Marathon: risks and safety

We all know that exercise is good for our health but few believe in it whole heartedly. The world is divided between exercise lovers and haters. It is difficult for some people to experience the ‘bliss’ of endorphins after a good session of exercise. There seems to be a reason behind it. Some experiments show that the chemical response in body to exercise can differ significantly in different individuals. Some experience a ‘high’ due to secretions of chemicals like endorphins and endocanabionoids. On the other hand, some simply do not produce enough of these chemicals in reaction to the exercise. So they tend to dislike exercise for the discomforts and the muscle soreness that follows. Despite all these factors, people do exercise; if not for pleasure, for the health benefits exercise brings. The scientific evidence for exercise is quite substantial. Most doctors and health agencies prescribe exercise. There is a general consensus that exercise is good for us. The only question remains as to how much exercise is actually good and when does it become too much.

            Endurance sports are known to offer tremendous stress to the body. In a marathon and a half marathon one has to run for 42 km and 21 km respectively. However people seem to like this challenge and we now see increasing number of runners every year in marathons. Some endurance sports like triathlons are even more challenging. A person with a heart condition or illness would not attempt such a challenging physical activity. The people who participate in endurance sports are considered to be virtually healthy . This is one of the reasons why most people are shocked to learn about deaths during a marathon run. They start wondering if marathon and similar events are safe. The media exclusively covers all the events of collapse and deaths during a marathon. Social media also pays enormous attention to these events. Similar instances from the past are retold as a reminder. The articles about dangers of running marathons spring up like mushrooms. However some information is dubious. Most of us are not convinced but these articles usually succeed in creating a lingering doubt. I have seen experienced runners getting worried about the risk of running a marathon. Some people get so worried that they do not let their loved ones run in any event. I was approached by some patients and readers enquiring about my opinion on the risk of endurance sports. I gave it a thought and would like to share some scientific articles which might help you make an informed opinion on this subject .

 

              The biggest concern regarding long distance running is about the number of deaths during marathons. We usually presume that the participants are healthy. This makes these deaths unacceptable even though the number is small. The increasing number of collapse and deaths in the last few years has been a cause of worry. However , we need to consider these numbers closely. The ‘denominator’ is an important part of statistics that is hardly discussed in the media. There was an excellent study conducted in America by Jonathan Kim, Rajiv Malhotra and colleagues which was published in the New England Journal of Medicine in 2012. America had witnessed a total 59 cases of cardiac arrests among 10.9 million runners from years 2000 to 2010. They found out that the risk of collapse and death was more in marathons than half marathons. Around 1in 2 lakhs collapsed in half-marathons while same happened to 1 in 1 lakh during a marathon. They could save around 30 percent of those who had collapsed. That makes the risk of death even lesser. This study mentions that the numbers of cardiac arrest during these long distance running events were less than the number of cardiac arrest occurring in middle aged males jogging in routine life. The study concludes that marathons and half marathons have low general overall risk of cardiac arrest or sudden death.

 

A similar study in Japan showed the number of collapse due to cardiac arrest to be around 1 in 50000. They had a better survival rate in Japan and around half of those collapsed survived the cardiac arrest. So that makes one death in 1 lakh runners. Similar numbers were seen in England. After considering studies from all over the world experts opine that we can expect one cardiac arrest every year and one death every 2 to 3 years in a field of 50000 marathon runners. The experts generally consider marathons to be fairly low risk. I haven’t found any data for Indian running events. I would like to imagine that the numbers of cardiac arrest would be similar in an Indian setting. The survival rate may differ in different parts of the nation. Some cities have excellent healthcare facilities while some places are simply not at par. However overall number might not differ significantly to international estimate. These numbers are not as bad as portrayed by the social media. If we were to compare these numbers to the number of deaths on Indian roads due to traffic accidents, they would shock us. Around 1,37,000 people died in road accidents in India in 2013. This was published by NDTV based on data by various sources including National crime records bureau and Global status report on road safety 2013. This article also states that 5 people die every day on Delhi roads. There were around 1214 road crashes killing around 377 people daily. So if we consider the numbers, it appears that driving on Indian roads is riskier as compared to running a marathon. It is ironic that the everyday news of death in a road accident hardly causes any reaction but the rare death in a running event scares everyone to the core!

 

The number of deaths do not tell us the complete truth. For understanding the risk of endurance sports, we need further information. There are studies about causes of deaths amongst marathon runners. The American study mentioned above also looked into this matter. They found out that amongst all the cardiac arrest cases 52 percent had Cardiomyopathy (which means disease of heart muscle). Majority of these had a specific kind of heart muscle disease called ‘Hypertrophic Cardiomyopathy’. This is a medical condition where the heart muscle is deformed and enlarged in some parts. This causes obstruction in the blood flow when heart rate accelerates. These people are also at increased risk of abnormal heart rhythm and sudden death. This is a genetic condition and people are usually do not show symptoms at rest and routine daily work. There could be a history of sudden death in the family. In the same study, they found that the chances of revival after cardiac arrest are less in patients of hypertrophic cardiomyopathy. This disease is often goes undetected as the  person looks healthy and has no significant complaints. This disease is an important cause of sudden death during a sporting event. Some tests like electrocardiogram (ECG) and Echocardiography can help in identifying this condition.

 

We have an electrical system in our hearts which makes it run rhythmically. If there is some problem in this system, the heart rhythm may go haywire and can lead to death. This is called ‘arrhythmia’ in medical terms. This arrhythmia could be triggered in stressful conditions . This could be a silent medical condition and a person may not experience any problems for long time. An prolonged ECG recording is carried out in symptomatic people. Around 14% of those who had cardiac arrest were found to have such rhythm problems in above mentioned study. Undetected coronary artery disease (usually called as heart attacks ) was found in 16 % people. Around 7 % of those who died had low levels of sodium in the blood and 3 % had died due to heat stroke. Cause of death could not be identified in around 3 % people.

 

It is clear from above data that the majority of those who collapsed had some form of a hidden heart condition. If such conditions could be diagnosed beforehand, these deaths could be avoided. There are certain check-ups and tests for young athletes before major events like Olympics. Similarly, before a sporting event , one should have a complete physical check up , an ECG and blood tests to understand current health. This needs to be looked at by an expert physician especially if there is coexisting obesity, hypertension, diabetes or any other medical condition. The American study also points out a very interesting thing. Usually heart attacks happen due to rupture of fat laden ‘plaques’ in the arteries. This causes formation of a sudden clot in the coronary arteries which leads to heart attack. They found out that this was not the case in case of runners. Most of them had a heart attack due to inability of the coronary arteries to supply enough blood to the fast running heart. This happens due to stiff and thick coronary arteries which fail to dilate . This led the authors to think that a stress test (or treadmill test) could be useful to such patients before marathons. If someone develops a problem during stress test, then he should not be a candidate for long distance race. This stress test might give a false positive result which means that there may not be actual blockage in coronary artery but the test may still be positive. It’s because of this reason that stress test is not routinely advised. But the observations of the study and opinion of authors indicate that it could be used as a helpful test before long distance running. Especially in people with risk factors. There are some studies which indicate that taking an tablet of aspirin can help in reducing the risk. People who have conditions like obesity, hypertension, diabetes , kidney diseases and people with family history of cardiac deaths have higher risk of death than normal population. Similarly, individuals with symptoms like chest pain, shortness of breath, dizziness after exercise are at increased risk. The echocardiography and stress test can also be useful in such people apart from the routine ECG.

 

Doctors can identify people at risk identifying some hidden cardiac conditions with physical examination and tests. It is wise to undergo such examination before training for any sport. The risk of sudden collapse is more in new and inexperienced athletes. Also, the risk is higher in people with sedentary life style who suddenly decide to run a marathon. Preparation for a marathon is of paramount importance. It is usually suggested that one should prepare for around 4 to 6 months for a marathon. In this period , one is expected to practice for 3 to 5 days a week and gradually build up the stamina. There should be adequate time for rest and recovery. Such thoughtful preparation gives our body a chance to withstand stress of marathon. There are programs like ‘Couch to 5K’ in UK where people are helped to start an activity and slowly increase the endurance. Marathon or any long distance running is not something to ‘try’. It needs careful planning .

 

Long distance running stresses not just the heart but our whole body. Muscles, bones, lungs, kidneys and other organs, all face the stress of the exertion. This stress could be immense, especially in challenging weather conditions and may lead to other dangers. Our body loses sodium with our sweat. During marathons, this minor loss could turn out to be significant. If a runner drinks a beverage without any salt (like plain water ) during a marathon, the sodium levels in blood could drop to dangerously low levels. This is called hyponatremia in medical terms. Adding salt to drinks can help in preventing this problem. Adequate water intake keeps our body working properly. During a marathon run, muscles can get damaged due to over exertion and this may lead to leaking of myoglobin from the muscle into the blood. The myoglobin is a big protein compound which can obstruct functioning of the kidneys. If one is dehydrated then it puts additional stress on the kidneys as well. Staying hydrated also helps in regulating the temperature of our body. This will give you an idea about how important it is to keep drinking enough fluids with electrolytes. The drink should contain enough salts to maintain sodium level. Adequate carbohydrate intake is equally important before a marathon. Carbohydrates are our energy source and need to be replenished to cope with the efforts of a marathon. People on diet and trying to lose weight should bear this in mind. Food and drink need a careful thought before attempting a sporting event, Planning it ahead of the event helps and reduces the risk of developing complications later.

 

India has hot climate for most part of the year. This presents new challenges. There is a certain danger of heat stroke in hot climate. Heat stroke is a condition where the body fails to regulate its temperature and the body temperature starts going up. This could prove fatal. Wearing suitable clothes, staying hydrated and getting acquainted to the weather conditions are some things that can prevent a heat stroke. Excessive fatigue, dizziness, vomiting or feeling sick are some of the symptoms of heat stroke. If you experience any of these then you should stop and seek medical help immediately. A fever also increases the risk of heat stroke. So even minor infections and viral fevers should not be ignored. If you have a fever or are not feeling well, it is better to avoid a run.

 

Running, like other sports, has an inherent risk of injury to muscles and joints. Good preparation is again a key to evade this. A well prepared athlete is less likely to sustain an injury. I believe that coaches and trainers can help you in avoiding a injury . There is usually a fear of damage to the knees amongst the general public. Some studies however show that running could actually be beneficial for health of the knees. Athletes have shown to have many health advantages over people with sedentary lifestyle. So overall benefits of running are more.

 

We have so far talked about efforts at individual level. Organisers should also try to provide infrastructure for safe marathons. Early CPR (cardiopulmonary resuscitation) and prompt use of defibrillators have shown to improve the survival in case of a cardiac arrest. Provision of such facilities and medical backup can help. The record of adverse events and medical problems can help in further identifying risk factors. I recently visited Spain where a marathon was conducted at night. Such policies can be used in India to avoid heat strokes.

 

Marathons and long distance running events have some definite risks as they puts lot of physical stress on the body. This risk can be reduced by proper preparation and training before a marathon. Individual factors also play a role. Some individuals have high risk while some have low risk. Such individual risk assessment can be done with physical examination and medical tests. People with high risk can avoid marathons or can seek professional advice. Although it is a tough physical challenge, Marathon is not as dangerous as portrayed by the media. If you want to run a marathon then there are safe ways to do so. You need to acknowledge the risk and effort involved and prepare for it. Staying away from the ‘fads’, avoiding scaremongering and seeking help from experts are some ways to make it easy.

 
Dr Renuka & Dr Vinayak
 
हा लेख मराठीत वाचण्यासाठी लिंक:
 
 
 

The dark clouds and the silver lining

img_20160523_152937

The nurse quickly put a cannula in his vein. Someone tore apart his vomit soaked clothes with a hope of preventing further absorbtion of poison from the skin. While he was paralysed by the insecticide and was  choking on his own secretions, I quickly put a tube in his windpipe and  connected him to the ventilator. Another tube was passed through his foodpipe, into the stomach, to remove the poison. Someone took blood samples for investigation. The resuscitation scene looked chaotic as usual. The peculiar odour of  organophosphate compounds spread through the room. I was quite sure about my clinical diagnosis. It took nearly six hours to stabilize him. Rahul was a young married man with a job and was not suffering from any medical conditions. There were no clues in his medical history to indicate a cause for his attempted suicide. Once Rahul’s medical condition had stabilized I could speak to the family. They were shocked with the incident as it was totally unexpected . I started digging into Rahul’s story. Since past few months, he had lost his sleep. He was not eating properly and looked worried. Rahul was really good at playing guitar but had stopped playing it for sometime now. He hadn’t met his friends in last two months. He was also unhappy about his job but refused to discuss it further with his wife. He clearly showed symptoms of depression but his family was unaware about the seriousness of the condition. The day before he tried to kill himself, Rahul had visited his brother. Rahul told his brother that he felt very depressed , empty and  had thoughts of killing himself. The brother, unaware of the situation, assumed that Rahul was just upset due to job troubles and would not harm himself. He tried to cheer Rahul up. He told Rahul not to be a coward and face life with enthusiasm! Unfortunately the brother failed to understand that Rahul would really try to kill himself. Before landing up on ventilator, Rahul had given us a chance to save him. We missed it. He is one amongst many who are neglected by family and friends due to ignorance and apathy.

Depression kills. According to one report, depression shares around 4.4 percent of total disease burden. Around 5 to 13 percent of outpatient visitors have depression, which is very high. The risk of death from suicide and other medical conditions like heart disease , stroke etc is higher in depressed patients. Though a humongous problem in itself, what concerns me more is our apathy towards the condition. Stupid memes and derogatory remarks on social media is just the tip of iceberg. As doctors, we can clearly see the scornful attitude of people around the patients of depression.

Depression is not mood. Rather, it is a mood disorder. Depression as a medical condition is usually seen with either major depressive illness or bipolar mood disorder. In contrast to depressed mood, depression is sustained for a longer time and affects the person’s physical and social health along with mental health. Unlike blue mood, it is difficult to simply cheer up a person out of depression. It needs medication and expert help.

Many factors are thought to be responsible for this condition. For example, emotional triggers (like loss of dear ones) or underlying medical conditions (like  cancer ) can cause depression. Conversely, as seen in many, there may not be any trigger. Various factors, including hormonal and chemical imbalances in the brain , genetic factors and environmental factors are thought to be associated with depression. However many of us ignore this and tend to believe that the depression is due to lack of mental strength. Patients are accused of being weak or coward and incapable of facing life. (Especially if there isn’t any obvious stressor). We need to understand that they are not cowards but they are sad because of a medical condition. Some people around the patients are unaware of depression as an entity. They go about their personal triumphs and expect patients to follow their example and ‘be tough’ which obviously doesn’t work. Patients instead need  expert consultation, risk assessment and medical treatment. This has been proven to be a life saver.

Listening compassionately helps a lot. Patients often feel lonely. It becomes harder especially if treatments take longer than usual or if they  get recurrent episodes. Support from family and friends is  always helpful. Showing interest and empathy makes them comfortable in talking to you. The patients, who would  otherwise have retracted into a shell , often share their sorrows with a sympathetic friend, sometimes even a cry for help.

The stigma around mental health issues leads to apathy. Ignorance towards depression and mental health worsens the situation. We need to know about depression and empathize with these patients. A literary example would help you to picturize this.  JK Rowling has described depression in her famous books in the form of fictional creatures , dementors.

Dementors are among the foulest creatures that walk this earth. They infest the darkest, filthiest places, they glory in decay and despair, they drain peace, hope, and happiness out of the air around them… Get too near a Dementor and every good feeling, every happy memory will be sucked out of you. If it can, the Dementor will feed on you long enough to reduce you to something like itself… soulless and evil. You will be left with nothing but the worst experiences of your life.

Anyone who has seen a depressed person or has suffered depression can relate to this. Depression is as horrible as dementors but there is a hope. One can fight dementors. There is a charm called Patronus which works wonderfully against dementors. Our compassion and knowledge can guide us to produce a patronus. Let’s fight depression, together! Expecto patronum!!

Dr Vinayak Hingane & Dr Renuka Hingane.

हा लेख मराठीत सुद्धा वाचू शकताकाळे ढग आणि चंदेरी किनार

Effects and Adverse effects

IMG_20160625_124642

 

The patient walked in to the casualty with her face drooping on the left side. Her appearance alarmed the medical officer who thought that it looked like she had suffered a Stroke, a medical emergency! The resident physician examined the patient and suspected that there could be something more to the story than meets the eye .  He wasn’t convinced about it being a  Stroke. He dug deeper into the history and to his relief , it wasn’t a Stroke. His clinical findings were consistent with the story narrated by the patient. A few days back, she had received an injection of Botox for reducing her wrinkles . The Physician concluded that her drooping face was an adverse effect of that injection. She was happy to know that it would get better over time. She wasn’t aware that there could be side effects of the Botox injection and  neither did she regret having had it. Adverse effects of a desired treatment are often neglected!

In clinical practice, we come across many patients who get kidney diseases due to inappropriate intake of pain killers. Some get into trouble due to unsupervised treatment with medicines like steroids. Many adverse effects of medicines can be easily avoided. One just needs to remember that medicines have various  effects on our bodies, many of which may not necessarily be desirable. If we know that there could be some undesirable effects then we can report them earlier, get them treated  even change the medicine if necessary. Let’s discuss a few things about the good effects and adverse effects of medicines.

Whenever we take a medication, it causes some effect on our body. Rather, we choose active ingredients from substances which have effect on our body, as medicine. We can grossly differentiate such effects as expected and unexpected effects. Expected effects can be further classified as desirable and undesirable effects.

Most of the expected effects are desirable , which are beneficial for us; while some are unwanted or undesirable. The beneficial effects help us to get relief from our conditions while unwanted effects are known as side effects.These side effects could be benign or could be severe. Sometimes desired effect in excess can be troublesome and we may consider it as an adverse effect. Let’s see some examples. If someone takes a  laxative for constipation, then he might get excessive loose motions. This effect is expected but would be unwanted . Another example would be weight gain with some of the anti-diabetic medicines. The weight gain is expected but unwanted. Such adverse effects are sometimes tolerable and doctors can involve the patient in deciding whether the medicine should be continued. Most of the medicines are used only when the possible benefits outweigh the risk of side effects.

On other hand, there is a range of adverse effects which are unexpected. These are the effects of medicine which might  occur in a particular individual. This could be due to an allergic reaction to the medicine or due to idiosyncrasies. Such adverse reactions do not occur in everyone. They are person specific. We can not give the  same medicine to that particular person as it can cause catastrophic reactions. In such cases, there should be a record of what kind of reaction occurred to what drug. This record should be with the patient during each consultation and hospital admission.

Some of the adverse effects occur in certain age groups. For example some medicines are safe in adults but can be harmful in young ones. Because of this, even if the child has similar symptoms to those of adults, we cannot give the same medicines to the child without confirming with the doctor. Medicines have different effects and adverse effects in the elderly. Many adverse effects are also more common in the older population. We also need to be more cautious about medication in pregnant and breast feeding ladies, as the medicines given to the mother can harm the baby.  Some side effects can occur due to interaction between two different medicines.

Your doctor will usually look into all these aspects and then prescribe your medicines. The doctor may also warn you  about the possible side effects and what to do if they occur. You should always ask about the side effects of the medicines prescribed by the doctor. You should also  read the instructions on the medicines. If there is any doubt about the instructions, you should get it cleared. Many medicines have information leaflets which can be very useful.

Despite these precautionary measures, some patients may suffer from side effects. As we discussed earlier, the medicines are given only when the benefits outweigh the risks.  For example, the antivenom treatment for a snake bite can cause a severe allergic reaction. But if it is not administered, then the snake venom can kill the person. So we have to accept the risk of adverse reaction in order to save life. However , if the situation is not life threatening, the patients can choose the treatment amongst the available options or can even refuse the treatment if the side effects are undesirable.

An irrational fear of the adverse effects is  also as equally dangerous as ignorance of  it. Some people reject essential and life saving medicines for fear of side effects, only to find out that not taking the medicine has harmed them more. Some people think that modern medicines (or Allopathy ) have very strong adverse effects and other medicines (like traditional medicine) are mild and have no side effects. Such thinking is simplistic and often wrong. In modern medicine, we have a system to keep a check on adverse events and to declare the medicine unsafe if necessary. So called “mild and safe” traditional /alternative medicines are not necessarily safe. One of my diabetic patients had an irrational fear of modern medicines in general. He started taking  some alternative medicine which did not cause any side effect but at the same time had no effect on his diabetes. He had to be admitted with complications of uncontrolled diabetes and was in serious trouble. He was treated in an intensive care unit and thankfully his life was saved. He was later started on modern medicine which he tolerated very well. His diabetes is now well controlled.

People tend to think that medicines with doses like 1000mg or 500 mg  are stronger and have more side effects than medicines with smaller doses in mg. This is not true either. Every medicine needs to be taken in a specific dose to have desired effect. For some medicines this dose could be in micrograms while for others it is in grams. A medicine with a  dose in micrograms can cause adverse events while some might be extremely safe even when taken in doses of grams.

Our tendency to generalize about medicines and side effects takes us nowhere. Know more about your medicines and stay safe!

Dr Renuka and Dr Vinayak Hingane

Conspiracy Theories are in vogue

Screenshot_2015-11-30-21-54-09

Diabetes is a common condition. The progressively increasing number of people with diabetes is worrying. Changes in diet and living conditions are some of the reasons behind the rising diabetic population. Better and easily available diagnostic facilities help us to reach more people with diabetes and help them to fight it. Recently I came across one post on social media which claims that the diabetes is being over-diagnosed because of influence by pharmaceutical companies.This post has tried to sound like a fact based  but it is just another conspiracy theory. I felt annoyed with it, because such posts misguide patients and make them feel fooled .

Diabetes is broad term. There are many types of diabetes. Two important types are Type 1 Diabetes Mellitus and Type 2 Diabetes Mellitus. Type1 diabetes is characterized by deficiency of insulin hormone. Insulin is one of the important hormones secreted by the pancreas . Insulin tries to reduce the blood sugar level while other hormones try to increase the  blood sugar level. The balance between these two forces keep the sugar level in control. In type 1 diabetes, secretion of insulin from pancreas is reduced significantly. Due to this the blood sugar level is very high. This diabetes is usually seen in young age and often diagnosed when the patient develops symptoms . The blood sugar level can be so high that it might not be recorded on glucometer. These patients need admission in hospital and diagnosis of diabetes is often made during such admissions. These patients need insulin injections to keep up with the deficiency of insulin in the body.
Now let us look at type 2 diabetes which is more common. This condition develops gradually and has many stages before it can manifest as diabetes.This condition develops because of many factors. Some of these factors are correctable like excess weight, lack of exercise and faulty diet while some of the factors are unavoidable. This condition starts with resistance to the action of insulin on cells of our body. Thus there is unopposed action of other hormones and blood sugar level tend to increase. Body tries to correct this by increasing secretion of insulin. In this early stage, the patient’s blood sugar level remains in normal range and there are no symptoms. Gradually, the resistance to the action of insulin increases to a level where it is not possible for the body to compensate and blood sugar level starts rising. In this stage , fasting blood sugar level could be in between 100 mg/dl to 125 mg /dl . This stage is called as pre-diabetes. This stage is not diabetes but the person is at risk of developing diabetes. Doctors do not prescribe any medication for this stage.
In the next stage, the fasting blood glucose level rises to 126 mg/dl or more. The resistance to insulin continues and pancreas get fatigued by  continuously trying to compensate; due to this the insulin level starts  going down while the sugar levels after meals tends to rise more . If a glucose tolerance test (GTT) is performed at this stage, which involves checking blood sugar levels 2 hours after consumption of 75 gm glucose , then the  results are more than 200 mg /dl. Doctors prescribe a medication called Metformin which helps to reduce the insulin resistance. There are some more tablets which increase insulin secretion and can be used as needed. As diabetes grows older , these medicines cannot keep up the insulin levels and sugar levels are not controlled. This is the next stage of the condition and insulin injections are needed in such situation.
Over last few decades, our understanding of TYPE 2 Diabetes has improved. Obviously, the better understanding of the disease leads to changes in practices by doctors. New approaches and strategies are introduced. Some of these strategies turn out to be excellent and revolutionary while others are discarded over  time. We have understood recently that the pre-diabetes stage is really important. Studies have shown that if people in pre diabetic phase reduce around 7% of their body weight or exercise half an hour daily, then they can reduce the chances of developing diabetes. This is the only possible way of avoiding diabetes and medication. Once the condition is advanced we have to take medication to control it. Why would pharmaceutical companies give us a chance to avoid medication by promoting diagnosis in early phase! As I have mentioned earlier, doctors will not treat pre diabetes with medicines. A diagnosis of pre-diabetes (fasting blood sugar 100mg/dl to 125 mg /dl ) thus does not help pharma companies but helps us to try and avoid or at least slow down the process of diabetes. This social media post has used only partial information to scare and misguide people.
This conspiracy theory post also gives a feel as if doctors diagnose diabetes based only on sugar level. Even the discussion in my post has eventually been about the blood sugar levels. Just to clarify this , the diagnosis of diabetes made by any qualified doctor is usually a combination of patient`s symptoms and laboratory results. If the blood sugar levels exceed the normal limits and the patient has symptoms of diabetes, then the diagnosis is easy. But if the sugar levels are in doubtful range then the doctors weigh the symptoms, signs, family history and  associated conditions. If necessary the doctors can ask for a test called HBA1C which gives an idea about blood sugar level control over the last few months. A glucose tolerance test is conducted to check patient`s response to a glucose load. Sometimes doctors choose to wait for few weeks to re-check sugar levels before starting treatment.
Diabetes has many aspects apart from blood sugar levels. Many patients show great courage and determination to change their diet and lifestyle to fight with diabetes. Social media posts like the mentioned post and advertisements try to portray modern medicine as a villain. They attack doctors for their malpractice, pharma companies for their profit oriented attitude and medicines for their side effects. Many patients have insecurities and such misleading posts add to those those insecurities and fears by quoting half-truths and lies. Products like effortless weight loss remedies and treatments for diabetes without medication are the examples where businesses thrive on the insecurities of patients.
This article is just an attempt to show how truth is twisted in some media posts and advertisements. This also gave me an opportunity to discuss about the basics of diabetes. Please comment, share and discuss any doubts or thoughts you have!

Lets talk about smoking

064

Once in a group discussion, a girl was talking about the financial losses caused by smoking.  To counter her argument, a boy came up with an objection about the cost of cosmetics used by girls. According to him, girls use expensive cosmetics and probably spend more money than boys do on smoking! Obviously this statement turned the discussion into a fierce “boys versus girls” debate! Most of us would think that the point raised by the boy was irrelevant. It is not logical to compare smoking with cosmetics. We can see that this boy had perceived smoking as the “male” issue and cosmetics as the “female” issue. In India, where smoking is much more common in males as compared to females, smoking is considered as an issue related to men. This lead the discussion in the wrong direction and the focus drifted away from the ill effects of smoking. Many of us must have experienced a similar situation. Talking about smoking to a friend, relative or family member who smokes is usually a tough task. They come up with strange counterarguments, get irritated or do not speak up at all.  We need to dig deeper into the issue to understand why it is difficult to convey that smoking is a bad.

It is proven beyond any doubt that smoking is injurious to health. Many smokers have experienced it too. Most of them agree to it but still one may find it hard to talk to someone about his/her smoking. The reason could be lack of proper communication. As it happened in the above example, unnecessary generalisation could be one reason that we may lose an opportunity to communicate effectively with a person who smokes. It is true that in some countries, the proportion of men is significantly more than women amongst smokers. In such a case, one should be very careful. By going with statistical correlation, we might inappropriately attribute the cause and effect of smoking to male gender. Nobody smokes just because he is a man! No woman smokes to state that she is a feminist. Similarly, ‘stress’ is a common trigger for smoking but it is not necessary that every smoker will have underlying stress. Every individual can have a different reason to smoke. Not that any reason could be valid for smoking but it is important to know why someone smokes. Then it would be easy to address the cause of smoking. Assumptions make conversation difficult.

Generalization of the effects of smoking could also have a similar effect. For example, imagine someone who doesn’t mind getting a cancer due to smoking.  He/she might argue that cancer may be caused by multiple reasons other than smoking. Many people choose to smoke in spite of knowing most of the health hazards associated with it. Talking to them about the ill effects of smoking could annoy them or make them believe that you are just another preacher. This doesn’t mean that the discussion is a waste. They may have some concerns which no one has spoken to them about. It is a good idea to assess their knowledge and concerns first and then talk about the specific issues.

I agree that it could be difficult at times, not to get mad at your loved ones who smoke. It is exceptionally hard to see your family member/friend to lose their perfect health to smoking. But we need to be sympathetic towards people who smoke. A person addicted to tobacco will develop a craving for it. Sometimes the craving is so severe that they need help. So, in spite of a strong resolution, they may fail to quit smoking. Family or friends get so irritated with this, that they start accusing the person for their attitude. Being gentle and trying to keep them motivated can help in such situations. For example, consider that someone has cut down on the number of cigarettes but hasn’t completely stopped. In this case we should congratulate him/her for this effort and encourage him/her further to quit smoking rather than blaming and criticising for the continued smoking. In such instances we should get into details. Check whether the person is really motivated or not. If the person isn’t really motivated, we should not get frustrated but instead start working on motivation again. Being a non-smoker, it is difficult for me too, to understand a smoker’s point of view. But as a doctor, I need to accept smoking as a lifestyle chosen by the patient. I can try to convince or warn a patient, but forcing an opinion can be counterproductive. It is the individual’s will to quit smoking which matters the most. Our role in smoking cessation is that of a facilitator and the process is driven by the individual. If we take the driver’s seat then it could become a problem. Smoking cessation experts and support groups can help as well. I would like to mention that being sympathetic does not mean that you should risk passive smoking. Being sympathetic and to allow someone to smoke are not the same. You can ask them not to smoke when they are with you or around children.

I think that talking to someone about smoking cessation is really challenging. Some of our assumptions make it tougher. It is widely believed that it is impossible to quit smoking. Many of us might have given up our attempts to convince someone after a while. It is true that smoking cessation is difficult and people may start smoking again. It is also true that chances of smoking cessation are higher in persons who continue to try. So, it is prudent that we continue to try to convince our loved ones to stop smoking with the same spirit. Many people quit smoking successfully. I have seen a grandpa quit smoking very easily after his grandson asking him to quit. When I asked how he managed to quit so easily, his answer was simple. “Nobody had ever asked me to quit. So when my grandson asked me, I just quit “. No two smokers are same. Not all elders are intimidating and not all youngsters are difficult.  Our previous unpleasant experiences with smoking talks could be due to communication barriers and prejudices we carry. It is natural to get anxious or scared about the health of our loved ones but planning our smoking talks instead of speaking out your worries and anger can help. We need to fight smoking together. This article is written to share my experiences and concerns with friends and families of people who smoke. Please comment and share your experiences.

Fathers beware!

Last week’s New England Journal of medicine has published an interesting article called ‘Epigenetic Signature of Obesity’1. Though it is “genetics” and “research”, it is not very difficult to understand if we simplify some of the things. In fact, the concept inheritance not alien to us. Article is about how overeating related obesity is transmitted from one generation to the next. It also gives us some food for thought.Here is my attempt to discuss the article in simple language with a try to avoid medical jargon.

From ages we know that children inherit some of their features, traits and qualities. Like father, like son. Despite of this knowledge, we do not know how exactly this happens or to what extent! No parents and children are exactly alike. We understand some of the mysteries of this complex world of inheritance as we understand chromosomes, DNA, genes and proteins. In simple terms one can say that genes are responsible for transfer of some of the features or some diseases from one generation to other. However some features or variation in the traits can be independent of the genes. The study of such cellular or physiological trait variations which are not caused by changes in the DNA or genes is called ‘epigenetics’. Obviously environmental factors also play a significant role in the expression or variation in different traits.  So after knowing what epigenetics is about, now we move to the story of this interesting experiment Anita Ost and colleagues described in December 2014. 2 They used flies (Drosophila) for their experiment. They fed some of the male flies a diet high in sugar. This high sugar diet increased their fat (triglycerides) level (yes! it is similar to what happens with us humans) and they used another groups of male flies which were fed on normal fly food or very low sugar food. They got remarkable results in the offspring. These offspring were also divided in groups and were fed on high-sugar and normal diet. The adverse effect of father’s diet was not evident in offspring fed on normal diet. But in the group of offspring fed on high sugar diet showed that role of father’s diet was very important indeed. The progeny of flies fed on either very low or very high sugar showed increased levels of fats (triglycerides).

We already know that mother’s nutritional status affects the child in the womb. This is called as developmental programming. A study by Dr Yajnik from India ‘Transmission of obesity-adiposity and related disorders from mother to the baby’ is one of the studies which emphasize such effect. 3 Children of the mothers who are undernourished or overfed have higher chances of getting obese. Now, one has to ask the question whether father’s diet or nutritional status affect children? The answer is yes. Obesity related changes were seen not only Drosophila flies, but mammals such as mice and humans also show chemical changes in the chromatins (which are complex structures made up of DNA , RNA and proteins) . These scientists were also able to show the imbalance caused by such changes affected one particular protein named Su(var). They have found one clear ‘signature’ for obesity! So apart from genes, there are ways by which a trait like obesity can express themselves from one generation to other and environmental factors like diet can affect it.

Scientists will use this information to further benefit and we might get new tests to diagnose our susceptibility to obesity. We might even find treatment for it in the future. For now, we should think that how can this information help us apart from academic interest? Diet and other lifestyle related factors affect us immensely.  Wrong food, sedentary lifestyle and risky habits like smoking damage your health; make you prone for diseases like obesity, diabetes and heart disease. Now we know that parent’s diet can affect children as well. In one study by Ng SF, it has been seen that high fat diet in fathers is related to beta cell dysfunction in daughter rats4. (Beta cell dysfunction can cause diabetes). We may actually damage beyond our own body and affect our children with faulty diet. Probably we have to be careful with other lifestyle-related risk factors as well. However there is also a possibility of reversing this effect by adopting a healthy lifestyle. You can be healthy if you want! Embrace the healthy diet, teach your children to eat right food and stay away from obesity and related problems. (Now there could be a debate upon what is right and what is wrong to eat. You are free to choose a healthy and balanced diet for yourself!)

There has always been an emphasis on mother’s health and her ‘responsibility’ for the baby’s health. This article in a way shows us that father is equally responsible for the baby’s health. Not just socially but also physically. Not only his genes but his lifestyle can affect the baby. So shouldn’t it be the duty of a future father to try and stay healthy? Many factors like diet, smoking and sedentary lifestyle can be modified. It will make fathers healthy and they could pass on the inheritance of health. So fathers beware!

References:

  1. Susan E Ozanne. Epigenetic signatures of obesity. NEJM2015;372;973-974.
  2. Ost A, Lempradl A, Casas E, et al. Parental diet defines offspring chromatin state and intergenerational obesity. Cell 2014; 159; 1352-1364

3.Yajnik CS. Transmission of obesity-adiposity and related disorders from mother to the baby. Ann. Nutr Metab.2014;64 suppl 1:8-17

4.Ng SF, Lin RC, Laybutt DR, Barres R, Owens JA, Morris MJ. Chronic high-fat diet in fathers programs Beta cell dysfunction in female rat offspring. Nature2010; 467:963-966284