play a big role in making breast feeding more acceptable. For example, departmental stores can certainly help by providing special nursing cubicles for customers. The husband must be both encouraging and supportive if the wife is contemplating nursing for a while. The general public should refrain from ‘gawking’ at the sight of a mother nursing her baby in a restaurant or coffee shop. After all, there must be a very good reason why mother nature has endowed us with the ability to produce milk!

Recently a 79-year-old lady from Indonesia was evacuated to my care because of ‘liver problems’. It transpired that she had been jaundiced (developing a yellow discolouration all over her body) for two and a half weeks. Just prior to her coming to Singapore, she was informed that she needed an urgent operation to remove her gallbladder. After her arrival, the various blood and X-ray tests ruled out infective, viral and obstructive causes for her acute liver failure. It turned out that there was nothing wrong with her gallbladder. She and her accompanying relatives denied that she had consumed any medication or herbs recently. A few days later when I asked another relative about recent history of self medication, I was informed that she had been taking a herbal health supplement for one month prior to becoming ill! The supplement was a kind gift from a friend and its supposed effect is to ‘help strengthen the liver’!

The body detoxifies and excretes all noxious chemicals, drugs and herbs via the liver and kidneys. Both organs can only handle so much insult before they stop working. For those who develop kidney failure, they can rely on a dialysis machine to keep them alive. However, those who develop acute liver failure are not so fortunate. At present, there is no effective liver dialysis around to sustain life. The only option available to those with life-threatening liver failure is liver transplantation. Most cultures have a history of using herbal remedies and medicine for improving health and treating diseases. However, even so called established herbal concoctions can lead to toxic side-effects in some people.

The herbal remedy, xiao-chai-hu-tang (syo-saiko-to in Japanese), has been widely used by the Chinese for treating respiratory, hepatobiliary and gastrointestinal diseases. It is especially used for patients with chronic liver disease because it is claimed to have a liver protective effect. A recent publication from Taiwan (J Chin Med Assoc 2006; 69: 86 – 88) reported how a 52-year-old woman developed acute liver failure after taking this herbal remedy for 1.5 months. Thus, a herbal remedy that is said to be good for the liver may turn out to be harmful to the liver. Why?

The reasons for unexplained toxicity are many. It could be adulterants within the herbal components, the replacement of a non-toxic herb with another which is toxic or confusion of nomenclature through time leading to the use of a related species which contains toxic constituents. 

A patient with a long-standing history of inflammatory intestinal disease started taking the herb Herba Aristolochia Mollissemae. Two months later he developed unexplained deterioration of kidney function. Five months after starting the herbal remedy he developed a cancer affecting the lining of bladder. Twelve months after starting the herbal therapy, the patient had renal failure requiring dialysis. Subsequent analysis of the herbal sample showed the presence of aristolochic acid (AA), well known for causing kidney failure and inducing the development of cancer in the kidney and bladder. Further investigation found that the originally prescribed non-kidney-toxic herb had been substituted by AA-containing Herba Aristolochia Mollissemae at the wholesaler level. The result of this investigation led to the withdrawal of the AA-related herbs from the market by the Hong Kong health authority (Am J Kidney Dis 2005; 45: 407 – 410).

Weight-reducing pills containing Chinese herbs gained notoriety in Belgium in the late 90’s when a cluster of patients developed cancers of the urinary system. The common factor among them was the consumption of weight-reducing pills. Subsequent investigations found that one of the herbs in these pills, called Stephania tetrandra, was inadvertently replaced by Aristolochia fangchi, which contains AA (N Engl J Med 2000; 342: 1686 – 1692). The DNA combined with AA in the body and this led to the development of cancer involving the kidney, bladder and ureters (the tube connecting the kidney to the bladder).

So the next time your doctor asks you if you have been taking any new medication recently, don’t forget to mention that bottle of health supplement pills or herbal supplements. Even though you may have been taking it for months, a recent change in the manufacturing process or ownership may lead to inadvertent change in the ingredients in your supplement. As the saying goes, Caveat emptor. Buyer beware!

“Doctor, please don’t tell my mother (or father) the diagnosis.” I get this request from time to time during the course of my work in caring for patients with inoperable cancers. I have noticed that I get this request much more often during my 12 years working in the East than during my two decades in England. The oft quoted reason for requesting non-disclosure of the diagnosis is “I don’t think she can take the news!”.

Putting aside the fact that the doctor has a duty to be honest with the patient, let’s examine what problems we would encounter by non-disclosure. When you ask your parent to see an oncologist for further treatment, you may well be asked “Why?”. Even if you managed to fob him off with some banal answers, sailed through the consultation with the oncologist and convinced your parent to undergo chemotherapy, how are you going to stop him from talking to the other patients in the treatment room receiving chemotherapy. He is bound to chat to one or two of the patients there or could overhear a conversation between patients. The conversation will go something like this: “What kind of cancer do you have and how long are you going to have the treatment for?” . “Oh, I have colon cancer and will have to undergo a minimum of 6 months therapy.” “You are lucky, I have been receiving chemotherapy for 18 months and the doctor had to change my medicine 3 times. I could not tolerate the side-effects of the medicine so he had to change the medicine on two occasions. Recently the cancer has started to grow again. So the doctor had to change my medicine again!” How do you think your parent will react to this?

Let us look at another scenario and assume that you have decided not to subject your parent to chemotherapy or chemotherapy is not appropriate. When he develops symptoms, you take him to the doctor and some medication is prescribed. After a while, the symptoms recur or become worse. The doctor is consulted again but there is not much improvement. When the symptoms get more troublesome and you ask your parent to visit the doctor with you again, he may well say “What is the use, the medicine does not seem to work. I’d rather not bother!” or “You told me the recent operation has solved my problem, why am I getting worse?”.

If the patient is aware of his diagnosis, he is likely to be more understanding of the symptoms he is experiencing. If he is receiving chemotherapy, he is likely to be more tolerant of the side-effects because he knows this is the price he has to pay in order to have a chance of bringing the cancer under control. In my experience, it is always better to be honest with the patient and disclose the diagnosis of cancer. You would be amazed at how many times I have sat down to tell a patient about the diagnosis and the patient has looked me in the eyes and said “Is it cancer, doctor?”.

A report from Stanford University (Chest 2000; 118: 1172 – 112) studied the ethical decision making of doctors and patient autonomy among doctors and a small group of patients in Japan and United States. A majority of both US doctors and patients, but only a minority of Japanese doctors and patients agreed that a patient should be informed of an incurable cancer diagnosis before their family is informed. A survey in Norway found that the majority (81%) of doctors who treat cancer patients practice full disclosure to the patient and the older doctors prefer to inform the patients without the relatives being present (Eur J Cancer 1996; 32A: 1344 – 1348). In Kuwait, 67% of the physicians questioned preferred full and complete disclosure of cancer diagnosis to patients. However, 79% of those would withhold the truth if the patient’s family requested them to do so (Int J Clin Pract 2002; 56:215 – 218).

What about from the public perspective? Researchers from the University of Tokyo conducted a general population survey on people’s preferences on full disclosure of cancer diagnosis and prognosis (J Med Ethics 2005; 31: 447 – 451). Eighty six percent of the respondents preferred full disclosure while only 2.7% of the respondents did not want to know. In Nepal, doctors traditionally do not discuss a diagnosis of cancer with the patient. A group of researchers from Hospice Nepal conducted a survey of the general population in and around the Katmandu Valley (Palliat Med 2006; 20: 471 476). They asked them 2 questions: If you were diagnosed with cancer would you like to be informed of your cancer? If a close relative was diagnosed with cancer would you like them to be informed of their cancer? Eighty percent (80%) of the respondents wanted to be informed if they were diagnosed with cancer, even if it was incurable. Seventeen percent wanted to be informed of such a diagnosis only if it was curable. Only 3% did not want to be informed of such a diagnosis at all!

I am sure some patients will not respond well to the news of being diagnosed with cancer. However, to assume that all patients cannot take the news would be making an unfair assumption on what the patient really wants. We must remember that it is the patient who has to endure the symptoms of the disease. When his symptoms get worse despite medication, he needs to know there is a reason for it. When he hears of the potential side effects related to the chemotherapy treatment, he will probably be able to endure them better if he knows the treatment is for controlling the cancer and thus giving him hope. While the act of shielding your loved one from the dreaded news is born out of love, in the long run you may end up hurting him more.