The Tribune, Chandigarh, India

How steroids cause heart disease
Dr Harinder Singh Bedi

A body builder from Ludhiana who required a major open heart surgery for a disease which may have been caused by steroid abuse.

Pick up any fitness magazine and shiny muscle-bound men (and women!) smile at you while gigantic veins course under their tanned oiled skin. While nature, genetics, good diet and proper excersie play a major role in good health, there is a disturbing trend in the use of anabolic steroids to bypass all the above.

Who can forget the scene of Canadian track star Ben Johnson literally flying past his competitors in the 100 metre dash at the 1988 Summer Olympics in Seoul in a record-breaking time of 9.79 seconds only to be stripped of his gold medal after traces of the drug stanozolol were detected in his urine ? Or the crying faces of Pratima Kumari and Sanamacha Chanu — the Indian women weightlifiters — which were splashed on all Indian newspapers after they were accused of doping and disqualified in the Athens Olympics ?

Six medals including 3 golds have been revoked in the Athens 2004 Olympics due to proven doping in the winners.

What are anabolic steroids and do they provide a real physiological advantage to athletes? Can they cause damage to the body of the user? What are the side-effects, especially to the heart and cardiovascular system?

Anabolic steroids are drugs that mimic the male sex hormone testosterone. By binding to specific receptor sites on muscle cells and other tissues, testosterone greatly contributes to male secondary sex characteristics and to the gender differences in muscle mass and strength that begin to develop at the onset of puberty. Like testosterone these drugs promote signs of masculinity (their androgenic effect) and increased synthesis of muscle (their anabolic effect). Used in the past to treat a handful of medical conditions — aneamia, breast cancer, metastatic cancer, osteoporosis in postmenopausal women and muscle wasting diseases, steroids are now being preferred by professional and amateur athletes alike, all looking to build muscle tissue easily.

Steroid users may or may not improve their performance and physique in the short term, they definitely damaged their body in the long run. They hasten adulthood, stunt and retard growth and height by premature closing of the epiphysis (bone plates) in children and cause early baldness and obesity in adults. In males they lead to gynecomastia (development of the breast) and in females to a deepened voice, hairiness and a male physique. There is development of hypertension, acne and edema and a tendency to bone fracture and rupture of various muscles.

Psychiatric dysfunction in the form of mood changes, depression, hallucinations, paranoid delusions and manic episodes can also occur. "Roid rages" — uncontrolled outbursts of anger, frustration or combativeness that result from steroids — are not uncommon.

The kidney, live and heart may be damaged. Autopsy of long-term steroid abusers shows an enlargement and dilatation of the heart — the so-called cor bovinum or "cow heart"; along with disseminated interstitial fibrosis. There may be the development of irregular heart rate and heart failure. Atheroschlerosis — deposition of fat in the arteries leading to heart attack — may develop as steroids raise LDL (bad cholesterol) and lower HDL (good cholesterol). Added to this is the fact that two other risk factors of heart disease — namely hypertension and diabetes — can be aggravated by steroids.

In a paper published in the May 2004 issue of the reputed international journal hearts, it was reported that anabolic androgenic steroids (AAS) cause left ventricular hypertrophy (increase in the size of the heart) with restricted diastolic function which leads to severe cardiac complications. The effects are seen even one year after discontinuing the steroids.

There have been several instances of acute heart attacks in young male athletes and college-going students using anabolic steroids due to the adverse effects of these drugs on the body’s intrinsic thrombotic and lipid profiles. The steroids trigger off extensive intracoronary thrombosis (blood clots) inside the heart arteries leading to a sudden cut off of oxygen and the death of heart muscle (a number of such cases have been treated by this writer).

Delicate heart valves may get damaged and block the passage of blood. This writer had to perform emergency surgery in a young body-builder of Punjab whose valve was like a piece of concrete and a special drill had to be used to blast an opening into it. Interestingly, the young man’s role model was Arnold Schawzernegger who has also had an open heart surgery for valve replacement. The association, if any, of steroid abuse and heart valve damage is, however, still unproven. Blood can clot inside the heart itself — called intracardiac ventricular thrombosis. The clot from the heart can now be pumped out to block off the brain, liver, kidney or leg arteries with disastrous results. A number such cases have been documented in the medical literature.

Diet supplements

Energy boosters and diet supplements to increase the body mass for increasing the biceps are a growing fashion fad. Food supplements containing creatine monohydratre amino acids, DHEA (dehydro epiandrosterone), heavy proteins, glutamines, antioxidants are now in, just as vitamins and minerals are a thing of the past. These compounds are quite the rage at any gym. Young men use them in their quest for the body beautiful which they feel that exercise alone cannot achieve. With job avenues opening up in modelling, acting in music videos and body-building, a number of youngsters get attracted. The problem is that the so-called coaches may not really be trained or qualified to administer these potent drugs/diet supplements.

Any dietitician will tell you that the body requires 60-70% carbohydrates, 20-25% fats and 10% proteins. One may increase the protein intake to 20% and that too with a simple protein-rich diet without the need for any drugs. For any amount beyond that the excessive amount of protein can damage the kidneys.

The writer, Executive Director & Chairman, Cardiac Sciences, Sigma Newlife Heart Institute, Ludhiana, is a former senior consultant, Fortis, Mohali

Asthmatics: wait for smog to disappear before going out
Dr S.K. Jindal

It sometimes looks strange that we have to perpetually live with the problems of smog, created largely by ourselves. This is perhaps for the sociologists and policy-makers to dwell upon. These are the adverse effects on health with which we are concerned for the present.

Smog is a composite term coined from smoke and fog. Unfortunately, the smoke component is worst during winters when fog is also at its peak. Emissions from innumerable fire crackers during festivals, marriages and other celebrations, burning of foliage, crop residues and other solid fuels in the fields add to the over present vehicular and industrial exhausts. Smoke, hung on to the water vapours in the fog, becomes heavier, does not rise away from the ground and remains in the atmosphere in which we live and breathe. The oxidation process promoted by the presence of sunlight during the day results in further degradation of air in the evenings.

It was the infamous London episode of 1952 which focused the world’s attention on health problems of smog. There were 4000 extra deaths in London within one week between December 5 and 9. Most of these victims were already suffering from chronic respiratory or cardiovascular disease. The deaths were attributed to the presence of a dense blanket cold, fog, which hung over the city of London. People got almost suffocated to death as would have happened from the presence of a dense cloud of smoke. A cloud of smoke will rapidly disperse and thin out into nothingness. On the other hand, the smog-blanket is rather larger, thicker and stays for longer, sometimes for weeks together.

Smog has got the potential of causing harm as it happens in the case of both smoke and fog. The dual effects factually get multiplied than being merely additive. The effects are attributable to the cold and dry air containing several chemical and acidic constituents some of which are even poisonous. While the direct contact causes problems of skin, eyes, mouth and nose, the inhalation causes injurious effects on the lungs, which may be serious and sometimes fatal.

Dryness and itching of the skin, eyes, nose and throat are some of the common problems. Allergic manifestations may cause redness, excessive discharge of secretions and irritation. Cough is an important symptom which is quite troublesome. It is frequently persistent and progressive. Increased occurrence of infections during the season adds to the frequency and severity of cough. Smokers are the worst affected people since they continue to provide themselves with an active trigger all the time. The presence of even minute quantities of smoke in the air is enough for almost everyone present in the room, to be busy with coughing.

Patients suffering from chronic obstructive pulmonary disease, asthma and other illnesses get frequent exaggerations of their illnesses. Asthma attacks get precipitated and prolonged. Respiratory infections, especially pneumonias, are particularly alarming and risky.

It is important for people to be cautious during the season. Needless to say, the most important issue is to clean the atmosphere by preventing the generation of smoke and poisonous gases. Avoiding prolonged exposure is an important preventive strategy. Any worsening of symptoms must be promptly handled. Asthmatics and chronic lung disease patients may need to increase their drug dosages, and additional drugs might also be required. These decisions should, however, be made in consultation with the family physicians. Lastly, there is need to dispel the notion that the air in the early morning is richer in oxygen. While a walk at this time is certainly more convenient and pleasant, it is not the oxygen which is available in any greater quantity. As stated earlier, the individuals who are more prone to harmful effects should wait for the smog to clear and the temperature to rise before venturing out.

The writer is Professor and Head, Department of Pulmonary Medicine, PGI, Chandigarh.

Ayurveda & you
High uric acid can cause gouty arthritis
Dr R. Vatsyayan

Gout is a systemic disease and also one of the common forms of arthritis caused by the accumulation of uric acid in the joints. Centuries ago Acharya Charaka, while writing his famous compendium, devoted a separate chapter to it. Known as "vata rakta" or "vata shonitam" in ayurvedic parlance, gout affects mostly men between the age of 30 and 50 years and is seen very rare in women until after the menopause.

Causes and risk factors: Ayurveda believes that it is the dietary indiscretion, faulty lifestyle and to some extent genetic predisposition which are responsible for the occurrence of this disease. The dietary reasons include excessive use of food articles which are predominantly acidic, bitter and salty in taste and hot and unctuous in effect. High intake of non-vegetarian food consisting of red meat and fish, idiosyncrasy with regard to even vegetarian diet of peas, lentils and beans and regularly taking eatables which are incompatible upset the metabolic process, raising uric acid in the body.

People who are either easy-going, obese, given to sedentary lifestyle or careless about their diet and proper daily schedule are more prone to get gout in their life. Regular use of alcohol and its accessory diet of rich protein additionally contribute the building up uric acid in the body. Some ayurveda scholars have aptly described gout as "adhya vata", meaning a disease occurring among the opulent sections of society. Aspirin and some of the diuretics and antihypertensive drugs may also interfere with the body’s ability to excrete the uric acid.

Types of gout: Ayurvedic texts have described gout as of two types — superficial and deep. In fact, these are the stages of the same disease process. The first stage is the milder one and is marked by abnormal perspiration, hyper pigmentation, vague body aches, feeling of exaggerated pain on injury, boils and carbuncles, laxity in joints and easy fatigability. The second type relates to the stage when actual gout sets in with pain and inflammation in the joints.

Modern medicine also refers to different stages of gout. The asymptomatic hyperuricemia is a condition when a person has an elevated level of uric acid in the blood, but no other symptoms. The acute stage refers to a condition when there is severe pain and swelling in the joints.

Signs and symptoms: Over a period uric acid in the blood crystallizes and settles in the joint spaces causing inflammation and stiffness. This leads to a sudden and acute attack commonly occurring at night which is marked by intense pain, tenderness and swelling in the big toe or the ankle joint. Most of the time the acute attack is triggered by the intake of wrong diet, alcohol and stressful conditions. Fever, sweating, loss of appetite, malaise, constipation and scanty and dark-coloured urine are common accompaniments of the acute attack. Initially, these attacks subside within three to 10 days and the next attack may not appear for a long time.

Later, these attacks can last longer and occur more frequently, and a stage is reached where remissions between them are incomplete and there is persistent pain and stiffness in the joint. An increase in the uric acid level supported by wrong diet can also result in the formation of stones not only in the urinary tract but also in the gall bladder. Gradually gout becomes polyarticular — the ankle, hands and wrist get affected first and then the knees, elbows and hips. But proper and adequate treatment can prevent the disease from progressing to this advanced stage.