Constipation - 2 " My Abdomen is colicky and I am constipated"

A 41 year old man weighing 104 kg with a BMI of 40 and thus labelled as "morbidly obese" came to the clinic looking irritable and depressed. By the way I notice that patients who are constipated are generally glum and down.

This is his third time of seeing a doctor for colicky abdominal pain and constipation. He claimed everytime he came to see a doctor, all they gave him was stool softener and advice to take more fibre, vegetables, fruits and drink plenty of water. Well, according to him the problem settled after taking the stool softeners but it recurred despite him taking the suggested foods to help reduce his constipation. when asked whether he passed flatus (fart), he replied "hardly now".

I could have given him the same prescription of stool softeners but I thought it would not help him. In fact I was tempted to just do that seeing that the patient was irritable and seemed to think that the world owed him a living. He was also accusatory of the "unhelpful treatment" received so far.

I asked him how long had he been constipated and he replied for the last one month or so. He was not constipated before that neither did he have colicky abdominal pain. He also denied taking any medications which could contribute to his current problem. Then I asked him what was " something new" that he had been taking over the last one month or so.

He paused to think then he said that about six weeks ago he went to see a private doctor for aching pain in his knee joints and the doctor advised him to drink a special high-calcium milk as he (the doctor) thought he had "bone problems". The patient had been taking the milk three times a day and now he realised that his current problem started a few days after his thrice a day milk drink.

Too much calcium in the blood (hypercalcaemia), depending on individual response , could cause constipation with abdominal colic.

I told him to stop taking the high calcium milk and prescribed him stool softeners to tie him over the period before the return to normal calcium level. He came for review after three weeks looking more cheerful as his abdominal pain and constipation had both subsided.

He complained that he spent so much money buying the "special milk" only to throw it away. I advised him to lose weight as he is unhealthily obese (morbid obesity). He is 34 kg overweight and now suffering from knee arthritis causing him aching pain. Taking more calcium is not going to help him, in fact too much of the  mineral had adversely affected his bowel movements.

Excess weight strains the knee joint causing arthritis and pain

Obesity affects knee joints by placing more force on them, gradually wearing the joints away causing arthritis, pain and inactivity leading to more weight gain and worsening obesity. A vicious cycle.

Constipation-1 "Help! All my children are constipated"

A few months ago a mother of four children ranging from the age of seven to fourteen complained that all her four children were suffering from constipation for some time. They have been coming to the clinic and have been advised to take more fibre like cereals, more fruit and vegetables and plenty of fluid but it seemed to no avail as the problem kept on recurring.

The children's stool were hard and they really had problem defecating according to the mother. I noticed that stool softeners had been prescribed on a number of occasions but the problem persisted. I asked whether the parents were also constipated for which the mother answered in the negative.

Fried sausages taken everyday for lunch and dinner

Interestingly all four have a similar problem. It must be something that they eat. So I asked the mother what was the children's favourite food that they eat most of the time at home.

The mother said that the children loved sausages. She fried them the sausages day and night. And if she did not do so the children themselves will fry and help  themselves. They loved sausages and eat them like their staple food.

Now that piqued my curiosity. What is sausage? Sausage is defined as ground meat mixed with fat, salt and other seasoning,preservatives and sometimes fillers. You can actually make your own sausage if you know the recipe and have all the time in the world to do it.

Most people buy them  ready-made from the supermarkets  and I suppose they can be rather tasty given the right amount of salt and other seasoning and no wonder the children in question got hooked on this "easy food". But eating them everyday is a bit too much as being a processed food there could be too much of certain items such as pectin or thickening causing their stool to be hard.

To cut the story short, I told the pregnant mother to stop buying and serving the children with sausages for a few weeks and see the effect on their bowel and comfort of life.

True enough after a few weeks of no-sausage meals the children stopped having constipation!

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And  Happy New Year 2014

ASB Unitholders - 2013 Dividend and Lowest Bonus in Five Years and PNB's Lack of Appreciation for Loyal Investors

As the sunset of 2013 is fast approaching, the last of the dividend of the fixed-price PNB unit trust fund that is ASB was timely declared on Thursday 19 Dec for financial year ending on 31 Dec. The unitholders (Bumiputra) will receive a dividend of 7.70 sen per unit and a bonus of 1 sen per unit.The rates are noted to have declined by 0.05 sen and 0.15 sen in dividend and bonus respectively from 2012

There are 8.26 million unit holders who collectively hold 127.2 billion ASB units with the income distribution amounting to a total payout of RM9.38 billion and bonus accounted for RM 706.88 million.

As usual the Chairman of PNB, Tun Ahmad Sarji said that the dividend was competitive amid the global economic uncertainties and that, according to him, the fund could have declared a dividend of 10.54 sen per unit but it decided to bring forward 2.71 sen per unit to help the fund's portfolio to become more competitive in future.

It does look like the fund is forever under declaring its dividend and may,as a result, not really looking after those long-term loyal investors many of whom are elderly and would benefit from a higher dividend in the current financial year. Some have invested since the launching of the fund in 1981 as ASN and later migrated to ASB in 1990, a good 32 years and are now expected to keep looking to the future! Lamented one of my elderly ASB- investor acquaintances. Many of these investors are in the twilight years of their lives.

ASB should have rewarded the above such investors by giving a bonus at least at 1.25 sen per unit to offset a little the lower dividend rate. In short, PNB should value loyalty.

Bursa Malaysia: FBM KLCI Index gaining 200 points
from 1600 over a period of one year , 
Jan-Dec 2013 ( STAR online)

While our stock market is doing reasonably well with FBM KLCI index going from 1600 points to 1800 in the last 12 months, it does not reflect in tandem with the PNB income generation possibly partly due to its portfolio contents.

The fact is 2013's ASB income distribution is lower than in 2012 and the bonus is the lowest in the five year period as seen in the following table. Of particular concern is the performance of its overseas' investments and how they are presented in its annual report. Unlike banks which are regulated by BNM (Central Bank), which body is regulating the mammoth PNB?

ASB Dividend and Bonus 2009 - 2013

Year	Dividend	Bonus
*2009	7.30	1.25
*2010	7.50	1.25
*2011	7.65	1.15
*2012	7.75	1.15
2013	7.70	1.00

* Source: ASB Scheme Annual Reports

Granted that many ASB investors are grateful for the dividend and bonus rate for 2013 and that historically, PNB has never declared income generation inclusive of bonus lower than 8.50 sen per unit, a number is also unhappy with the lack of caring displayed by PNB for its loyal investors, putting them at the same level with new ones who are mostly the y generation who could still keep looking to the future.

On top of this rate reduction, the investors and other Malaysians are being burdened by higher cost of living starting with the removal of subsidy for sugar ( though most of us doctors welcome it), an increased electricity tariff, introduction of GST and now talks of toll rates being hiked as well, all coming in one go. Look like 2014 is not really going to be a happy new year for many low income groups.

In deciding on the dividend and bonus rates for ASB (many investors are low income group Bumiputras), PNB should take into account the current economic situation where cost of living is increasing and the need to reward its long-term loyal investors. 

By the way, is PNB's decision on income distribution and bonus declaration being influenced by external non-market forces? Just thinking aloud.

And curiously, for the first time, I am hard pressed trying to find one -for- the album photo of PNB's CEO appearing with the Chairman at the ceremony for ASB  dividend and bonus declaration for financial year 2013.