Dan

A. Dear Dan,
I am sorry to hear about your travails. I can only imagine how painful your experience was. The fact that you continue to have multiple symptoms long after a bout of hemorrhagic dengue fever is indeed a puzzle. Most recover uneventfully within several weeks. As you probably know, immunity is not granted as a result of one or more infections. An infection can increase the chance of acquiring another contagion. The local infectious disease specialists I spoke with claim that, in the practical world, all bets are off. What the textbooks claim is simply a conceptual dogma.  Therefore, prevention is the key to good health.

Since a definitive answer to your current dilemma isn’t possible, we need to come up with an educated guess that would work for you. There are anecdotal accounts of folks developing fibromyalgia like complex after a bout of dengue fever. Others have described the onset of diffuse arthritis. Depending on your orientation, you may wish to seek help from a very experienced homeopath, an acupuncturist or an Ayurvedic practitioner. A main stream approach would be to get into a regular exercise program (a sine qua non), consider brief pharmacotherapy, reframe your current illness by means of cognitive based therapy and or some form of a spiritual practice. An ancient Chinese proverb states that water cannot be cut with a knife. Human beings cannot be divided into body parts or for that matter, the distinction between the mind and the body is arbitrary. A holistic approach using one or more of the above mentioned modalities will offer you some amount of relief.

Regarding your labile blood pressure readings, we can be more specific and hopefully more helpful. The best way to obtain an accurate reading is to get a 24 hour monitor. A single reading is inadequate. A drop in blood pressure while one is asleep (if you are not dreaming) is a good sign while its absence betrays a pathological state. The so called “white coat syndrome” (high readings in a setting of doctor’s office or hospital) may not be so benign after all. There are many people who have a “reactive vascular pattern”. That is, ones reaction to an ordinary stimulus is over exaggerated. This may account for the majority of people who have high blood pressure. Just look at the word hypertension; hyper and tense. Describes the phenomenon quite well, doesn’t it? There is a significant genetic predisposition to high blood pressure (I will discuss an emerging field of epigenetics later where we can alter the gene expression through natural means). Many are also salt sensitive. It is very important to mention that high blood pressure needs to be controlled. However, before jumping into pill taking, you have many reasonable alternatives. If your blood pressure is excessively high (say 170 over 120) chances are that you will need to initiate your treatment with pharmacology since the more natural approaches won’t be as effective. For labile hypertension aka pre-hypertension (as is yours) here are some means for your consideration. The fact that your diastolic number (the bottom number of your blood pressure reading) is disproportionately high suggests a “tense” response. Therefore, moderate exercise, reduced salt and caffeine use, relaxation techniques, massage, reduced alcohol consumption (if you drink) should work. There are many nutritional supplements and mechanical gadgets available to lower your blood pressure but I personally don’t think these are necessary if you are diligent with the former approach. Incidentally, there is a myth among Western medicine practitioners that ones blood pressure naturally rises as one gets older. This may be so in cultures where old people get fat and lazy. In cultures where older folks stop working, approach their waning years with calm and ease, continue to exercise moderately (such as walking) and maintain judicious diets, their blood pressure actually drops after retirement. So I would suggest that you use your “high blood pressure” as a message from your body to get more introspective and by using the innate wisdom of your body and mind, turn things around for a healthier and happier life.

Dr. Philip Bhark M.D., FACC

Let us first roll our eyes inwards and look more closely at our body. Our body was designed to move. We have over a hundred joints. What are joints for? It should be a no brainer. Our ancestors did not have a built in weapon such as fangs or claws. Nor did we have speed or excessive strength or ability to fly. But we had something that most animals don’t have, endurance. This unique ability allowed us to track animals for hours if not days. This allowed us to cover great distances as we foraged. If need be, we could even run for hours at a time at a slow steady speed. We had no couches to lie on and certainly no remote controls to play with. No one needs to be convinced that exercise is good for us in so many different ways. The human body speaks for itself with its form and function. So we could all agree that some amount of movement is intrinsic to who we are. The key issue again is what type of movement and how much? Couch jockeys claim that if one lives extra years from exercising, those extra years are spent on exercising, so why bother? It is to be hoped that they will also be thinking about how great it is to avoid crippling strokes, heart attacks, Alzheimer’s, diabetes, obesity, low energy, insomnia, depression, mood swings, etc.

Walking daily for two miles (3.3 km) in about 30 minutes is all most of us need to be in good shape (with all the attendant benefits). Yes, there are many guidelines on exercising but please remember, these are just that, guidelines, and therefore not chiseled in stone. For example, we all have different rates of metabolism. Thus, someone with a high metabolic rate will burn off more calories for the same amount of exercise than his/her neighbor who happens to have a lower metabolic rate. One thing you will hear me repeating until the sun rises from the West is that we each have unique composition and thus one of the major keys to happiness and health is for us to tailor our activities, nutrition, etc., to who we are (don’t compare yourself to the person next door). We also need to be able to distinguish between mental fatigue and physical fatigue. Thus when mentally exhausted, often related to stress, it would be of great benefit to exercise and burn off some of the accumulated stress hormones. On the other hand, if you are physically exhausted, yes, this would be a good time to get on the couch and enjoy your favorite program or simply take a nap. Exercising when fatigued, because your mind says you need to stick to your program can be quite harmful. And yes, exercise is not always beneficial. For you garden lovers, time spent gardening can be equally helpful. Dancers, yoga enthusiasts, Tai Chi or Chi Gong practitioners are generally quite fit. Please consider if your exercise routine before you became an ex-pat is still appropriate in this climate. For example, if you ran ten miles, six days a week in Massachusetts, doing the same during the hot season may build enough free radicals to shorten your life. While in Boston, I would see young athletes who ran while experiencing flu symptoms. Some ended up with irreversible heart disease as a result.

We are fortunate to have many choices in deciding how best to stay fit. Therefore, choose an activity that you really enjoy. Do not engage in something you dislike but think that it is “good for you”. You won’t last and there is a good chance you will get an injury. So if you are not already doing something fun on a regular basis (remember, weekend warriors are placing themselves in harms way), consider, swimming, hiking, jogging, biking, or any other activity where you are continuously moving for a period of time. For beginners, it is perfectly OK to pause while exercising, thus walk and run or alter speed while hiking, etc. It takes several months to get into shape, so there is no need to rush. Ones “aerobic capacity” is the ability of the cells in the muscles to consume the oxygen that so easily enters our body through the lungs. The muscles only produce a certain amount of energy called ATP (a combo of sugar molecule and an oxygen molecule) which is determined by our current physical activities.  Thus a non-exercising person’s muscular system will only produce the minimum amount of ATP. As this person wakes up to the importance of regular activity (and I am not talking about opening the refrigerator door) and starts to demand more ATP, the body will hear the message and act accordingly. This is what is known as the “exercise effect”. Over time, the energy production will have been reset, at a much higher level. This explains why someone in shape can perform so well without running out of gas so quickly. Simply let your body know that your demands are increasing and your body will respond accordingly.

There are many with extreme competitiveness, obsessive-compulsive disorders who pride themselves with their physical performances. Let them be. I hope they realize that this is not the key to happiness. They should also know that they often have higher levels of stress hormones than the folks who not only exercise in moderation but also carry what the Thais call “jai-dii” (a good heart).

Next time, I would love to discuss barefoot running (with the five finger shoes). If you jog regularly, please check it out. You will be impressed. Breathe in and relax.

]]> http://www.chiangmaisos.com/working-out/feed/ 0 http://www.chiangmaisos.com/chiang-mai-sos-announces-new-service/ http://www.chiangmaisos.com/chiang-mai-sos-announces-new-service/#comments Wed, 28 Dec 2011 12:05:09 +0000 cmsos http://www.chiangmaisos.com/?p=646 SOS Announces a new service: “Expression of Wish.”

A recent tragic case has highlighted the fact that Expats living here in Chiang Mai need someone to act on their behalf, sometimes urgently, in the event of their sudden death or in case of a serious life threatening accident.

More >>

Your consul can offer only a limited service, and, due to the structure of the consular system, cannot involve itself in legal matters on your behalf. Although we are not lawyers, we understand the practical and legal factors that your friends and loved ones may face in the event of your death overseas, and to this end, we would like to offer an additional service to our members at a small extra cost. We can also help you to create a Will pertaining to your assets here in Thailand, which would not be covered by any Will made in your home country.

SOS’ ‘Expression of Wish’ Service means that information you provide us with i.e next of kin contact details, instructions etc. will be held in a sealed envelope only to be opened in the event of your death or serious illness. For more information or to speak to an advisor Email: info@chiangmaisos.com / Call 0870 52 03 89

A reader asked me how to obtain Lipitor, a cholesterol lowering drug.

I have only had limited experience with local pharmacists and therefore will make the following suggestions with a caveat.

Yes, Lipitor is readily available as are many brand name medicines. However, prices vary and therefor you need to do due diligence and find a pharmacy you feel comfortable with.

Drugs manufactured in Western countries or elsewhere but under the guidance of the parent company need to meet very high standards of production. Unfortunately, this is not true for drugs coming from some of our neighboring countries. I believe that generic Thai pharmaceuticals are fine, especially if the cost of medication is a consideration. So ask your pharmacist where the drug is manufactured and by whom before making a decision. You will also notice that some brand name drugs are cheaper here than back in the West. The simple reason is that the parent company has subsidiaries in this part of the world. Cheaper brand name drug doesn’t mean that it is fake, however, fake drugs are common, especially on the Web. Fake drugs are not only ineffective but can be quite dangerous. They are usually made with highly toxic chemicals. They can look uncannily real. Therefore it is important to work with a pharmacist whom you can trust. Finally, about 80% of generic drugs are just as effective as the brand name. Therefore, when taking a generic medication, make sure that it is doing whatever it was designed to do. So for example, if you were taking a brand name drug to lower your cholesterol and then switch to a generic med and a follow up cholesterol check reveals a markedly elevated blood level for no apparent reason, it would be possible that the generic med is less efficacious. For this particular article, I will not comment on other means of lowering your cholesterol.

All the Best, Philip Bhark, M.D., FACC

Email: newsletter@chiangmaiexpatsclub.com for a chance to have your health questions published in Expat Newsletter and online at www.chiangmaisos.com/d-o-c

Dear Dr Bhark,

Following on from your very interesting talk last Saturday (@ChiangMaiExpats), may I ask you a question. 

Our daughter aged 45, suffered an unexpected ‘cardiac event’ about 18 months ago, following a period of overwork and chronic stress.   

Thankfully she fully recovered after treatment at a leading cardiac hospital in the UK.    Her own GP put her on Simvastatin 40gms, Ramipril 10gms and Congescor 2.5mgs.  Since then there has been a radical and negative change in her personality.  

Have you experienced similar personality changes with patients on statins? 

Many thanks for your guidance on this matter.

Liz Spring   

Dear Ms. Spring,

As a general rule, when someone complains of a possible drug related  side-effect, we need to give them the benefit of doubt, even if the stated side effect has not been published previously. There is always the first time. Having said that, there is also a maxim which states that when you hear hoof beats, think of horses first and zebras last. That is, the more common cause for a personality change might be explained by the fact that your daughter suffered a heart condition at a young age. At any age, a sudden cardiac event may potentially be devastating to ones psyche. This coupled with the fact that she has suffered from “chronic stress” may have placed her in a position where her coping skills may have been compromised. Cardiac rehab is highly recommended in this situation and if need be, some type of supportive therapy. A person with a known heart condition who subsequently suffers from extreme negativity or depression can potentially impair their overall prognosis.

 When one questions the possibility of an adverse drug effect, the best thing to do is to replace the possible suspect with another drug of the same class. Fortunately, there are many statins readily available. Also, change one drug at a time so that the “culprit” can readily be identified. She will be on medications for some amount of time and therefore going slow and steady is necessary.

Finally, it may be too early to mention this but for many people who have experienced a cardiac event, at some later point in life, many often state that “this is the best thing that ever happened to me”. It can truly be a life altering experience in a positive way. This possibility is always present. I wish you both good health and happiness.

Philip Bhark, M.D., FACC

Email: newsletter@chiangmaiexpatsclub.com for a chance to have your health questions published in Expat Newsletter and online at www.chiangmaisos.com/d-o-c

Dear Dr. Bhark,

Are there valid tests for Alzheimer’s for people over 70? How do you distinguish between dementia and Alzheimer’s?

Al

A. Hello Al, you have just ruled out any dementia on your part with your good questions!

Dementia is a very broad umbrella term for chronic (greater than six months) cognitive dysfunction (memory, attention, language and problem solving). Dementia isn’t a single disease but a syndrome, a set of signs and symptoms. The most common cause of dementia happens to be Alzheimer Disease (AD).

Unfortunately, AD is ubiquitous. It is estimated that 14% of the population over the age of 65; 28% of those over 70 and greater than 40% of the population over 80 years of age have AD. The incidence is expected to grow as the world’s population ages and longevity increases.

It is not clearly established what causes AD. It is known that pathologic brain changes predates the clinical manifestation by a decade or two, usually starting in the memory center of the brain and thus impaired memory being a relatively common feature of AD. (Forgetting where you placed your car key is a common feature as we age and therefore nothing to be concerned over. But if you look at your car keys and don’t know what they are for, you may be in trouble.) Once clinically apparent, AD often becomes a progressive disease, ultimately causing ones demise.

Now to answer your question more specifically, the diagnosis of AD is most often made on clinical grounds with or without corroborating evidence by psychological testing or neurologic imaging such as CT scan or MRI. It is often the person with early AD or a family member who seeks an opinion from a physician as a result of noticing some amount of cognitive impairment. How to diagnosis AD during the preclinical stage (that is, how to discover brain changes before one notices cognitive dysfunction) is currently a hot topic. This is where genetic testing, exotic lab work including spinal tap analysis, high tech brain scans such as PET where metabolic function of the brain can be analyzed are being scrutinized but primarily for research purposes.

There are several rules of thumb in making a clinical diagnosis of mild dementia due to AD. One, there is a concern by the person or someone close to him/her, that a change in cognition has occurred or is occurring. Two, a noticeable impairment in one or more of the cognitive domains where a lower than expected performance is noticed given the persons age and education. Three, there is a preservation of independence in the functional abilities of the person. He/she may be slower but is able to chug along. Four, no obvious social or occupational impairment is present. The diagnosis of advanced AD is obvious and often tragic.

Where testing becomes crucial is to rule out other causes of dementia. For example, Parkinson’s disease, brain tumors, alcohol related brain changes, infection such as syphilis, vitamin deficiencies, thyroid disease, multiple small strokes from poorly managed hypertension, bleeds, and multiple traumas may cause symptoms of dementia.

While the causes for AD are many and speculative (inflammation, aging process, cardiac risk factors such as cigarette use, hypertension, diabetes, abnormal cholesterol count), toxins, genetics, and vitamin deficiencies, it is important to note that we need to consider taking good care of our brain much as we would for the rest of the body. There is an axiom in medicine which states “what is good for the heart is also good for the brain”. Thus, physical exercise, reasonable nutrition, brain exercises, rest, and treating or preventing cardiac risk factors may be the proactive steps to take. Please note that there is no definitive treatment for AD, but only symptomatic remedies. Finally, AD is sporadic and very infrequently familial.

Wishing you joy and health,

Dr. Philip Bhark M.D., FACC

Email: newsletter@chiangmaiexpatsclub.com for a chance to have your health questions published in Expat Newsletter and online at www.chiangmaisos.com/d-o-c

Introducing Dr. Philip Bhark who will be offering free medical advice in Expat Newsletter in response to your emails from the December issue onwards.

Philip Bhark, M.D., FACC is a Columbia and Harvard trained cardiologist. He has also worked as a volunteer physician in Korea, Nepal and Tibet. He is currently living in Chiangmai with his wife Isabelle.

Email: newsletter@chiangmaiexpatsclub.com for a chance to have your health questions published in Expat Newsletter and online at www.chiangmaisos.com

It may be just the result of a simple communication break down due to the language barrier but, nevertheless, situations such as these may soon escalate as tempers fray.

What would SOS do?

• Visit police station to establish cause
• Arrange legal assistance
• Liase with police/immigration on member’s behalf
• Contact friends or family and explain situation
• Inform police and immigration
  

SOS would contact your next of kin and your health insurance company on your behalf, helping to make sure you receive the necessary treatment as quickly as possible.

What would SOS do?

• Contact next of kin
• Inform medical insurers
  
• Inform hospital of medical history
  
• Provide legal assistance if required
• Arrange for your nominated hospital ambulance to attend the scene (Chiang Mai area only)

What would SOS do?

• Inform all insurers
  
• Arrange legal assistance if required
• Inform hospital of medical history
• Contact friends or family
  
• Liase with police to establish circumstances surrounding the accident