Hunger - The Final Frontier

Hunger is a primal instinct. It is amongst the first senses you feel when you are born. The satiety after feeding kicks off a lifelong cycle of longing followed by satisfaction! So basic is this need that one never stops to question it.

Obesity is a pandemic in its own right. If we hope to address the overweight problem, we must analyze hunger.

Ask a young child and he or she will tell you that hunger suggests a bodily need for food or fuel. While this is true some of the times, the more common reasons for hunger are surprisingly different.

To understand these reasons, we must have a basic knowledge of a hormone called insulin. Insulin is secreted by a gland called the pancreas (which is in the tummy). The food we eat is absorbed from the intestine and reaches the blood as a fuel (measured as blood sugar level). This is then transported into each living cell by insulin. When we eat food, the body will detect a rise in blood sugar and the pancreas will release insulin which in turn will drive the sugar into the cells and reduce the blood sugar level. The body likes to keep the blood sugar level under tight control with the help of insulin.

Now, if the insulin were to reduce the blood sugar more than necessary, then the body would normalize sugar by initiating hunger. This typically happens if insulin levels in the blood go very high which is called an insulin spike.

Different foods have a different effect on blood insulin. Certain foods like a sugary cola (simple carbohydrate) will increase blood sugar very quickly as there is no digestion. This will cause an insulin spike. The spike will reduce blood sugar more than necessary and that in turn will initiate hunger.

So hunger depends on blood insulin levels. If insulin is spiking too often, we will experience more hunger. And this hunger is not because our body needs food! What we eat will decide how hungry we will become in the next few hours. This is the more common reason for hunger.

If we eat foods that keep the insulin levels stable and avoid spikes, then we won't feel hungry for the wrong reasons. If we don't feel hungry, we wouldn't want to eat as much. In this situation, losing weight becomes easy and possible.

Losing weight is not only about calorie restriction. It is about eating the right type of food, which keeps the insulin levels stable and avoids hunger. Carbohydrates will spike insulin much more than fats or proteins. Simple carbohydrates are the worst. Sugary drinks, sugary deserts, sweets, chocolates, cakes and mithai are classic examples of simple carbohydrates.
So even if you eat a small portion of a sweet desert, not only is it calorie dense but it will ensure more hunger.

Vegetables (cooked or raw) are the best food to keep insulin stable.

This is also the reason why a heavy breakfast is not a good idea. I know this is against traditional teaching but it is time for a paradigm shift. A heavy breakfast (especially if it is carbohydrate rich) will ensure an insulin spike and you will be hungry throughout the day. With so much hunger, dieting or calorie restriction becomes difficult. It's the reason why so many people fail to lose weight.

If we want to lose weight we must first conquer hunger. We must eat the right types of food so that we are in control of hunger and not the other way around. The next time you have an urge to eat a small snack, think about how hungry it will make you!

 

Unicondylar Knee replacemnt - 2

As we have seen in the previous article, unicondylar knee replacement is a natural evolution of total knee replacement. It has advantages. It is done using a minimally invasive technique. There is less cutting of skin and tissue. Muscles are not cut. This results in a faster recovery and little postoperative pain and swelling. The amount of bone removal and blood loss is less. The surgery is safer than traditional knee replacement.
The incision for unicondylar knee is half the length of a total knee replacement. The surgery is done using special instruments designed for minimally invasive surgery (MIS). The quadriceps (thigh muscle) is spared. The muscle strength remains intact after surgery. Patients can walk comfortably without a walker. As against this, the quadriceps is cut in total knee replacement, which results in weakness post-surgery. After traditional knee replacement, all patients need a walker to help them walk surgery for as long as 3-4 weeks. 
Safety has been a long standing concern of total knee replacement, especially because the surgery is performed in elderly patients. The cutting of muscle, removal of bone and blood loss puts a stress on the body. This stress becomes significant in those who have preexisting compromises like a weak heart, lung or kidney. Surgeons are worried for infection with diabetic patients. With Unicondylar surgery the stress is reduced. More patients are now eligible for knee replacement with much less risk! 
To be able to sit on the floor is important for our religious customs and traditions. This vital function was snatched away from patients after traditional knee replacement! It is the primary reason for dissatisfaction. Do we finally have an answer?
Ligaments play an important role in knee function. They give the knee stability and allow people to do high demand activities like running, squatting and sitting on the floor. In a traditional knee replacement, the ligaments (anterior cruciate ligament & posterior cruciate ligament) are cut. This I strongly believe is a loss. It is the absence of ligaments after traditional knee replacement, which does not allow patients to squat in an Indian toilet comfortably or sit on the floor. In unicondylar knee replacement, both ligaments are preserved (ACL and PCL). Preserving the ligaments has advantages. After surgery the knee feels like the natural knee. It remains stable and strong. Unicondylar surgery gives the patient the confidence to perform all daily activities in a normal fashion just like they used to when they were younger! It is a cure in the true sense. After this surgery, patients are allowed to sit on the floor, sit cross legged and even squat in an Indian toilet!
So can all arthritis patients benefit from this surgery? Ligaments are not only preserved in this surgery, they are also crucial for the success of this surgery. Unfortunately, in the arthritis process, sometimes ligaments are also damaged along with the cartilage. In patients with damaged ligaments, Unicondylar surgery does not work. For them traditional knee replacement remains the only way out. Your doctor will be the best judge to decide if you can benefit from Unicondylar surgery.       

Squatting after Unicondylar Knee Replacement

Knee Replacement is a revolutionary surgery. It gives patients a miraculous cure from severe knee pain and deformity. Patients achieve a lasting and complete relief from pain. It is a boon for patients handicapped by knee arthritis. It is one of the most successful surgeries in all of medicine.
In an effort to continuously improve, science makes breakthroughs all the time. The knee is made of 3 compartments. Arthritis damages these compartments but often not uniformly.  When we as surgeons are doing total knee replacement, we often find that one compartment is badly damaged whereas the other compartments are well preserved. In total knee replacement, we replace all the compartments irrespective of the damage. The knee also has two important ligaments called the anterior cruciate ligament (ACL) and the posterior cruciate ligament (PCL). These ligaments are removed in a total knee replacement. Replacing all compartments leads to much bone loss and bleeding. In order to do a good knee replacement, we need to take a big incision (cut) in the skin and the muscle. Big cuts result in more pain and slower recovery. Patients need supervised physiotherapy to regain knee function. After total knee replacement patients can walk freely and comfortably, however the absence of ligaments doesn't allow them to sit on the floor or squat easily.
Scientific research has led to the evolution of Unicondylar Knee Replacement (UKA) to solve these issues. The principle of UKA is to replace only the damaged compartment. Only one of the three knee compartments is replaced. There is minimum cutting of bone and less blood loss. Patients feel much less pain and recover quickly. No painful physiotherapy is required after surgery. My UKA patients are walking comfortably just a few hours after surgery. They hardly feel postoperative pain. The surgery is done through a small cut in the skin using special instruments with a minimally invasive technique. Both ACL and PCL are preserved. After UKA patients are able to easily squat in a toilet and sit on the floor. UKA feels like a natural knee. The long term results of UKA are comparable to total knee replacement. UKA is just as durable and will give a patient many years of pain-free knees.
Not all patients are eligible for UKA. It cannot be done in very advanced arthritis where all compartments are damaged. It also cannot be done in patients who have damaged ACL or PCL ligaments. Even so a large number of arthritis  patients can benefit from this modern surgery. Your doctor is the best judge of whether you are eligible for UKA.
UKA is a bone, muscle and ligament preserving surgery done through a minimally invasive technique with advantages of fast recovery, less pain and better function. It is a spectacular gift of modern scientific research.

Unicondylar Knee Replacement

Total knee replacement is an excellent surgery. It has evolved over the decades to become one of the most successful procedures in all of medicine. Patients are cured of pain and disability. They regain their ability to walk normally, without a limp or support. They can resume living normal lives again. Without surgery, they are stuck in a rut of suffering and handicap with a lifelong dependency on kidney destroying medicines.

However, total knee replacement comes with a bag of its own problems. It is not without reason that patients fear the surgery. The foremost fear is that the surgery is a major surgical adventure.

Major surgery means more risk! The risk of an adverse event in the peri-operative period is always lurking round the corner.

Major surgery means more pain! Post operative pain is dreaded! Only recently have we truly succeeded in pain control with the use of ultrasound and nerve locator guided nerve blocks and LIA (local infiltration analgesia). 

Major surgery means more weakness! Patients routinely require a walker to walk for a week or two after surgery. 

Major surgery means a longer recovery! Patients take up to 3 months to return to normalcy and actually start experiencing the benefits of the surgery. 

What is a half knee (or partial knee) replacement? The knee is made of 3 different compartments. Two compartments are between the thigh and leg bone and the third compartment is between the knee cap and the thigh bone. In total knee replacement, we replace all three compartments and sacrifice two ligaments (out of 4) and both menisci (natural shock absorbers found in the knee). However, arthritis does not damage all compartments equally. Most of the times, it is only the medial or inner compartment that suffers the brunt of the destruction. In partial knee replacement, only this compartment is replaced with sacrifice of a single meniscus. Two compartments, all 4 ligaments and one meniscus is preserved. Many studies have shown this procedure to be as effective in relieving pain as total knee replacement. The survival of partial knee prosthesis is also as good as total knee prosthesis. 

By doing this selective procedure we gain many advantages. This surgery is done by a minimally invasive technique. It involves less cutting of skin, muscle, tissue and bone. Most of the knee is left untouched as it is healthy. Hence this is not a major surgery.

Risk of an adverse event is less!

Pain is very less! Lesser volume of trauma coupled with modern pain management makes post op pain negligible.  

Less muscle cutting means minimal weakness! Patients can stand and walk without a walker on the same day, a few hours after surgery. All this translates into a faster recovery. No longer do patients have to wait for 3 months to get back to normal.  

Partial knee replacement or unicondylar knee replacement is a natural evolution of a total knee replacement. It retains all the effectiveness of a total knee and brings with it significant advantages! I have pointed out the advantage of less risk and quicker pain-free recovery in this article.....but it doesn't stop here! Stay tuned for the next article. 

Knee Arthroscopy

Arthroscopy is a procedure in which the inside of a joint is visualised using advance camera and lighting equipment. Technology has allowed both the camera and the light source to be incorporated in a thin tube. This tube can be introduced inside the joint through a very small incision or cut. The name key-hole surgery has been coined for arthroscopy as it is minimally invasive. Knee arthroscopy has many advantages. The interior of the joint can be completely visualised by this procedure. As it doesn't require a lot of skin and tissue cutting, it can be used as a diagnostic tool. Because the arthroscope tube is thin, we can visualise areas at the back of the knee which are difficult to see in open surgery.  As the surgery is done through small holes, postoperative pain is minimal and recovery is very quick.

Knee arthroscopy has revolutionised treatment of certain problems. A classic example is synovitis or thickening of the lining of the knee. Synovitis can happen due to various reasons. Sometimes it is necessary to remove a part of the synovium (or lining) as a biopsy. In other cases it is required to remove the entire lining as treatment. Formal open synovectomy (or removal of lining) was a major surgery that led to postoperative pain and knee stiffness. Besides some synovium would remain behind at the back of the knee due to difficult access. With arthroscopy, total synovectomy can be achieved with minimal pain and stiffness.
 
Another area where arthroscopy has made tremendous progress is in the field of ligament and meniscal injury. The commonest ligament which gets injured during a sport or road traffic accident is called the anterior cruciate ligament (ACL). Once this ligament is injured, it leads to instability. The patients knee buckles every now and then and he/she loses balance and may fall. The patients describe the problem as a 'wobbly knee' and get a typical 'giving way' sensation in the knee. These repeated instability episodes eventually wear out the knee and patients end up with knee arthritis in a few years. In earlier times there was no good solution for this problem. Open ligament reconstruction procedures were fought with failure. All this changed with the advent of arthroscopy. Nowadays arthroscopic ligament reconstruction has become an extremely successful procedure. The patients own hamstring muscle tendon is harvested and a new ligament is made by folding the tendon on itself. This new ligament is then fixed into pre-drilled tunnels in the patients thigh and leg bone to become the new ACL ligament. This eliminates instability so efficiently that patients can start playing contact sports like football after the procedure. The patients knee is restored to its original state and any further wear and tear is arrested. It has now been proved beyond doubt, in multiple studies done internationally that results of ACL reconstruction are much better than non surgical treatment.

The meniscus is a thick structure found inside the knee joint which acts like a shock absorber. Just like the ligaments, the meniscus can also tear due to injury. A meniscal tear classically causes pain and locking of the knee. The locking occurs because the torn meniscal fragment gets stuck between the two bones. Repeated locking episodes lead to pain and swelling. Before the advent of arthroscopy, it was very difficult to treat meniscal tears. Surgeons ended up removing the entire meniscus which was not only unnecessary but also harmful as it lead to early degeneration of the knee. With arthroscopy it is now possible to tackle only the torn fragment. Either the torn part is removed and the rest of the meniscus is left behind or the torn fragment is repaired. Again arthroscopy allows the knee to be restored to its original state.

Arthroscopy is a major advance in orthopaedics and it is now being successfully utilised in solving problems of other joints as well like the shoulder. Patients should be aware of the benefits of arthroscopy and must take advantage of this science when required.

Sarcopenia

We have all heard about osteoporosis or weakening of bones as we age. Many of us have done bone density tests and are taking supplements to prevent or treat osteoporosis. But what is sarcopenia? Sarcopenia is a loss of muscle mass that occurs as we age. As we mature into adults, hormonal changes ensure optimal muscle mass by the age of 25. But this muscle doesn’t remain constant with us throughout life. For those who lead a sedentary lifestyle, muscle loss starts as early as at the age of 30. Typically an inactive person loses up to 5% of muscle mass per decade.

What happens when we lose muscle? First and foremost a weak muscle offers poor protection to its neighbouring joint. Joints need strong muscles to function properly and durably for many years. When muscles are weak, the joints become vulnerable to damage. This damage can happen in any joint, but typically it is seen in the knee joint, the neck and the lower back. Initially patients complain of only occasional pain. Painful joints are instinctively rested by the patient. The rest worsens sarcopenia. This in turn predisposes the joint to even more damage. Thus the pain sets up a vicious cycle. This cycle ends in osteoarthritis of the knee or spondylitis of the neck or back, which in its last stages requires surgical treatment. 

Loss of muscle also results in a lower basal metabolic rate (BMR). In simple words, the body is unable to burn calories efficiently. Lower BMR combined with a modern high calorie diet leads to increase in body fat. Excess fat increases insulin resistance. The end result is central obesity or a pot belly with diabetes, coronary heart disease (heart attack) and hypertension (high blood pressure).

End stage sarcopenia which occurs in elderly patients results in frailty, loss of balance & frequent falls. Sarcopenia is thus responsible for not only musculo-skeletal problems like osteoarthritis and fractures but also life style illness' like diabetes.

Is sarcopenia preventable or treatable? The good news is that it is! We can slow down the loss of muscle that happens with age by making positive changes in our diet and lifestyle. If we work a muscle, it will respond by a tear - repair mechanism to become stronger and a stronger muscle means a reversal of sarcopenia. The best way to strengthen a muscle is by doing resistance training. This can be done by either lifting weights like dumbbells or by using our own body weight. Typical body weight exercises are squats, push ups and lunges. As sarcopenia affects all muscle groups, it is important to work out all muscle groups. We must exercise not only thigh and calf muscles but also chest, back, upper limb and abdominal muscles. Walking is not a good exercise for sarcopenia as it works out only leg muscles and it is not a resistance training exercise.

Diet is as important in the prevention of sarcopenia. For muscles to repair and become stronger they need protein as a raw material. Protein is essential in a healthy diet. We must ensure adequate protein intake. A normal adult requires 0•8 gm of protein per kilo of body weight per day. Meat, eggs and dairy products are rich sources of protein. Roasted, boiled or baked chicken or fish are the healthiest source of meat protein. Milk, cheese and yogurt are good dairy sources. Vegetarian sources of protein include beans, lentils, green peas, chickpeas, soy, spinach, asparagus and brocolli. Nuts like almonds and peanuts also contain protein. Fruits can also provide protein with the richest sources being guavas, berries and apricots. To be effective, a high protein diet must go hand in hand with a low carbohydrate, low sugar and low fat diet.

A lot of research is going on but there still is no medicine that can stop or reverse sarcopenia. Exercise and diet remain the key to prevention as well as cure. We must eat clean and exercise hard to remain healthy and keep illness at bay. We really have no choice!

Which exercise is best for weight loss?

We now know that obesity is a problem. The pot belly is a house of disease. Obesity and high blood pressure go hand in hand. So do obesity and diabetes and obesity and coronary heart disease (chest pain and heart attack). Losing weight is the need of the hour. Weight loss is no more a goal for mere good looks. It is essential if one wants to lead a healthy life.

Diet is the key to weight loss. I have written on diet and weight loss, the pot belly and the evils of sugar. For some people, diet alone may not be enough. Their basal metabolic rate (B.M.R) is so low that changes in food habits are not enough to bring about the weight loss. In simple words they are just not burning enough calories. The fat burning engines of their body have gone to sleep. Exercise is the only way to increase their metabolic rate.

All of us think of walking when we are considering exercise. We feel it is the best exercise to do the job. In fact it is the first exercise that comes to our mind. Many of us have taken up walking only to give it up after a few months or weeks. Many of us have stuck to walking for years. But how many have really succeeded in losing weight by walking alone? Probably very few. All our life we have been brain washed by health experts, doctors and dieticians into thinking that walking is the best exercise. Gyms spend crores on treadmills and have entire sections dedicated to cardio. Those who can walk are encouraged to jog and even run. Marathons have evolved from a sporting competition to the new health fashion! But alas, all this is far from the truth!

Walking is not the best exercise to lose weight. Walking falls in the category of what experts call 'steady state cardio'. Walking is a basic life function and the body has evolved over the years to make it very energy efficient. So not enough muscle groups get involved when we walk. If we walk for longer distances then the muscles quickly adapt and become more energy efficient. A similar process happens when one jogs or runs at a constant pace. That's why we feel tired or get palpitations (can feel our heart beating) only for a few of the initial walks. After a week or so of walking, we can walk the same distance with ease. An energy efficient muscle will conserve calories and not burn them! However for patients with existing heart problems, walking remains a good exercise. They require an exercise that will put less strain on the heart. Heart patients should not try any other exercise without consulting their physician.

Which are then the best exercises to lose weight? To lose weight we must increase our metabolic rate. That will happen when large groups of muscles work hard. To achieve this we must do the opposite of steady state cardio. It is called High Intensity Interval Training (HIIT). As the name suggests periods of high intensity workouts should alternate with short intervals of rest. If you choose to exercise on a treadmill, then short bursts of brisk walking should alternate with short periods of walking slowly. People who are more fit, can do bursts of sprinting alternating with intervals of slow jogging. A similar interval training can be done in cycling and swimming. These short bursts require the muscles to work hard. By pushing the muscles out of their comfort zone we can force them to become calorie hungry. Metabolic rate and calorie burn is thereby increased.

Another way to lose weight efficiently is by weight training. By lifting weights we can exercise large muscles of the body and the exercise is not restricted to only a few muscle groups. The entire body musculature gets involved. Furthermore by pushing the muscles to their limits, there is a tremendous increase in calorie burn which lasts throughout the day as the muscles recover. We can thus achieve a sustained rise in metabolic rate. Weight training is perhaps the most efficient way to increase metabolism. 

Boot Camp exercises or Body Weight training is an alternative for those who cannot join a gym. These are sets of exercises which make use of the body weight instead of dumbbells and machines. Examples of such exercises include squats, dips, lunges and burpees. Quick sets of such exercises performed with short breaks are effective in achieving a higher metabolic rate.

Losing weight is all about diet for most of us. Both quality and quantity is important. For some people changes in diet are not enough. They need to fire up their metabolic engines to burn up those calories. Age old beliefs of types of food which increase weight, have recently been proven to be wrong. Similarly its time for a paradigm shift in our ideas about exercise. The words cholesterol and walking have now been replaced by sugar and HIIT!

The Not So Sweet Reality

Lets introspect on how things were a half century ago. At that time people consumed lots of fat, butter and pure ghee. Sweets were eaten rarely and the sweetener used was honey. Ninety percent of the food that people ate was cooked at home. The fast food industry was nearly non existent and there were few available brands of biscuits, potato chips, cakes, mithai, chiwda, chocolates, colas or ice cream. Going out to eat ice cream would be nothing less than a family event which would be fondly remembered for days. A box of mithai would come home but once in months. All of these snacks were consumed rarely! Restaurants were few and going out to eat was infrequent. Also infrequent at the time were here heart attacks, blood pressure, obesity and diabetes.

Then cholesterol was identified as the substance which was found in blocked blood vessels. This lead to a diet revolution based on fear. We were told that dietary cholesterol is bad for our health. We started avoiding fatty foods like cheese and butter, oily food or deep fried food. We didn't eat the egg yolk and only preferred the egg white. At a restaurant we started to ask for normal roti and not 'butter-roti'. We would frown if we saw a dish with excessive oil. This movement against fats and oil tilted the diet towards carbohydrates. Slowly but surely diets around the world became carbohydrate rich.

Simultaneously there was a surge in the economy and people's spending power increased. The food industry expanded and packaged foods and fast food became affordable. Refined sugar and refined flour became the main ingredients of these snacks. What was a luxury enjoyed once in many months, could now be easily consumed every week or even every day. Today, the smallest event is celebrated by cutting a cake. Home refrigerators are loaded with ice creams and colas. They have become oft consumed midnight snacks. Historically sugar consumption has increased from barely 2kg per person per year in the eighteen century to a whopping 70kg per person per year in the twenty first century. Calorie intakes have increased but physical activity has reduced. People are enjoying a sedentary lifestyle. With elevators and cars there is no need to exert. What has also increased unfortunately are the rates of obesity. People are developing pot bellies more than ever before. Low fat and high carbohydrate diets are not having the desired effect that was hoped for. In fact the absolute opposite is happening. Along with obesity, rates of blood pressure, diabetes and heart disease are up.

Only recently, the veil has been lifted. It is not fat, butter or cholesterol that is the real devil. It is the carbohydrates, especially the simple ones like refined sugar and foods that contain large quantities of this sugar. To reduce the rates of obesity, diabetes and heart disease we must re-adopt the lifestyle our ancestors. We have to change the way we think about food. It is time for a paradigm shift. We should not consume sugary drinks like colas, tang, rasna or sugary tea. They are directly linked to obesity and therefore many diseases. Biscuits are a strict no, at least not daily. We can eat a biscuit, or a piece of cake, or a few chips once in a while. Jam is full of sugar and we must stay away. Same is true with tomato ketchup. Snacks and mithai must be consumed only occasionally. On the same note, we must not eat out often. It is desirable to stick to home cooked food made with hand picked, quality ingredients. In addition to simple sugar, we must eat less quantities of starchy foods like potato, maida, rice and bread.

Sugar from a cola or an ice cream or a chocolate is easily digested and quickly absorbed in the blood stream. This puts a strain on the pancreas to produce a large quantity of insulin. This insulin in turn reduces the sugar in the blood by converting it into fat. Moreover it makes you hungry and you end up eating more food. Regular high sugar consumption literally burns out the pancreas and the end result is diabetes.

Along with diet we must re-adopt the physical activity of our ancestors. We must exercise by going to the gym, walking, cycling, swimming or similar activity. The best results are seen with weight training either in the gym or by using body weight (push ups, dips, squats etc).

In conclusion, sugar is the real problem. Lots of sugar indirectly enters our system through packaged foods. We must make it a habit to read the ingredients before we consume any foodstuff. Our food should come from our own kitchens and not from restaurants, bakeries or factories. Carbohydrates are the new enemy!