The History & Significance of Chinese New Year

 

Chinese New Year is just two weeks from today in 2025. Chinese New Year, or the Spring Festival in China is a festival that celebrates the beginning of a new year on the traditional lunisolar Chinese calendar. Marking the end of winter and the beginning of spring, this festival takes place from Chinese New Year's Eve (the evening preceding the first day of the year) to the Lantern Festival, held on the 15th day of the year. The first day of Chinese New Year begins on the new moon that appears between 21 January and 20 February. Chinese New Year is one of the most important holidays in Chinese culture. It has influenced similar celebrations in other cultures, commonly referred to collectively as Lunar New Year, such as the Losar of Tibet, the Tet of Vietnam, the Seollal of Korea, the Shogatsu of Japan and the Ryukyu New Year.

It is also celebrated worldwide in regions and countries with significant Overseas Chinese, especially in Southeast Asia including Singapore, Malaysia, Brunei, Cambodia, Indonesia, Myanmar, the Philippines, and Thailand. It is also prominent beyond Asia, especially in Australia, Canada, France, Mauritius, New Zealand, Peru, South Africa, the United Kingdom, and the United States, as well as in many European countries. The Chinese New Year is associated with several myths and customs.

The festival was traditionally a time to honour deities as well as ancestors. Within China, regional customs and traditions concerning the celebration of the New Year vary widely. The evening preceding New Year's Day is an occasion for Chinese families to gather for the annual reunion dinner. Traditionally, every family would thoroughly clean their house, symbolically sweep away any ill fortune to make way for incoming good luck. Windows and doors may be decorated with red papercuts and couplets representing themes such as good fortune or happiness, wealth, and longevity. Other activities include lighting firecrackers and giving money in red envelopes.

Let me give my own views and thoughts as much as I know on the origin of the lunar year for the Chinese, how did it start, its origin and history and how does it differ from the Gregorian calendar?  How did the zodiac animals came into existence, its history and significance. I am more interested in the astronomical aspect of the lunar calendar.

Let me also explain why  the Chinese  couldn’t  follow the solar calendar instead of the lunar or lunisolar calendar from the astronomical perspective.

First of all, we  know the moon is receding from earth. The moon is receding from Earth due to gravitational interactions between the two celestial bodies due to tidal interaction. The moon's gravity causes Earth's oceans to bulge, creating tides. Earth's rotation causes the tidal bulge to be slightly ahead of the moon in its orbit. Friction between the tidal bulge and Earth's rotation transfers energy to the moon's orbit. This energy transfer pushes the moon into a higher orbit, causing it to slowly move away from Earth due to the conservation of angular momentum. We know the rate of recession of t Moon from Earth is about 3.8 cm per year. This rate has slowed over time. The moon has been receding since it formed 4.5 billion years ago. The moon's recession slows Earth's rotation, making days slightly longer. The moon's speed of movement could affect life on Earth, but this could take billions of years to happen.

In such a case will there be any Chinese New Year or any kind of festival that depends on the lunar calendar in the distant future?  

Allow me to address all these issues systematically in detail.

Origin and History of the Lunar Year for the Chinese.

The Chinese lunar calendar, also known as the lunisolar calendar, is one of the oldest calendars in the world, dating back over 3,000 years. It is believed to have been established during the Xia Dynasty (2070–1600 BCE) and refined during the Shang (1600–1046 BCE) and Zhou (1046–256 BCE) Dynasties.

The Chinese calendar is lunisolar, meaning it incorporates both lunar phases and solar cycles. Months are based on the lunar cycle (29.5 days), and the year is adjusted to align with the solar year (365.24 days). This requires the addition of a leap month roughly every three years to ensure the calendar stays synchronized with the seasons.

The Chinese New Year starts on the second new moon after the winter solstice (between January 21 and February 20). The winter solstice was a key marker for ancient Chinese astronomers, symbolizing the transition to longer days and the anticipation of spring.
The calendar was developed for agricultural purposes, guiding farmers on when to plant and harvest crops. Observations of celestial phenomena, such as the movements of the moon and sun, were crucial for this.

How does the lunar calendar differ from the Gregorian calendar? The Gregorian calendar is purely solar, with months of fixed lengths to approximate the 365.24-day solar year. The Chinese calendar is lunisolar, where months correspond to lunar cycles and years are adjusted to the solar year with leap months.

A Gregorian month has a fixed number of days (28–31). A Chinese lunar month alternates between 29 and 30 days, resulting in 12 or 13 months in a year.

The Gregorian year begins on January 1, fixed by convention. The Chinese New Year date shifts annually, depending on the second new moon after the winter solstice.

What about the origin and significance of the zodiac animals? 

This has mythological origins. The Chinese zodiac's origin is rooted in mythology. One popular story tells of the Jade Emperor, who invited animals to a race across a river to determine their order in the zodiac. The first twelve animals to complete the race were honoured with a place in the zodiac: Rat, Ox, Tiger, Rabbit, Dragon, Snake, Horse, Goat, Monkey, Rooster, Dog, and Pig. This has cultural significance. Each zodiac sign is associated with unique personality traits and fortune-telling. The cycle influences many aspects of life, from matchmaking to business decisions.

It also has an astronomical basis. The zodiac loosely corresponds to the twelve lunar months. The division into twelve parts reflects the alignment with Jupiter's orbital period of ~12 years, which was observed by ancient Chinese astronomers.

The question people may ask is, why not use a solar calendar?

First, the Chinese in ancient times, and still are, consider agricultural needs. The lunisolar calendar brings into line better with both the lunar phases and the solar year, which was critical for determining planting and harvesting times in ancient agrarian societies. It also brings into line with their cultural and spiritual practices. By this, I mean the moon holds deep cultural and spiritual significance in Chinese traditions, symbolizing renewal, harmony, and the cyclical nature of life. Besides, there is historical momentum. The calendar became ingrained in Chinese society and traditions over millennia, making a shift to a purely solar system less feasible.

In the area of astronomy where I am more familiar and interested, we may ask what is the future impact on Chinese New Year  when the Moon recesses?

The moon is receding from Earth at ~3.8 cm/year. Over billions of years, this will cause lunar cycles to lengthen, disrupting the alignment of lunar calendars with Earth’s seasons. Thus, if the lunar month becomes significantly longer, lunisolar calendars may require increasingly complex adjustments, or societies may transition to purely solar calendars. But I personally believe there will be cultural continuity even if astronomical conditions change, traditions like CNY could adapt, retaining their symbolic meanings while bringing into line with new celestial or conventional cycles.

What about the cultural, social, and economic aspects of Chinese New Year?

The cultural aspects would still be these:

Reunion Dinner.  Families gather for a lavish meal on New Year’s Eve, symbolizing unity and prosperity.

Decorations. Red is prominently used to ward off evil spirits, as per the myth of Nian, a beast scared away by red and loud noises.

Customs of cleaning the house, wearing new clothes, and giving red envelopes signify renewal and good fortune.

The social aspects, come what may, CNY strengthens familial and community bonds through gatherings, exchanges of greetings, and shared rituals.

In terms of economic impact, I envisage CNY to trigger the world's largest human migration (Chunyun) as people return home. In retail, businesses see a surge in spending on food, gifts, and decorations. In terms of global reach, the festival boosts tourism and fosters cultural exchange in countries with significant Chinese populations.

There is also historical and symbolic significance of CNY. For example, honouring ancestors and deities. CNY originated as a way to pay respect to ancestors and pray for a prosperous year ahead. CNY is a seasonal transition when it celebrates the end of winter and the rebirth of nature in spring.

What about integration of astrology others may ask? The alignment of CNY with celestial phenomena reflects ancient China's sophisticated understanding of astronomy.

Conclusion:

Chinese New Year is a profound blend of astronomical observation, cultural tradition, and spiritual significance. Its enduring legacy, rooted in humanity's relationship with nature and the cosmos, exemplifies how societies adapt celestial cycles to their cultural rhythms.

May this Year of the Wood Snake (2025) bring my readers and their families abundant health, happiness, bountiful wealth and prosperity. 

May your celebrations be filled with laughter, love, and countless happy moments.

Gong Xi Fa Cai!

谢谢您! (Thank You) 

jb lim 

 

Patented vs. Generic Antidiabetic Drug: Which Is Better?

 I received a request from Dr Jasmine on the 5^th December. 2024 who wrote:

Good evening, Dr Lim 

I need your help as you are the best person I can rely on for scientific and medical explanation. 

Recently I had an Indian patient who was diabetic. I prescribed metformin for her as this was what she has been taking all along. But she insisted that metformin does not work for her. She wanted a patented drug which she believed would work for her. I told her whether patented or generic they are the same thing. The only difference is patented antidiabetic drugs are much more expensive. 

Maybe you can write an article to explain all that so that when I get problems like this from stubborn unbelieving patients, I can ask them to refer to your article for the explanation. Compliance from many patients is headache    

JK

Thank you, Dr Jasmine, for your request and question

Sorry for this late reply because I have much more interesting articles about life and spiritual mysteries  awaiting to be posted here than on medicine which is very boring subject for me now after retiring from this field long ago.

But since you requested, I shall oblige. But what can I do if your patient does not believe that generic drugs are the same as the original patented drugs. They are your patients, not mine. If you cannot explain to them, what can I do?

The best I can do here is to explain the difference, not just for patients and doctors, but  for everybody, the differences  between Metformin, the generic version of this antidiabetic drug, and the original patented version called Glucophage.

 I can write a little bit more than this -  how this antidiabetic drug works (if your patients can understand simple pharmacology). If they cannot, what can I do?

Let me try to explain the differences between the original patented Glucophage and the current generic Metformin

(Later, I shall write a more detailed essay between patented vs generic drugs, plus biosimilar analogues – how they are manufactured plus a contrast between their mode of actions). But let me tackle Metformin you asked first.  

Generic vs. Patented Status the patented name and status of Metformin:

Metformin is currently a generic drug, widely available and manufactured by multiple pharmaceutical companies globally. It was first synthesized in the 1920s but was not used clinically until much later. The original patented name of metformin was Glucophage, developed and marketed by the French company Laboratoires Aron in 1957. The patent for Glucophage expired long ago, allowing metformin to become a widely used generic medication for type 2 diabetes mellitus.

Thus, I am sorry to say that you,  Dr Jasmine, as well as your patient are both wrong to believe that Glucophage (brand name)  which used to be the patented version of metformin  is more expensive than the generic version metformin. Both are the same metformin chemically, structurally and pharmacologically. They act exactly the same way.

To be more precise, Metformin hydrochloride is the same as Glucophage, namely,  1,1-dimethylbiguanide hydrochloride, with the molecular formula C4H11N5 • HCl and a molecular weight of 165.62 g/mole. Maybe you should educate your patient on this. It is also wrong for your patient to believe that the original patented Glucophage is more suitable for her that can ‘cure’ her diabetes. Diabetes is an incurable disease that no pharmaceutical drug, whether  patented, or the generic equivalent can permanently  ‘cure ‘ except controlled by dietary approaches,  and lifestyle modification with one of the antidiabetic agents such as sulfonylureas, meglitinides, biguanides (like metformin), thiazolidinediones (TZDs), alpha-glucosidase inhibitors, dipeptidyl peptidase 4 (DPP-4) inhibitors, sodium-glucose cotransporter (SGLT2) inhibitors, and of course  insulins, an injectable drug for type I and type II diabetes as  well as for gestational diabetes added if necessary.

Pharmacology of Metformin as an Antidiabetic Drug:

Metformin is a biguanide class drug, and its pharmacodynamics and pharmacokinetics make it unique among oral antidiabetic agents.

Pharmacodynamics primary mechanisms of Metformin:

In simple language, this antidiabetic drug works by  acting on its inhibition on hepatic gluconeogenesis.

In even simpler language, this means it blocks sugar production in the liver. If patients still cannot understand this, what can I do?

In technical  language, Metformin reduces the production of glucose in the liver by suppressing mitochondrial respiration, which leads to decreased energy (ATP) production. This inhibits gluconeogenic enzymes such as phosphoenolpyruvate carboxykinase (PEPCK) and glucose-6-phosphatase.

It works by improvement in insulin sensitivity by increasing insulin-mediated glucose uptake in skeletal muscle and adipose tissues, likely by activating the AMP-activated protein kinase (AMPK) pathway. AMPK activation is critical for improving metabolic homeostasis. This explanation, and all the rest of the explanations  below are meant only for pharmacologists who know more about drug actions.  

Metformin also increases GDF15 (Growth Differentiation Factor 15) secretion. This hormone reduces appetite and caloric intake, which may aid in weight management in patients with type 2 diabetes.

The secondary mechanism of Metformin is the reduction in lipogenesis and fatty acid synthesis. This means that Metformin inhibits lipogenic enzymes in the liver, such as acetyl-CoA carboxylase, reducing lipid accumulation.

It also enhances fatty acid beta-oxidation by promoting AMPK activation, metformin increases the breakdown of fatty acids in the mitochondria.

Recent studies suggest metformin alters gut microbiota composition, contributing to its glucose-lowering effects and systemic metabolic benefits, such as it decreases glucose absorption in the intestine. Thus, Metformin slightly reduces intestinal glucose absorption, although this is not its primary mechanism.

Pharmacokinetics of Metformin:

Metformin is absorbed in the small intestine, primarily via organic cation transporter 1 (OCT1). Its bioavailability is approximately 50-60%.

Distribution:

It is distributed to tissues through transporters such as OCT1 and OCT2, with high concentrations in the liver and gastrointestinal tract.

Metabolism:

Metformin is not metabolized by the liver or other enzymes, which is unique compared to many drugs.

Excretion:

It is eliminated unchanged by the kidneys via active tubular secretion. Its half-life is approximately 4-8 hours, and dose adjustment is required in renal impairment.

Additional Pharmacological Effects:

Metformin has been shown to reduce levels of inflammatory cytokines such as TNF-α and IL-6, potentially improving outcomes in chronic low-grade inflammation seen in type 2 diabetes.

Anticancer Properties:

Ongoing research suggests that metformin may reduce cancer risk by inhibiting mTOR (mammalian target of rapamycin) signalling via AMPK activation. This is of interest in breast, prostate, and colorectal cancers.

Cardiovascular Benefits:

Metformin improves lipid profiles by reducing LDL cholesterol and triglycerides. It also enhances endothelial function and may reduce the risk of atherosclerosis.

Neuroprotective Effects:

Studies suggest metformin may have a role in reducing cognitive decline and neurodegenerative diseases, possibly through its effects on mitochondrial function and insulin sensitivity in the brain.

Anti-Aging Effects:

Metformin is being investigated for its potential role in slowing aging by influencing pathways involved in metabolism, cellular senescence, and inflammation.

Clinical Considerations:

Advantages of Metformin is, it does not cause hypoglycaemia due to its non-insulinotropic nature. Weight neutrality or modest weight loss, making it ideal for overweight diabetic patients.

Long-standing safety profile and limitations is that  Metformin common side effects are  gastrointestinal symptoms (e.g., diarrhoea, nausea, and abdominal discomfort). Rare but serious: lactic acidosis in patients with significant renal impairment, liver dysfunction, or other conditions causing hypoxia.

Here are some useful information on the pharmacology (mode of action) of metformin:

1.      Mechanism of Action: Metformin primarily works by reducing hepatic glucose production through the inhibition of gluconeogenesis, largely mediated by the activation of the AMPK (AMP-activated protein kinase) pathway. It also enhances insulin sensitivity and promotes glucose uptake in peripheral tissues like muscles while reducing intestinal glucose absorption.

2.      Pharmacokinetics: After oral administration, metformin exhibits 50–60% bioavailability. It is not metabolized by the liver but is excreted unchanged via the kidneys. This emphasizes its safety in patients without renal impairment and highlights the risk of lactic acidosis in those with compromised renal function

3.      Clinical Applications Beyond Diabetes: While primarily used to manage type 2 diabetes mellitus, metformin has shown promise in other areas, including polycystic ovary syndrome (PCOS), cardiovascular risk reduction, and even potential neuroprotective effects in conditions like Alzheimer’s and Parkinson’s diseases

Side Effects: Gastrointestinal issues (e.g., nausea, diarrhoea) are common but manageable. The risk of lactic acidosis is rare but serious, especially in patients with kidney dysfunction

Closing Thoughts:

Finally, as a closing note, there are actually many other types of antidiabetic drugs, not just Glucophage  or metformin.  The major classes of oral antidiabetic medications include biguanides, sulfonylureas, meglitinide, thiazolidinedione (TZD), dipeptidyl peptidase 4 (DPP-4) inhibitors, sodium-glucose cotransporter (SGLT2) inhibitors, and α-glucosidase inhibitors. Some common antidiabetic agents used in Malaysia and in other countries under different brand names include:

alpha-glucosidase inhibitors (acarbose, miglitol), amylin analogues (pramlintide),

dipeptidyl peptidase 4 inhibitors (alogliptan, linagliptan, saxagliptin, sitagliptin), incretin mimetics (albiglutide, dulaglutide, exenatide, liraglutide, lixisenatide), insulin, meglitinides (nateglinide, repaglinide), non-sulfonylureas (metformin), SGLT-2 inhibitors (canagliflozin, dapagliflozin, empagliflozin), sulfonylureas (chlorpropamide, glimepiride, glipizide, glyburide, tolazamide, tolbutamide), and thiazolidinediones (rosiglitazone, pioglitazone).

One very popular and effective antidiabetic medication used in Malaysia is Dyanil which is Glibenclamide 5mg.  Glibenclamide is an adopted name for glyburide, a member of the sulfonylurea class of drugs. Dyanil is produced by Dynapharm (M) Sdn Bhd, a member of DNG Corp., 

Recent antidiabetic drugs include glucagon-like peptide-1 receptor agonists (GLP-1RA) and sodium-glucose cotransporter-2 inhibitors (SGLT-2i)

A new trend has been getting a lot of attention from people using the diabetes drug Ozempic for weight loss. Ozempic, known generically as semaglutide, was approved in 2017 by the U.S. Food and Drug Administration (FDA) for use in adults with type 2 diabetes. However, Ozempic has a lot of side effects. Reducing caloric intake and changing our dietary lifestyles is the only safe and permanent way of reducing body weight, not using all kinds of drugs.

 References:

For further reading, consider the following articles:

A comprehensive review on metformin’s cellular and molecular mechanisms in Endocrine Reviews link here

Insights into its therapeutic benefits beyond glucose regulation, particularly in neurodegenerative disorders, published in MDPI Pharmaceuticals link here.

Historical and clinical perspectives in the JAMA Network Open review link here

Role of Cholesterol: Its Not Bad After All

A friend of mine sent us through a WhatsApp group this video about cholesterol as something bad for health and for the heart. It is an interview by Esha Chopra, an Indian actress and screenwriter to her father Dr Alok Chopra who is a cardiologist. He spoke about the functions of cholesterol in the body here:

https://www.instagram.com/taseer60/reel/DCsk_0yNxqJ/

After hearing what Dr Alok Chopra said, I decided to add more to what he explained, more than just the role of cholesterol in the body. It is always associated with something bad for health that causes cardiovascular diseases.

Let me first of all put the record straight. Cardiovascular is not about heart attack only. The nature of cardiovascular diseases is multifactorial. It is a group of diseases involving the heart and its blood vessels. They include coronary heart disease – a disease of the blood vessels supplying the heart muscle, cerebrovascular disease – a disease of the blood vessels supplying the brain, peripheral arterial disease – a disease of blood vessels supplying the arms and legs, rheumatic heart disease – damage to the heart muscle and heart valves from rheumatic fever, caused by streptococcal bacteria, congenital heart disease – birth defects that affect the normal development and functioning of the heart caused by malformations of the heart structure from birth, and deep vein thrombosis and pulmonary embolism – blood clots in the leg veins, which can dislodge and move to the heart and lungs.

Neither is cardiovascular disease caused solely by high blood cholesterol. In fact, cholesterol is needed and has a functional role in the body such as it helps build the structure of cell membranes that control what enters and leaves cells.

Cholesterol has its structural, hormonal, and metabolic functions such as it supports tissue repair, serves as a precursor for hormones such as oestrogen, testosterone, and adrenal hormones, and plays a critical role in synthesizing vitamin D

Cholesterol also helps produce bile acids, which in turn helps the body digest fat and absorb nutrients. It helps create bile in the liver as Dr Chopra explained

Cholesterol also helps the body's metabolism work efficiently.

 Low -density lipoproteins (LDLs) although always dubbed as the “bad cholesterol” too have its function in the body. LDLs are the primary carriers of cholesterol in blood because their main role is to deliver cholesterol to both peripheral and liver cells.

Low- and High-Density Cholesterol:

Let me explain a little bit more about Low-Density Lipoprotein (LDL) Cholesterol. 

LDL cholesterol is often termed "bad cholesterol" because high levels can lead to harmful health consequences. Some of the reasons are:

1.      Transport Function and Plaque Formation:

LDL's primary function is to transport cholesterol from the liver to tissues for cell membrane formation, hormone production, and other needs.

When there is excess LDL in the bloodstream, it can deposit cholesterol in the walls of arteries. This leads to the formation of atherosclerotic plaques, which narrow and harden the arteries (atherosclerosis).

2.      Inflammatory Response:

The cholesterol deposits trigger an immune response, leading to inflammation in the arterial walls. This exacerbates the damage and contributes to the progression of cardiovascular diseases.

3.      Oxidation of LDL:

Oxidized LDL is particularly harmful. It attracts white blood cells, which engulf the cholesterol to form foam cells. These cells accumulate and contribute to plaque formation, further increasing the risk of blockage.

Health Risks:

Elevated LDL levels are strongly associated with an increased risk of

1. Coronary artery disease (CAD) 

2. Heart attacks 

3. Strokes 

4. Peripheral artery disease

High-Density Lipoprotein (HDL) Cholesterol - The "Good" Cholesterol:

HDL is considered "good cholesterol" due to its protective effects on the cardiovascular system. Here are some of the reasons:

Reverse Cholesterol Transport:

HDL plays a crucial role in removing excess cholesterol from tissues and arterial walls. It transports this cholesterol back to the liver for processing and excretion via bile.

Anti-Inflammatory Properties:

HDL has anti-inflammatory effects, reducing the risk of inflammation in the arterial walls and protecting against atherosclerosis.

Antioxidant Effects:

HDL prevents the oxidation of LDL, reducing the formation of oxidized LDL, which is a major contributor to plaque development.

Cardiovascular Protection:

Higher levels of HDL are associated with a reduced risk of cardiovascular diseases because it helps maintain arterial health and prevents cholesterol build-up.

The Balance Between LDL and HDL:

The ratio of LDL to HDL is critical in assessing cardiovascular health here:

1.      High LDL and low HDL: Increased risk of plaque formation, heart disease, and strokes.

2. Low LDL and high HDL: Protective against these conditions.

Key Takeaways are:

1. LDL cholesterol becomes harmful when its levels are high, leading to cholesterol deposits, arterial damage, and cardiovascular disease.

2.HDL cholesterol is beneficial because it removes excess cholesterol from the bloodstream, has anti-inflammatory and antioxidant effects, and protects the arteries.

Plaque formation due to oxidative stress and free radical oxidizing LDL-cholesterol is taken up by macrophages and deposited in atheromatous plaques that develop into atherosclerotic lesions.

LDLs have apoB-100 as their sole protein constituent, which interacts with LDL receptors on target cell surfaces. The LDL-receptor complex is then taken up into the cell where LDLs are degraded, and cholesterol is released. This, in turn, regulates the amount of cholesterol produced by the cell. Cholesterol taken up by peripheral cells redistributes to various cell membranes and in this way, becomes involved in metabolic reactions.

Having explained the above, however, the longitudinal cohort Framingham Heart Study (FHS) that started in 1948 initially found that high cholesterol was a risk factor in cardiovascular disease. But later as the study continued longitudinally among the cohort population, it was shown that other factors are also the precipitating factors, not just high cholesterol. They include high blood pressure, unhealthy eating patterns, smoking, physical inactivity, or unhealthy weight. Researchers also know that these conditions can affect people differently depending on a patient’s sex or race. These findings are important because they are behavioural risk factors of heart disease and stroke.

Hence, we also need to consider behavioural patterns of individuals at risk such as unhealthy diet, physical inactivity, tobacco use and harmful use of alcohol. Amongst environmental risk factors, air pollution is an important factor. The effects of behavioural risk factors may show up in individuals as raised blood pressure, raised blood glucose, raised blood lipids, and overweight and obesity. These “intermediate risk factors” can be measured in primary care facilities such as in any government or private health clinics in Malaysia. An elevated HDL-cholesterol level indicates an increased risk of heart attack, stroke, heart failure and other complications. Cessation of tobacco use, reduction of salt in the diet, eating more fruit and vegetables, regular physical activity and avoiding harmful use of alcohol have been shown to reduce the risk of cardiovascular disease. A variety of coloured fruits and vegetables not only are rich in a variety of antioxidants, but some of them are very salicylates or salicylic acid (aspirin) that thins the blood and lowers the risk of heart attacks.

Vegetables rich in salicylates include broccoli, cauliflower, cucumber, mushrooms, radishes, spinach, and zucchini. Vegetables from the nightshade family, like brinjals, and peppers, also contain salicylates. So are tomatoes, apples, grapes, oranges, avocado, berries, cherries, grapes, peaches and plums including most tropical fruits  that are very high in salicylates

Many herbs and spices contain salicylates. Examples of salicylate-rich spices include thyme, rosemary, curry powder, paprika (a spice made from dried and ground red peppers), chilli and garam masala.

Not only salicylates or aspirin is cardio-protective, but studies have shown that salicylates in curry powder colon cancer protective. 

In Malaysia, the Chinese have the highest incidence of colon cancer, followed by the Malays, lest are the Indians whose diet is mainly curries that contain a lot of salicylates.

Most cardiologists would prescribe low doses (100 mg) of aspirin as a prophylactic against heart disease. A standard tablet aspirin contains 300 mg of acetyl salicylic acid. 

 Health policies that create conducive environments for making healthy dietary choices affordable and available, as well as improving air quality and reducing pollution, are essential for motivating people to adopt and sustain are also important. 

 Unfortunately, doctors concentrate only on cholesterol, such that they rampantly continue to prescribe all these statin drugs to reduce blood cholesterol ignoring the patient lifestyle and other more important factors such as free radicals damage. There is over-reliance on statins and the pharmaceutical industry's influence

Despite the availability of high-quality research, there remains a concerning reliance on pharmaceutical materials provided by drug companies, which may inadvertently bias clinical decisions. Often doctors are highly influenced by the pharmaceutical companies to prescribe out-of-date remedies that have nothing to do with their patients’ disease, such as using statins rampantly given for high cholesterol whether or not their patients are at any risk of any cardiovascular disease.

It is concerning that some clinicians may overlook the wealth of knowledge available in peer-reviewed medical journals, potentially limiting the integration of the latest research into clinical practice. The root causes such as lifestyles are never addressed. Clinicians should revisit their approach through published research papers.

Research papers published in medical and scientific journals do not come cheap. Each study can cost anything between RM 100,000 in Malaysia to several hundreds of thousands or millions of US dollars in the United States or elsewhere and they take the combined efforts of multidisciplinary medical and scientific teams many, many years to study especially in longitudinal studies, lesser time in cross-sectional studies.

Maintaining a healthy balance involves lifestyle choices such as a balanced diet (rich in fruits, vegetables, and healthy fats), regular exercise, and avoiding smoking. If needed, medications like statins or other lipid-lowering drugs may be prescribed by healthcare professionals.

Instead, they are highly influenced by the pharmaceutical companies to prescribe out-of-date remedies that have nothing to do with their patients’ disease, such as using statins rampantly given for high cholesterol whether their patients are at any risk of any cardiovascular disease. The root causes such as lifestyles are never addressed.

References for further reading:

Saturday, December 16, 2023

Does Cholesterol cause coronary heart disease?

References on Cholesterol, LDL/HDL, CVD, and the Framingham Heart Study

Here’s an overview and suggested resources:

Cholesterol Functions and Types (LDL & HDL):

Cholesterol is essential for:

Cell membrane structure: It maintains fluidity and integrity.

Hormone production: Precursor for steroid hormones like oestrogen, testosterone, and cortisol.

Bile acids: Helps digest fats.

Vitamin D synthesis: Crucial for calcium metabolism.

LDL ("Bad" Cholesterol): Transports cholesterol to tissues. High levels can lead to plaque buildup in arteries, increasing the risk of cardiovascular disease (CVD).

HDL ("Good" Cholesterol): Removes excess cholesterol from tissues and arteries, transporting it back to the liver for excretion. Higher HDL levels are generally protective against CVD.

Framingham Heart Study:
This landmark study, begun in 1948, explored risk factors for CVD, identifying key contributors like high cholesterol, hypertension, smoking, and obesity.

Framingham Heart Study Website: 

https://www.framinghamheartstudy.org

Article: “LDL vs. HDL Cholesterol in Cardiovascular Risk” (PubMed: 10.1016/j.amjmed.2020.06.020)

NIH on Cholesterol:

 https://www.nhlbi.nih.gov

History of Money - Is it the Root of All Evils?

My brother-in-law who is a Senior Civil Engineer wrote this question in a WhatsApp chat:

"How to survive without money? It is money,  and money and  a money world. Why is the world made like this?"

Just two days ago I was robbed by a snatch thief of my money, smart phone, two bank saving books, ATM cards, LRT (Light Rail Transit) travel card, house  keys, my wife's identity card. The snatch thief must be very desperate of money to survive. I just gave all of them to him, after which I blocked all my bank accounts, smart phone, LRT card, and made a police report. My wife got a new replacement identity card the next day. 

I think it is wrong to say that money is everything and we cannot survive without it. It gives the impression that money is the root of all evils. Let me give my thoughts on this. 

Sufficient money is required just to live basically a simple life, in fact, a very comfortably without using money to acquire all sorts of properties and investments that only burden our lives trying hard to upkeep and maintain them for at maximum 100 years, only forced to leave all of them behind along with our properties and investments into the grave. 

In 1 Timothy 6:10 in the Bible it clearly says:  For the love of money is the root of all evil: which while some coveted after, they have erred from the faith and pierced themselves through with many sorrows.

The Bible never says money is the root of all evils, but it says that ‘the love of it’  is the root of all evils. There is a very big difference between needing money for basic subsistence and the love of money beyond basic needs.

Money cannot buy love, health or prevent us from disease, illnesses and death. 

 In fact, in ancient times, they did not even use money at all. They used the barter system to exchange what they needed only, such as exchanging a cow, a donkey or goats for food grains. That was not evil or the root of all evils? It was just for basic living

I think it would be better to say that the root of all evil is not money itself but people's need for money, which they could use to improve their basic livelihood, but not greed of money to increase one's status, or jealousy over losing in the status game to others.

Money can be used for charitable purposes to help those in need of basic requirements for food, clothes, shelter and medicines like what Mother Teresa did in Calcutta who finally won her the prestigious Nobel Prize for Peace. She  used her money from her Nobel Prize for charity work to help the poorest among the poor instead.  But others can use money to exploit people, harm others, or divide communities. 

History of Money:

Since we are talking about money at this moment I might as well write something further about money, its history and how it compares with other equivalent commodities.

 The invention of money is indeed a fascinating milestone in human history. I first came to know about the barter system when I was a young boy in school. 

Later I read economics and sociology, surprisingly these subjects too I needed to learn as part of my postgraduate course in nutrition at the University of London. Let me share with you what I learnt about economics in London

When Was Money Introduced?

The concept of money evolved over thousands of years and has no single point of "invention." Here's an approximate timeline of its development:

Barter System (Prehistoric Times): 

 Before money, societies relied on barter—direct exchange of goods and services. For example, one person might trade wheat for livestock. Then came commodity money (~3000 BCE): Early forms of money were commodities like cattle, grains, or precious metals. In Mesopotamia, grain and silver were used as units of account. Later man used metal coins (~1000 BCE): The first standardized coins appeared in the ancient kingdom of Lydia (modern-day Turkey) around 600 BCE. These coins were made from a naturally occurring gold-silver alloy called electrum. Following that,  paper money (~700 CE) was introduced.  The Chinese Tang Dynasty began using "promissory notes," and by the Song Dynasty (~11th century), paper money was widely used.

However, modern money  was introduced in the 17th–18th Century.  With the rise of banks and the issuance of banknotes, money evolved into its modern forms, eventually leading to fiat currency (money with no intrinsic value but established by government decree).

Was money invented to replace barter?  The answer is, money was introduced largely to address the limitations of the barter system. The barter system, while functional in small or simple economies, posed several challenges such as:

Double Coincidence of Wants: Barter required both parties to have something the other wanted at the same time.

Indivisibility: Some goods, like livestock, were difficult to divide for smaller transactions.

Lack of Standard Value: It was hard to measure the value of goods consistently (e.g., how many sacks of grain equals a goat?).

Storage Issues: Perishable goods like food could not be stored as a reliable medium of exchange.

Money simplified trade by acting as a medium of exchange (avoiding the need for direct bartering). It is a unit of account (providing a standard way to measure value). Money has a store of value (retaining value over time and enabling savings).

Why Was Money Important ? Money revolutionized economies by enabling large-scale trade and specialization of labour. It supports the development of complex societies and market economies. Money acts as a foundation for taxation, governance, and wealth accumulation.

In essence, the introduction of money was a response to the growing complexity of human societies and their trade networks, facilitating economic growth and innovation.

Why Were Early Coins Not Made of Pure Gold?

First, gold has durability and practicality. Pure gold is soft and malleable, making it impractical for coins that would endure constant handling. By alloying gold with silver or copper, the coins became harder and more resistant to wear.

Gold also has cost efficiency. This means gold was (and still is) extremely valuable. Mixing gold with silver or other metals allowed governments to produce more coins and facilitate trade without exhausting their gold reserves. There is also standardization.  Ancient economies used alloys like electrum because it was naturally available in some regions, simplifying coin production without requiring extensive refining technology.

Gold and the Economy:

Gold has been a cornerstone of wealth and economic systems for millennia. Here’s why:

Gold as a Reserve Asset: Many countries hold gold in reserves as a hedge against economic instability. Historically, the gold standard (where currencies were directly tied to a fixed quantity of gold) provided stability. While most nations abandoned the gold standard by the mid-20th century, gold reserves still reflect a nation's financial security and credibility.

Cultural and Practical Value: Gold’s rarity, beauty, resistance to corrosion, and ease of shaping made it ideal for use in coins, jewellery, and even electronics today.

Universal Acceptance: Unlike fiat currency, gold is universally recognized and valued, making it a preferred store of wealth in uncertain times.

Why Do Gold Prices Fluctuate?

Gold prices are influenced by several interconnected factors:

Supply and Demand:

Firstly, the supply of gold is limited, as mining is costly and slow. Secondly, the demand fluctuates with trends in jewellery, technology, and investment.

Gold has economic stability. Gold is often seen as a "safe haven" during economic turmoil. When markets are unstable (e.g., inflation, currency devaluation, geopolitical tensions), investors flock to gold, driving up its price. When interest rates are high, investments like bonds and savings accounts become more attractive than gold (which doesn’t yield interest). This can lower demand and reduce prices. Conversely, lower interest rates often make gold more appealing.

Currency Strength:

Gold is priced in US dollars internationally. When the US dollar strengthens, gold becomes more expensive for buyers in other currencies, reducing demand and lowering prices.

Inflation:

Gold is often used as a hedge against inflation. When inflation rises, gold prices tend to increase because its intrinsic value remains stable.

Global Events:

Political or economic crises, such as wars or financial collapses, boost gold's appeal, increasing demand and raising prices.

Are There Commodities More Valuable Than Gold?

Yes, several commodities are more valuable than gold on a per-unit basis, although they may not serve the same economic role:

First, we have platinum and rhodium. These metals are rarer than gold and often more expensive due to their use in industries like automotive (catalytic converters) and electronics. Then there are also diamonds.  While valuable, their pricing is highly controlled by the diamond industry, making them less universally "liquid" than gold.

Next, we also have rare Earth elements (e.g., Scandium, Terbium). These elements are very expensive, as they are essential for advanced technologies like smartphones and green energy, these are in high demand but have specialized applications.

Then we can also consider antimatter (hypothetical). Theoretically, antimatter is the most expensive substance on Earth, costing billions per gram due to the complexity of its production.

However, gold's universal recognition and liquidity make it unparalleled as a global store of value.

Closing Thoughts

Gold has stood the test of time due to its unique combination of rarity, stability, and cultural significance. Its price fluctuations reflect its role in balancing economic confidence, technological demands, and human psychology.

Hence, money is not the root of all evils, but a basic commodity for our basic temporary existence here in this world till we journey on into the next - where probably enrichment  and wealth are entirely different. What we get here, we may not get there in reversed karma. It is the love of excess money over basic comfort in life that is the root of all evils, not money itself. The excess of them goes into our graves as the soul flies away empty handed. 

 "For we brought nothing into this world, and it is certain we can carry nothing out" 

(1 Timothy 6:7)

The verse continues, "And having food and raiment let us be therewith content. But they that will be rich fall into temptation and a snare, and into many foolish and hurtful lusts, which drown men in destruction and perdition". 

 

 

 

Ethics and Protocols in Medical and Clinical Research: My Take and Experience as a Former Senior Researcher

 

by: lim ju boo 

Summary:

Let me briefly summarize my thoughts before detailing further

First, the researcher needs to have an aim and objective to embark into the study, especially in a clinical trial where human subjects are involved. He / she must write out the purpose of the study based on some existing research, previous findings or a problem, whether about a disease, an epidemic or a public health problem.

Second, he (includes she) needs to submit his proposal in writing to a committee for the vetting for the much-needed research funding that can run into hundreds of thousands of ringgits or US dollars

Third, he needs to select the subjects carefully in consultation with a biostatistician on sampling size, usually randomized with adequate sampling numbers to represent a population.

Fourth, he needs to have collaborators who specialize in their own fields to help out in their own areas as a multi-disciplinary team as it is not possible these days to work solely on his own. For example, a clinician cannot just do the clinical examination only, as physical examination is subjective and cannot yield any data that are much needed as evidenced-based. So, the clinician(s) needed scientists also who can support with their specialized findings and measurements in their analytical laboratories that can yield the much-needed data for statistical analysis

Firth, the researcher needs to face the medical ethic committee, often several times who will question the researcher to ensure the safety of the subjects undergoing a clinical trial either on a new drug or some nutritional studies

Sixth, the subjects must clearly be explained about the purpose of such a study, and they must give their written legal consent to participate in the study

Seventh, what happens if some of the subjects fell sick during the study? Should they be treated with drugs that may interfere with the study, especially if the researchers are evaluating a new drug or a treatment including a food they are taking (drug-nutrient interaction). If the subject falls sick and is taken off the study, this will affect the sampling numbers already statically selected out. Should the subjects be treated non-pharmacologically, such as using naturopathic medicine by a qualified Naturopathic Doctor that should be drugless. I think in such an event a pharmacologist also needs to be consulted on drug interactions with other drugs or nutrients should the subject fall sick but need to be treated with drugs and retained in the study.

So a nutritionist too needs to be consulted on food and drug interactions. In short, a multidisciplinary team, each member in the team leading their own expertise to be consulted.

All subjects in the study too must comply with strict lifestyle protocols such as not being allowed to take their own medicines, smoke, eat whatever they like or refuse to cooperate with the study design and regulations, etc.

The Details:

Clinical trials conducted jointly among clinicians and medical scientists are among the most vital processes in advancing medical knowledge and treatment.

Since I was a senior medical researcher at the Massachusetts Institute of Technology (MIT) in the United States, and later at the Institute for Medical Research (IMR) in Malaysia  before I retired, let me outline the protocols and pre-requirements we must adhere to before embarking on a clinical trial:

Pre-Requirements and Protocols for Conducting a Clinical Trial

1. Define the Research Question and Objectives

a.      The researcher must identify the hypothesis and specific objectives of the trial.

b.     Develop a detailed plan to determine what the trial seeks to achieve, such as testing a new drug, treatment, or diagnostic method.

2. Conduct a Comprehensive Literature Review

a.      Examine existing studies to ensure the trial addresses a novel or unanswered question.

b.     Avoid duplication of previous work unless replication is essential.

3. Develop the Clinical Trial Protocol

This is the core document that outlines every aspect of the trial. It must include:

a.      Study design (e.g., randomized control trial, observational study).

b.     Inclusion and exclusion criteria for participants.

c.      Methodology, including interventions, dosages, and timelines.

d.     Primary and secondary endpoints (outcomes being measured).

e.      Data collection and analysis plan.

f.        Risk management and safety monitoring plan.

4. Secure Ethical Approval

The trial must be reviewed and approved by an Institutional Review Board (IRB) or Ethics Committee (EC) to ensure it adheres to ethical standards, such as:

a.      Protecting participant rights and safety.

b.     Minimizing risks and ensuring risks are justified by potential benefits.

c.      Informed consent processes are clearly outlined.

5. Obtain Regulatory Approval

Submit the trial proposal to the relevant health authorities or regulatory agencies:

In the US: Food and Drug Administration (FDA) for an Investigational New Drug (IND) application.

a.      In Malaysia: Ministry of Health &  National Pharmaceutical Regulatory Agency (NPRA).

b.     In the EU: European Medicines Agency (EMA).

6. Develop Informed Consent Forms

Create clear, comprehensive forms that explain the trial in lay terms, including:

a.      Purpose, procedures, risks, and benefits of participation.

b.     Assurance of voluntary participation and the right to withdraw at any time.

7. Secure Funding

a.      Identify funding sources such as government grants, private organizations, or pharmaceutical companies.

b.     Budget for trial costs, including personnel, materials, and facilities.

8. Establish a Research Team

a.     Recruit qualified personnel with expertise in the required fields, including:

b.     Principal investigator (PI) to oversee the trial.

c.      Medical staff, statisticians, data managers, and monitors.

9. Register the Clinical Trial

Register the trial in a publicly accessible database such as:

Ministry of Health Malaysia

In other countries these may be required.

ClinicalTrials.gov (US).

EU Clinical Trials Register (Europe).

WHO International Clinical Trials Registry Platform (ICTRP).

10. Prepare Study Sites

Select and prepare locations where the trial will take place, ensuring they meet requirements for:

a.      Equipment and facilities.

b.     Patient recruitment and monitoring capabilities.

11. Pilot or Feasibility Study (Optional)

a.      Conduct a smaller pilot study to test the feasibility of the trial's design, logistics, and protocols.

12. Secure and Store Data Management Systems

Ensure a robust system for data collection, storage, and analysis while maintaining confidentiality and compliance with data protection regulations (e.g., GDPR, HIPAA).

13. Risk Assessment and Monitoring Plans

Develop protocols for:

a.      Adverse event reporting.

b.     Safety monitoring by a Data Safety Monitoring Board (DSMB), if required.

14. Participant Recruitment Plan

Design a strategy to recruit and retain participants, ensuring diversity and representativeness.

15. Final Pre-Trial Review

Conduct a final review of the protocol, ethical approvals, and logistical readiness.

Key Ethical and Legal Principles

Declaration of Helsinki: Ethical guidelines for medical research involving human subjects.

Good Clinical Practice (GCP): An international quality standard for designing, conducting, and reporting trials.

Framework and My Additions

1. Aim and Objective of the Study

The importance of defining the purpose of the study. To add:

a.      Hypothesis Development: Besides outlining the purpose, the researcher should explicitly define the null and alternative hypotheses. This ensures clarity in the statistical analysis later.

b.     Alignment with Global Health Priorities: If the study addresses a pressing public health issue, it might increase the likelihood of securing funding and ethical approval.

2. Proposal Submission and Funding

a.      Detailed Budget Breakdown: The researcher must provide a granular budget detailing all anticipated costs, including personnel, laboratory analyses, participant compensation, and contingency funds.

b.     Pilot Data: Including preliminary data from smaller studies or feasibility assessments strengthens the funding proposal.

3. Subject Selection and Sampling

My personal demands when I was the leader of the medical and scientific team  emphasis on statistical rigor and collaboration with a biostatistician is crucial. To enhance these, we did these:

a.      Stratification: In addition to randomization, stratified sampling can ensure that subgroups (e.g., age, gender, comorbidities) are adequately represented.

b.     Inclusion and Exclusion Criteria: Clear criteria must be established to ensure the selected participants are homogeneous enough for meaningful results but diverse enough to reflect real-world populations.

c.      Recruitment Challenges: Strategies like community engagement or collaboration with primary healthcare providers can improve recruitment and retention.

4. Multidisciplinary Collaboration

Adding to this we incorporated these experts into our research team

Clinical Pharmacologists: To manage drug interactions and dosing strategies during the trial.

1.      Behavioural Scientists: If lifestyle interventions or behavioural changes are part of the protocol.

2.      Bioinformaticians: For handling large datasets, especially in genomic or proteomic studies.

3.      Regulatory Experts: To navigate the complex approval landscape and ensure compliance with evolving laws.

5. Ethical Considerations

Multiple interactions with the ethics committee are often required. To expand:

Risk-Benefit Analysis: A detailed analysis should demonstrate that the potential benefits outweigh the risks.

Independent Reviewers: Ethics committees often include independent reviewers who are not affiliated with the institution to ensure impartiality.

Cultural Sensitivity: The study design and consent process must respect cultural norms and values, particularly in diverse populations like in Malaysia.

6. Informed Consent

We made it a point to explain clearly to our participants the aims and objectives of our study and ask them to sign a letter of consent if they agree to participate. Before signing the consent form, participants could be tested on their understanding of the study to ensure they fully grasp its implications.

7. Managing Adverse Events

My medical and scientific I was leading have discussed how to handle participants falling sick is a critical one. My thoughts then were:

1.      Predefined Withdrawal Criteria: Clear criteria should be established for when a participant is withdrawn from the study due to adverse events.

2.      Non-Pharmacological Interventions: I suggested, naturopathic or non-pharmacological treatments can be explored. However, their efficacy and safety must also be evidence-based to avoid confounding results.

3.      Consultation with a Pharmacologist: Absolutely necessary, especially when participants are on concurrent medications or supplements.

8. Lifestyle Protocol Compliance

Ensuring participants adhere to strict lifestyle protocols is essential. To build on this:

1.      Monitoring Mechanisms: Use digital tools such as wearable devices, food diaries, or smartphone apps to track participant adherence in real time.

2.      Regular Check-Ins: Weekly or bi-weekly check-ins with participants can help identify and address compliance issues early.

3.      Educational Sessions: Informing participants about the importance of adhering to the study design can foster better cooperation.

Additional Considerations

1. Data Integrity and Confidentiality

a.      Establish secure systems to ensure data confidentiality and compliance with data protection laws like GDPR (Europe) or HIPAA (US).

In Malaysia we lack of this system 

b.     Include a data monitoring committee to regularly review the data for consistency and adherence to the protocol.

2. Statistical Power

Adequately power the study to detect clinically meaningful differences between groups. Underpowered studies risk generating inconclusive results.

3. Interim Analysis

We planned for interim analyses to evaluate safety and efficacy during the trial. These analyses can inform decisions about continuing, modifying, or halting the study.

4. Post-Trial Access

Participants, especially in low-resource settings, should have access to the drug or intervention if it proves successful during the trial.

5. Publication and Dissemination

Predefine how results will be shared, including negative or null findings, to contribute to the broader scientific community.

Closing Thoughts

The way I planned these when I led my team in clinical trials, I believe was comprehensive.

My ethical concerns regarding drug interactions and lifestyle compliance reflect the care and responsibility needed in clinical trials. These touches, coupled with rigorous planning and collaboration, ensure that clinical trials not only generate reliable data but also respect the dignity and safety of participants.

 I believe this design also applies to both cross-sectional and longitudinal study which would be more an epidemiological study than a clinical study with new drugs, a new therapy, or a nutrition study. All fit exactly into the same rigorous demands and ethical and legal requirements.

At the Institute for Medical Research where I was asked by my former Director to lead a team of doctors and scientists in a few clinical trials, me and my team must face the Medical Ethics Committee, some 30 of them including ironically my own Director who asked me to do study, but sat there asking me why I wanted to conduct the study? How ironic?

The Medical Ethics Committee also  ‘unfortunately’ included one of my best friends, the late Professor MP Deva, Head of the Department of Psychological Medicine, University Hospital, University of Malaya whom we knew each other since our college days who also sat there questioning me twice with a stern face and voice in the Director’s Board Room at IMR. “Fortunately,after the interview lasted at least 2 hours we both went out together as friends for dinner. The ironical is, friends are friends, but when work and medical and scientific ethics is concerned, we are no friends - in opposition.

In the Medical Ethical Committee, me and my team must face twice, was also the Attorney General who also sat there to ensure that everything we did was legally protected by the government as well as the government itself was protected should there be any death among the participants because we experimented on them. The AG was there to ensure legal safety for all parties as it was a government project under the Ministry of Health

Medical research is very challenging with high risks involved for all parties for sure!

I think this essay too is a challenging one for me to write about my past working experience