Cover en Sat May 04 12:36:13 IST 2019 dos-and-donts-of-dieting <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p><b>AT THE OUTSET,</b> it is important to know that the food plan you choose to follow on a daily basis for long-term benefits is a lifestyle change and not a 'diet'. However, if you want a restricted food regime—which is then a diet—there are certain things you should keep in mind.</p> <p>&nbsp;</p> <p><b>Qualified help</b></p> <p>These days, there is a plethora of self-proclaimed nutritionists who claim to be experts because they lost a tonne of weight. This does not qualify them as experts.</p> <p>&nbsp;</p> <p><i><b>Do:</b></i> Consult a qualified nutritionist</p> <p><i><b>Don’t:</b></i> Fall for quacks</p> <p>&nbsp;</p> <p><b>Supplementation</b></p> <p>Nutrition is a subject wherein people have a lot of information but lack knowledge. With TV commercials and online advertisements, it is easy to fall prey.</p> <p>&nbsp;</p> <p><i><b>Do:</b></i> Get your values checked and then visit a medical nutrition therapist, who will help you supplement as per your needs</p> <p><i><b>Don't: </b></i>Supplement over the counter</p> <p>&nbsp;</p> <p><b>Consistency</b></p> <p>Make your healthy meal pattern a lifestyle modification. Compliance to the plan is what will give you results.</p> <p>&nbsp;</p> <p><i><b>Do:</b></i> Follow the plan with consistency</p> <p><i><b>Don’t:</b></i> Overdo the plan or binge eat</p> <p>&nbsp;</p> <p><b>Starvation</b></p> <p>Starvation has a boomerang effect. The body needs a basic amount of calories to go through the day. When you starve, you lose weight, not fat.</p> <p>&nbsp;</p> <p><i><b>Do: </b></i>Take small frequent clean meals</p> <p><i><b>Don’t:</b></i> Skip meals or starve</p> <p>&nbsp;</p> <p><b>Consume fat</b></p> <p>Consuming fat can help lose fat. Fat has been tarnished for way too long. However, all fat is not bad fat. For example, omega-3 is one such fat which helps burn fat.</p> <p>&nbsp;</p> <p><i><b>Do:</b></i> Embrace healthy fats</p> <p><i><b>Don't:</b></i> Consume saturated fats, trans-fats</p> <p>&nbsp;</p> <p><b>Cravings</b></p> <p>Cravings are natural. Don't be penny wise and pound foolish. It is OK to satiate your craving with a small portion. This will help you stay on track.</p> <p>&nbsp;</p> <p><i><b>Do:</b></i> Keep yourself well-fed to avoid drops in energy levels, which will lead to cravings</p> <p><i><b>Don't:</b></i> Hound yourself. Exert portion control on your cheat meal. Do not make it an entire cheat day and jeopardise all the effort you put in</p> <p>&nbsp;</p> <p><b>Eat smart</b></p> <p>Eating out can be a challenge. But do not let your diet stop you from socialising. Making the right choices while you eat out is important.</p> <p>&nbsp;</p> <p><i><b>Do:</b></i> Ask for substitutes and dressings by the side. Walk through a buffet before you load a plate. Eat mindfully and be aware of the choices you make</p> <p><i><b>Don’t:</b></i> Eat out of boredom or because you are sitting at the table for longer. Do not give in to peer pressure</p> <p>&nbsp;</p> <p><b>Share the sin</b></p> <p>Desserts can be a weakness. A teaspoon or two will not make much of a difference. However, if you have sweet tooth, you are likely to consume more than that.</p> <p>&nbsp;</p> <p><i><b>Do:</b></i> Share your dessert. This way there is no guilt but you are satiated</p> <p><i><b>Don’t:</b></i> Be greedy and eat an entire portion of dessert.</p> <p>&nbsp;</p> <p>—<i><b>Chanduwadia is chief dietician, Jaslok Hospital and Research Centre.</b></i></p> Sat Mar 07 15:46:27 IST 2020 my-only-vice-is-getting-hangry <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p><b>What diet do you follow?</b></p> <p>&nbsp;</p> <p>I do not believe in the term 'diet'. I prefer a nutritious and healthy meal that [becomes] a way of life.</p> <p>&nbsp;</p> <p><b>What is your daily food plan?</b></p> <p>&nbsp;</p> <p>My breakfast is fruits and black coffee. I usually have a bowl of papaya, dragon fruit or an apple. Mid-morning, I eat oat chillas (crepe) for carbs. I love my Indian home-cooked food. My favourite vegetables are pumpkin, cauliflower and bhindi (okra) and for protein, I add some lentils. I usually repeat my lunch for dinner. Midday, I snack on seeds, nuts, cucumber or a fruit and have my second and last cup of black coffee.</p> <p>&nbsp;</p> <p><b>What is the best part about the diet you follow?</b></p> <p>&nbsp;</p> <p>It is nutritional and easy to maintain and I stick to it, no matter where I am.</p> <p>&nbsp;</p> <p><b>How has it helped you in terms of weight loss and fitness?</b></p> <p>&nbsp;</p> <p>I try and be vegetarian when I am at home. If I am at a restaurant or travelling, then I am a pescatarian. Ever since I switched to vegetarian food, I have felt lighter, happier, less moody and more energised. I have never really been to a dietician or followed any plan as I have never had to make any drastic changes. But over the years, I have met many people and taken inspiration from them to plan my meals—whether it was including salmon in my diet for omega-3, or the benefits of several seeds and plant-based protein. I think everything is easily available online today and it also helps that a lot of organic and healthy food restaurants have come up.</p> <p>&nbsp;</p> <p>The one thing that has worked for me is reducing my salt and oil intake and giving up refined sugar completely. I took a food intolerance test once when I realised I was intolerant to gluten and lactose, and giving up those have helped cut down the bloating. It is important to understand your own body. What works for me does not necessarily work for you. Everything in moderation and balanced is a healthy and sustainable way of living.</p> <p>&nbsp;</p> <p><b>What about cheat days?</b></p> <p>&nbsp;</p> <p>I could live on sushi and south Indian food. These are two cuisines that make me super happy! I can never resist a chocolate dessert. I do not dedicate a day of the week to cheat, but if I am on holiday or celebrating an occasion or festival, then I allow myself to enjoy the food. All I do is portion control and make sure I go back to my routine the next day. Having said that, I feel a cheat meal is important once in a while to shock your body and change things up.</p> <p>&nbsp;</p> <p><b>Was there a time when you starved yourself?</b></p> <p>&nbsp;</p> <p>I have never starved. My only vice in life is getting hangry (angry when hungry). So I have to eat when I feel hungry. I could not possibly put myself through that.</p> <p>&nbsp;</p> <p><b>Was there any diet you followed which did not work?</b></p> <p>&nbsp;</p> <p>I have never tried a diet. It is a fad, and in my opinion, anything that cannot become a lifestyle is not worth it, nor is it healthy to sustain. No quick fixes, in my opinion.</p> Sat Mar 07 15:45:25 IST 2020 the-big-meal-deal <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>At 67, T.P.C. Mani feels fit as a fiddle. For the past 15 months, he has been fasting 17 to 18 hours every day. He eats only two meals a day, ensuring there is a gap of six to seven hours between both the meals. Through the day, he sips water and buttermilk alternately to avoid feeling hungry. He weighed 78kg before he started the diet, and within two months, he shed five kilos. He now weighs a healthy 70kg, which has so far remained constant. &quot;I tried a number of other diets before this one, but nothing seemed to really work,&quot; said the Mumbai sexagenarian who used to work for an MNC. He begins his day with a wholesome breakfast and has lunch at 2pm. His next solid meal is the next day's breakfast. &quot;My body has gotten so used to it that I do not feel hungry in-between. The liquids fill me up. The best part about this diet is that it does not restrict me in any way. I can eat anything I want as far as I am eating only twice a day, and that too when I feel very hungry,&quot; said Mani.</p> <p>&nbsp;</p> <p>Mani reveals that he follows what is popularly known as the Dixit diet. It was somewhere in the first quarter of 2019 that the two-meals-a-day diet plan—named after Dr Jagannath Dixit, a then low-profile medical college professor from Latur, Maharashtra—gained popularity as a magic formula for weight loss, especially for the obese and diabetic. Soon enough, millions tuned in to Dr Dixit's YouTube lectures. By November, he was appointed as the brand ambassador of Maharashtra's anti-obesity and anti-diabetes campaign, much to the chagrin of the state's Indian Medical Association, which demanded a scientific validation to his diet plan that advocates just two meals a day. The doctor, who is now associate professor at the Government Medical College, Aurangabad, recently presented his book to Prime Minister Narendra Modi, claims that if one diligently follows the diet, not only will it lead to an average weight loss of 6.8kg in six months, but it will also steady sugar levels and might even result in a “reversal of diabetes”. “The logic is simple,” said Dr Dixit. &quot;We have essentially been a civilisation that has been used to eating twice [a day]. Our cells and bodies are designed for starvation and not for over-eating. The food we eat is broken down by enzymes in our gut and eventually end up as molecules in our bloodstream. Carbohydrates are quickly broken down into sugar which our cells use for energy, or if not used, it is stored as fats. But sugar can only enter our cells with insulin, a hormone made in the pancreas. Insulin brings sugar into the fat cells and keeps it there. Between meals, as long as we do not snack, our insulin levels will go down and our fat cells can then release their stored sugar, to be used as energy. We lose weight if we let our insulin levels go down because raised levels of insulin are by and large the culprit for weight gain and type 2 diabetes. So the logic is to reduce the secretion of insulin by reducing the number of times one eats. You can eat twice when you are really hungry. The time gap is of no consequence.&quot;</p> <p>&nbsp;</p> <p>Many of his followers, he admits, have confused his diet with that of intermittent fasting (IF). The Journal of Clinical Medicine, which conducted studies to analyse the efficacy of IF as a foolproof weight-loss method, observed: &quot;In healthy, normal weight, overweight or obese adults, there is little evidence that IF regimens are harmful physically or mentally. Almost any IF regimen can result in some weight loss. Among the intervention trials included in this review, 84.6 per cent reported statistically significant weight loss.&quot;</p> <p>While Dixit emphasises limiting the number of meals to two, intermittent fasting involves eating only during a certain window of the day (eight hours) without restrictions, and fasting the rest of the time (16 hours). In essence, in both diets, the idea is to allow the insulin levels to go down far enough and or for long enough that we burn off fat. In IF, one can either eat during a certain window every day or on certain days of the week or eat normally for five days a week and control calorie intake on the remaining two days.</p> <p>&nbsp;</p> <p>Neha Bhise, mother of a two-year-old, enrolled with a nutritionist for a three-month programme in April last year and lost 10kg by simply following a healthy diet which was not very different from her regular diet. &quot;I simply had to tweak it for faster metabolism and digestion, such as having buttermilk after lunch, methi water on an empty stomach early morning, followed by apple-beetroot juice, brown rice replacing white rice and bingeing on soups and salads for fiber.&quot; On a regular diet, she managed to shed 8kg. But once her weighing scale read 55kg, she found it difficult to lose any more weight. It was then that she opted for IF to &quot;shake up the body from its slumber&quot;. &quot;By 7pm, I would finish dinner and then fast for 15 hours until 10am the next day,&quot; she said.</p> <p>&nbsp;</p> <p>In contrast, Hemapallavi from Bengaluru tried the twice-a-week IF plan. In addition to the daily 12 to 14 hour fasting, Mondays are water infusions day, Tuesday is only for soups and from Wednesday to Sunday, she would follow a regular diet. From 68kg, she came down to 51kg in eight months. &quot;I was diagnosed with PCOS [polycystic ovary syndrome] before marriage, which meant that my body had the tendency to gain weight,&quot; said Hemapallavi. &quot;It really did not bother me much until it really began showing on my body. I was feeling uneasy as I looked much older than my age.&quot;</p> <p>&nbsp;</p> <p>Experts say IF is not new for Indians. &quot;Our parents and ancestors fasted intermittently since ages and we used to mock them. Now, when the west gives it a fancy name, we all want it,&quot; said Dr Priyanka Rohatgi, chief nutritionist and dietician at Apollo Bengaluru. &quot;We had very good eating habits in India and a good practice of detoxifying our system ourselves. But with the westernisation of our menus we eliminated a lot of good things and picked up things that worsened our food habits and made us the capital of non-communicable diseases,&quot; she said.</p> <p>&nbsp;</p> <p>Besides IF, which allows one to eat all kinds of food within reasonable limits, the other diets that have been popular and trendy with Indians in the past two years have been the keto diet, the vegan diet, the flexitarian diet, the low-carb high-fat diet and, to a small extent, the paleo diet—all of which require you to either cut out certain things entirely (fats, carbs, sugar) or eat an excess of something else (proteins).</p> <p>&nbsp;</p> <p>Of late, the vegan diet, which is strictly plant-based, has found a number of takers, especially after Game Changers, a documentary about plant-based eating that was presented by Hollywood director James Cameron, aired late last year. &quot;We had a number of athletes calling in and wanting to go vegan after watching the film,&quot; said Ryan Fernando, cofounder and CEO, Qua Nutrition. &quot;But the vegan diet does not work for all. Out of 10 athletes, effective results were seen in only 3 to 4.&quot; Instead, he is a firm believer of what he calls the nutrigenomic diet that is based on your genes. &quot;I worked with Sushil Kumar (wrestler) and prescribed him a gene-based diet that [helped] him to win two Olympic medals,&quot; said Fernando. Nutrigenomics is the influence of nutrition on genes. It helps to understand the nutritional requirements of the individual and how they react to some nutrients. As per this diet, since each individual is different, with unique genetic variants, one diet does not work for all. &quot;Compare your body to a computer,&quot; said Fernando. &quot;Your body is the hardware and your genes are the software. So, when the software malfunctions, the hardware crashes. For example, when genes for gluten are mutated, this leads to gluten intolerance when the body is subjected to wheat, barley and rye.&quot; He suggests testing of one's genes before starting any diet.</p> <p>&nbsp;</p> <p>On two extremes lie diets which became very popular early on—the low-carb high-fat keto diet and the paleo diet. While some have benefited from these, others dismiss them as fads. THE WEEK spoke to Marika Johansson, who is an International Federation of Bodybuilding and Fitness pro athlete and fitness trainer and nutritionist for Bollywood stars like Ranbir Kapoor, Siddharth Malhotra, Alia Bhatt and Katrina Kaif. Johansson said she believes in the keto diet and often advises her clients to opt for it. &quot;Having worked in India for six years, I have realised that keto is one of the most popular diets with Indians,&quot; she said. &quot;It works well when you are an endomorph (someone with a high proportion of fat tissue) and need to shed that stubborn fat, provided you also do some form of physical activity. I do not recommend the keto diet for more than eight weeks as carbs are an essential macro for our well-being.&quot; About two years ago, when a pasta-loving Ranbir Kapoor felt the need to eat healthy when travelling, Johansson had him covered. She prepared special protein-loaded muffins and &quot;nutritional meatballs&quot; for him with oats, brown rice and minced chicken, flavoured with Tex-Mex and Indian seasoning. A couple of these were enough to fill him up, she said.</p> <p>For 41-year-old Dhiraj Khurana from Delhi, it became &quot;extremely essential&quot; to lose the protruding bulge on his waist. His aim was to go from 90kg to 75kg by way of a &quot;crash diet&quot; and then work towards maintaining it. Accordingly, he started on the keto and shed 11kg in eight months. But then, anxiety issues and body weakness set in. &quot;I realised that I had to get back to my normal way of eating and simply engage in a physical activity to maintain a good body weight,&quot; he said. Ditching cheese pizza and fried pakodas was OK, but going without wheat roti and paratha, which formed the core of his food intake since childhood, was a struggle.</p> <p>&nbsp;</p> <p>Fernando believes that the keto diet is detrimental to the Indian gene in the long run. &quot;If you are attempting a keto diet, do it under the supervision of a dietician and for no more than six months,&quot; he said. His voice finds an echo in Dr Phulrenu Chavan, endocrinologist at Hinduja hospital. &quot;The genetic makeup of Indians is such that we are able to digest 40 to 50 per cent of carbohydrates, 10 to 20 per cent of fats and the rest are proteins. And, our system needs food every three to four hours. You will not be able to maintain a keto diet or any other fad diet for a long period. Even a standalone high-protein diet is not recommended especially for diabetics because proteins are harmful for the kidneys. It worsens it,&quot; said Chavan. Clinically, doctors do not prescribe any of these diets. The Indian diet, they say, whether vegetarian or non-vegetarian, has sufficient quantities of carbs, proteins and fats.</p> <p>&nbsp;</p> <p>Nutritionists stand divided on the efficacy of diets. Even among qualified nutritionists there is no consensus on which diet best suits the Indian milieu. While earlier the focus was entirely on weight loss, and carbohydrates were perceived to be the enemy, no-carb or extreme low-carb diets such as the keto, paleo and Mediterranean diets were in vogue. They ensured quick weight loss and happiness. But then as research evolved, it became clear that carbs are not necessarily bad for the body and doing away with them altogether could be detrimental in the long term. &quot;Most people completely cut out carbs from their diet or eat too little carbs,&quot; said Johansson. &quot;But, eating the right amount and from the right sources like rice, quinoa, millet, buckwheat, potatoes and oats will not make you fat. Refined carbs loaded with sugar or fried [food] are the ones making you fat.&quot; Accordingly, very-low-carb diets got modified to low- to moderate-carb diets, thereby leading to contemporary diets such as the moderate-carbs high-fat diet.</p> <p>&nbsp;</p> <p>Sameer Chatterjee, a 43-year-old businessman from Kolkata, paid over Rs1 lakh for a seven-day &quot;master cleanse detox retreat&quot; programme at Atmantan luxury health and wellness resort near Pune. Chatterjee was used to a lifestyle that involved smoking, drinking and irregular food habits, and found out that he was pre-diabetic after undergoing blood tests before the programme. The diet required him to transition from solid foods to a zero-carb liquid diet. &quot;Through the day, I was provided with sugarless cold-pressed juice and soup at regular intervals alongside massage and treatments,&quot; he said. &quot;The only solids I had were salads on the first night and khichdi on the last.&quot; He went in overweight at 83kg, and came out lighter by 10kg. Unlike Chatterjee, Delhi-based Dr Gaurav Katyal, who is an anaesthesiologist and general manager, operations, at Indraprastha Apollo Hospitals, Delhi, has been maintaining his fitness without spending too much on his diet. &quot;I count my calories and keep my macros—proteins, carbs, fats—in check,&quot; said Katyal. &quot;My protein intake is around 1.2 to 1.4gm per kg of body weight, carbs are 2.4gm per kg and fats 1gm per kg.&quot; Katyal, 41, has always been conscious of what he eats and had quit smoking. &quot;My energy levels are always high and I do not ever feel sluggish. At 72kg, my BMI is 22 and body fat is at 12 per cent and I feel lighter and fuller with a high-protein low-carb diet,&quot; he said.</p> <p>&nbsp;</p> <p>A number of digital health care companies are using artificial intelligence to provide exhaustive weight loss plans, freshly prepared customised health meals and premium packaged foods and ingredients to the average Joe who is unable to take out time from a hectic corporate lifestyle to look after himself and his daily nutritional requirements. has an entire weight loss collection that provides a free diet chart and additional nutritional consultation. From their Lean Machine Program to ultra low-carb vegan smoothies to an entire section on keto products, including customised keto flours and low-GI gluten-free flours, everything is a click or an app away. &quot;People like to have everyday Indian food they are used to but tweaked with healthier options, like a low-carb biryani or a millet curd rice&quot; says Jyotsna Pattabiraman, founder and CEO, GrowFit, where one meal a day for a week would cost Rs1,610 for vegetarian food and Rs1,750 for non-veg food. &quot;Our keto range has been successful but 80 per cent of our customers come in for some kind of low-carb plan. About 30 per cent are interested in doing the full keto diet and 93 per cent see results in the first week, be it weight loss or balanced blood sugar levels.&quot;</p> <p>&nbsp;</p> <p>Doctors concur that a balanced diet of protein, carbs and healthy fats works best for Indians. &quot;There is a problem with a mindset that wishes to lose weight no matter what,&quot; said Johansson. &quot;Because not all weight loss is good. When your goal is to shed body fat, preserve your muscle mass and stay healthy. Nobody wants to be frail, skinny and weak.&quot;</p> Sat Mar 07 15:47:44 IST 2020 trial-will-impact-how-we-practise-management-of-stable-heart-disease <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p><b>What was the impetus for starting the ISCHEMIA trial?</b></p> <p>&nbsp;</p> <p>We wanted to bridge the knowledge gap from prior trials. The question after those trials was: are there subgroups of patients with higher degree of ischaemia that could benefit from revascularisation (widening of blocked or narrowed coronary arteries)? Observational studies seem to suggest significant benefit of revascularisation in those with higher degree of ischaemia.</p> <p>&nbsp;</p> <p><b>In what way was the trial different from previous ones on invasive therapies versus conservative strategies to manage stable heart disease?</b></p> <p>&nbsp;</p> <p>Our trial was different in two major ways. First, we had a higher bar for trial entry, including only patients with moderate or severe ischaemia on stress testing. Second, the randomisation was done upstream of the cath lab, that is before definition of coronary anatomy. Patients underwent coronary CT angiography but they and the physicians were blinded to the results. As such, the concern from prior trials that only low-risk patients were cherry-picked by the investigators was avoided in ISCHEMIA.</p> <p>&nbsp;</p> <p><b>In the post ISCHEMIA trial world, should patients suffering from stable heart disease expect to not undergo any invasive procedure in their life?</b></p> <p>&nbsp;</p> <p>The post trial world calls for informed discussion between patients and physicians. If the patient is symptomatic, the trial showed significant and sustained benefit of revascularisation at relieving symptoms. On the other hand, we do not know the utility of revascularisation in asymptomatic patients.</p> <p>&nbsp;</p> <p><b>Could you comment on how the results of the trial might have a bearing on Indian patients?</b></p> <p>&nbsp;</p> <p>I guess the trial should lend itself to shared decision-making. If patients opt to try medical therapy first, it should be completely reasonable to do so. If they opt for revascularisation to relieve symptoms, that should be reasonable as well.</p> <p>&nbsp;</p> <p><b>Which category of patients were excluded from the trial?</b></p> <p>&nbsp;</p> <p>There were notable exclusions—patients with left main disease, those with recent heart attacks, those who were very symptomatic despite medications, those who were dissatisfied with current medications and those with low heart function.</p> <p>&nbsp;</p> <p><b>Aside of the main trial, the secondary trial included patients with chronic kidney disease (CKD). Could you explain the implications of including those patients in the trial?</b></p> <p>&nbsp;</p> <p>The ISCHEMIA-CKD trial is the largest treatment strategy trial in patients with advanced CKD. Prior trials have routinely excluded this high-risk subset. In this trial, we showed that there was no significant benefit of invasive strategy when compared with conservative strategy both for clinical outcomes and for quality of life.</p> <p>&nbsp;</p> <p><b>How will the findings change the way patients of stable heart disease are treated around the world? How has the medical fraternity responded to the findings?</b></p> <p>&nbsp;</p> <p>The trials will have significant impact on how we practise management of stable heart disease for the next few years and will have a significant impact on guidelines. The medical fraternity has had a mixed response. There is something for everyone’s perspective, which makes the trial interesting and leads to good discussion. We hope this is true when they discuss with their patients.</p> <p>&nbsp;</p> <p><b>What would be the line of inquiry for future research on the subject?</b></p> <p>&nbsp;</p> <p>One important aspect would be if the curves for the two treatment strategies continue to diverge with time. We are planning a long-term followup of the trial called ISCHEMIA EXTEND. Stay tuned.</p> Sat Feb 15 18:55:11 IST 2020 ticker-talk <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>Inside the chambers of Dr T.S. Kler, chairman of PSRI Heart Institute, Delhi, it is a typical Wednesday. At about 10.30am, patients begin to stream in. The complaints are varied, ranging from shortness of breath, palpitations, a fit of epilepsy (a young man's parent worries if it could be a heart-related ailment), to a man who has brought in an angiogram of his father in his mid-50s. A quick flip through the images and the cardiologist delivers his assessment—the condition of the patient’s heart is beyond the angioplasty stage; he will need a bypass surgery, immediately.</p> <p>&nbsp;</p> <p>Minutes after finalising a date for the surgery, Kler is weighing on the relative merits of routine invasive procedures for this interview—the efficacy of percutaneous coronary intervention (PCI), also known as coronary angioplasty, and coronary artery bypass surgery versus medicines and lifestyle changes among patients with stable heart disease.</p> <p>&nbsp;</p> <p>The genesis of the discussion stems from the results of the largest clinical trial of its kind that had 5,179 patients from 320 sites from across the world—India was a top site for the study—and sought to evaluate the efficacy of routine invasive procedures over optimal medical therapy for patients of heart disease.</p> <p>&nbsp;</p> <p>The International Study of Comparative Health Effectiveness with Medical and Invasive Approaches (ISCHEMIA), as the trial is known as, was twice as large as any other similar trial done before. The crucial findings, now the subject of much debate and discussion, were presented at the annual conference of the American Heart Association, and are likely to be published over the next few months. The study failed to show that routine invasive therapy was associated with a reduction in major adverse ischaemic events when compared with optimal medical therapy among stable patients with moderate ischaemia (insufficient blood flow to the heart muscle).</p> <p>&nbsp;</p> <p>The randomised trial, funded by the National Heart, Lung and Blood Institute in the US, recruited 5,000-odd patients with stable heart disease, and divided them into two groups. The invasive strategy group underwent a surgery (stenting or bypass, as the case may be) after the stress test, and received drugs (statins inlcuded) and followed lifestyle changes to treat their blockages. The other group, however, received drugs and followed lifestyle changes only.</p> <p>&nbsp;</p> <p>Both the groups were closely monitored for 3.3 years on average and 5 years maximum. The outcomes at the end roughly remained the same—events such as cardiovascular death, myocardial infarction (heart attack), resuscitated cardiac arrest, or hospitalisation for unstable angina or heart failure at 3.3 years occurred in 13.3 per cent of the routine invasive group, compared with 15.5 per cent of the medical therapy group. Invasive therapy, it was found, was associated with harm of about 2 per cent within the first six months. However, a benefit was observed within four years.</p> <p>&nbsp;</p> <p>Put simply, the outcomes remained same regardless of whether patients had stenting or bypass surgery, bringing to fore an important question—do stents or bypass surgery work for a certain section of patients of heart disease?</p> <p>&nbsp;</p> <p>Cardiologists in India caution against a simplistic interpretation of the finding and dismissing one therapy in favour of the other. The clinical decision on whether or not to go for a stent or bypass surgery would depend on several factors, they insist. At the outset, they point to the exclusions in the study. “While the trial does show that there is no need to do angioplasty on every patient who comes to a doctor with angina (chest pain), the trial subjects do not constitute the entire spectrum of patients with heart disease. Those with acute coronary heart disease were excluded from the study,”says Kler. Patients suffering from left main stenosis (narrowing of a valve), those who had suffered a heart attack recently, had severe angina and had undergone a stenting or a bypass in the last one year or patients of heart failure were not included in the study. In a country such as India, that would constitute a majority of heart patients, at least in a hospital in a metro such as Delhi.</p> <p>&nbsp;</p> <p>India, says Kler, has an incidence of heart disease that is 2.5 times higher than in the west, and heart disease strikes patients here 10 years earlier than their counterparts in the west. In urban areas, heart disease incidence is found in 8-10 per cent of the population; in rural areas, it is 5-6 per cent of the population. Around 54 million people in India suffer from heart disease, a leading cause of death in the country. Over 80 per cent of these are patients with ischaemic heart disease and stroke.</p> <p>&nbsp;</p> <p>Despite the numbers though, awareness and access remain an issue. At a public hospital such as AIIMS, Dr Ambuj Roy puts the ratio at 60:40 for those suffering acute coronary artery disease and those that have stable heart disease (where symptoms come only when you exercise or feel stressed). A majority of patients also come to the cardiologist late. “Several times, discomfort due to heart disease is dismissed as a gastric episode,” says Roy, professor of cardiology, AIIMS. “Patients with a heart attack often don’t get lifesaving surgery within the golden hour, causing permanent damage to the heart muscle.”</p> <p>&nbsp;</p> <p>For patients whose disease is stable, the question of stenting or not has been controversial for a few years. In 2007, the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial, showed a similar outcome—as an initial management strategy in patients with stable coronary artery disease, PCI did not reduce the risk of death, myocardial infarction or other major cardiovascular events when added to optimal medical therapy. Later trials, including the ORBITA trial last year also showed similar results—in patients with medically treated angina and severe coronary stenosis, PCI did not increase exercise time any more than the effect of a placebo procedure did.</p> <p>&nbsp;</p> <p>“The criticism against the earlier studies such as COURAGE was that they used the older generation of stents. However, this has been overcome with the ISCHEMIA trial where they used the latest generation of stents,”says Roy.</p> <p>&nbsp;</p> <p>Most cardiologists agree that when it comes to patients with stable disease, there is no need to panic and opt for stenting or surgery immediately. “It also emphasises the need for aggressive medication (with four drugs including statins), and patient compliance to the drug regimen,”says Dr Ashok Seth, chairman and interventional cardiologist, Fortis Escorts hospital, Delhi. “During the trial, the patients on conservative therapy were followed up regularly and they stuck to the drug regimen and lifestyle changes that were suggested.”</p> <p>&nbsp;</p> <p>The panic aside, Seth says the study also shows that stenting did improve quality of life for those with symptoms, and 25 per cent patients from the conservative group had to undergo routine invasive procedure at the end of four years. “The key takeaway from the study then is that stenting works if the patient reporting symptoms such as angina is young and leads an active lifestyle, if they have symptoms and live in a remote area from where they can’t access immediate medical care in case their symptoms worsen despite drugs, and if the procedure can be performed safely without risk of a heart attack during the procedure [because of multiple, diffuse blockages],”he says.</p> <p>&nbsp;</p> <p>“It isn’t as if we weren’t following such a protocol before,”says Dr P.P. Mohanan, president-elect, Cardiology Society of India. “However, now with data, it will help both doctors and patients have an informed discussion about the future course of action in such cases,”he says.</p> <p>&nbsp;</p> <p>Invasive procedures such as stenting have their benefits, but many cardiologists concede that the trend of unnecessary procedures does exist in India. “About 25-30 per cent invasive procedures in this field are unnecessary, and done for increasing revenues,”says Kler. “The only way to deal with such unethical practices is to have medical audits. The justification for doing a procedure might still be subjective in some cases, but for a majority of the cases, it will be easy to regulate.”</p> <p>&nbsp;</p> <p>An industry official, however, bemoans the lack of guidelines in India for performing such procedures. “In the absence of such regulations, it is hard to dispute the placement of a stent or the justification of a bypass procedure,”he says. “The other side of the debate is that in India those who need a procedure such as stenting don’t get it. WHO figures suggest that of the 30 lakh people who have a heart attack, only 5 lakh reach a cath lab, and only 10 lakh get some form of medical treatment in the form of drugs to dissolve clots. Only 1,400 cath labs exist in the country.... Here, too, there are regional inequalities—a state like Bihar has only 15 cath labs, while an area like suburban Mumbai itself will have that many cath labs.”Also, there is the issue of affordability. “A developed state such as Gujarat has only two government hospitals where such a procedure can be performed,”he says. “And private hospitals will keep doing these procedures for profit.”</p> <p>&nbsp;</p> <p>Every month, around 55,000-60,000 patients undergo angioplasties in hospitals around the country, industry estimates suggest. During these angioplasties, the number of stents used could vary from 65,000-75,000 (since more than one stent could be required for the procedure for patients with multiple blockages). The average ratio, industry sources suggest, works out to be 1.3 stents per procedure, and the coronary stent market stands at Rs1,500 crore.</p> <p>&nbsp;</p> <p>India is the third largest market in terms of volume of stents after the US and China, but because of lower prices of stents (compared to the US and Europe) the total worth is less. When it comes to the number of stenting procedures done in a year, India is not far behind the US, where the number of angioplasties stand at about 10 lakh per year.</p> <p>&nbsp;</p> <p>This year, Asia's largest stent manufacturing unit is set to come up at Hyderabad, which will cater to both the growing stent market in India and neighbouring countries. The unit is being set up by the Surat-based manufacturer Sahajanand Medical Technologies.</p> <p>&nbsp;</p> <p>However, disparities in terms of reach and access to angioplasties continue to plague Indian patients. India has about 3,000 interventional cardiologists. The number of centres doing PCI in the US is around 1,758 for a population of 35 crore. Given India's 130 crore population, we need at least 6,000 labs as opposed to the 1,400 labs, says an industry official.</p> <p>&nbsp;</p> <p>As of now, the stent market in India has both Indian and multinational players. Post price capping for coronary stents (bare metal and drug-eluting stent) in 2017, however, the MNCs have been finding it hard to expand their market, say industry sources. “Indian companies are supplying directly to the hospitals but the MNCs do it through distributors which makes their prices higher,”he says. “The trade margins for coronary stents were fixed precisely because the margins were found to be over 200 per cent in certain cases by the National Pharmaceutical and Pricing Authority. Thus, post price control, this business model has meant that the foreign players have not been able to grow or expand their market, especially outside the metros. They do supply directly to other hospitals in other countries. So why not here?”</p> <p>&nbsp;</p> <p>Post the capping of prices, however, there were reports of hospitals making up for the loss in profits by revising the prices of other components in the angioplasty package. Patient advocates, however, argue that the lower price did increase the affordability of the procedure.</p> <p>&nbsp;</p> <p>With the advent of Ayushman Bharat, where the government reimburses 070,000 for the angioplasty package (including one DES), the market is only set to grow, say sources. In the private sector, though, costs of the same procedure, however, could go upto Rs2 lakh.</p> <p>But, how do patients decide between an invasive therapy and one that involves only medication and lifestyle changes? Dalchand Mohanpuri and his family had to make that choice last year. The 67-year-old retired income tax officer had started gasping for breath while climbing stairs to his third floor house in Delhi's Karol Bagh. A doctor at the nearby Central Government Health Scheme (CGHS) dispensary recommended he undergo certain tests to check his cardiac situation. The family, however, decided to go to a cardiologist at a prominent private hospital. “Initially, the cardiologist recommended that my father undergo an angioplasty procedure,” recalls Lokesh, Dalchand's son. Dalchand had suffered a heart attack about four years ago while undergoing treatment for dengue at a nursing home. The doctors at the nursing home didn't recommend any particular treatment. After an angiogram at the private hospital, doctors revised their opinion—the blockage in the arteries was too calcified, and Dalchand could neither undergo an angioplasty, nor was he a fit candidate for a bypass surgery. “He was then recommended a pacemaker. Alternatively, doctors said that we could opt for medicines only,”says Lokesh. The family opted for medication, and close monitoring of the situation. “Since then, my father is on medication for his diabetes, blood pressure, cholesterol and heart disease. He walks regularly, avoids oily food and tries to keep himself fit,” says Lokesh. “One year later, his condition has actually improved. From the earlier condition where doctors said only 35 per cent of his heart was good, they are now saying that it is about 45-50 per cent. In fact, now he might not need a pacemaker either.”</p> <p>&nbsp;</p> <p>Lokesh says it is a tough call to make for any family. “My father is a CGHS beneficiary, and so any procedure is not easily approved and has to be justified. Had it not been the case I am sure that the doctors would have opted for an angioplasty and/or a pacemaker without enough justification,”says Lokesh, an engineer. “For lay persons, getting medical treatment or going for a procedure is an emotional decision, not a rational one. Accessing treatment at a government hospital is difficult because of long queues, and private hospitals are only going for profit. In that situation, for a patient to make a rational decision is just impossible.”</p> <p>&nbsp;</p> <p>Dr Thomas Davis, however, did not face that dilemma. It was a typical day at the emergency room at Delhi’s Max hospital in 2003. Davis, then 38, was on duty, handling the rush of emergency patients. Little did he know that in the next few hours, he would become a patient. Davis had a heart attack that day, and then another one in 2013. “Both times my condition was acute, and there was absolutely no confusion in the line of treatment that was to be taken,”says Davis, who underwent angioplasty twice.</p> <p>&nbsp;</p> <p>Patient advocates, however, stress on the need for counselling patients properly. “We are aware that many a time patients are recommended angioplasty even though the patient may have been a good candidate for recommending medication and lifestyle changes. This is often a result of doctors' perceptions about the patient’s ability to follow instructions or is simply justified as a pragmatic approach (for example, when patient has travelled from far for the consultation it could be justified as reducing inconvenience),”says Malini Aisola, All India Drug Action Network. “Without appropriate counselling, patients are not given a chance to participate in treatment decisions and are deprived of options in lieu of an invasive procedure.”</p> <p>&nbsp;</p> <p>While he lay on the doctor’s table waiting for the procedure the second time, Davis says he made one decision that changed his life. “I was a heavy smoker. I had quit after the first heart attack, but somehow started smoking again three years later. But before the second procedure, I decided to quit forever, and since that day in 2013, I haven’t smoked even once,”he says.</p> <p>&nbsp;</p> <p>The 55-year-old also made alterations in his diet—he gave up red meat, alcohol and increased the portion of vegetables, fruits and proteins in his meals. Other than that, Davis says he has been on statins, blood thinners and beta blockers. “I have been really compliant with my medicines, and never missed a single dose in all these years,”he says. What Davis does regret though is that given his hectic schedule inside the emergency room, he doesn’t get much time for exercise. “Whatever exercise I get is from the running around that we do during duty hours,”says Davis, who now works with a different hospital chain.</p> <p>&nbsp;</p> <p>But Davis sees a lot of patients ending up with heart trouble in the emergency room, especially those in their 30s. “I tell them three things, give up smoking, reduce stress and make lifestyle changes,”he says.</p> <p>&nbsp;</p> <p>That is some sound advice, especially the one about smoking. It is one of the top risk factors for heart disease, say doctors.</p> <p>&nbsp;</p> <p>Though the ISCHEMIA trial focused on the outcomes and efficacy of coronary stents and bypass procedures, patients in both arms of the study—invasive or non-invasive—received optimal medical therapy that included aggressive medication and lifestyle changes. The drug therapy included anti-platelets, statins, antihypertensive and other lipid lowering and anti-ischaemic medical therapies. Drug therapy, say doctors, has to be aggressive, and patients need to comply with the regimen, too. Regardless of whether the patient has undergone a procedure, taking medicines and following a healthy lifestyle is key, they say. Quitting smoking is one of the major alterations advised. “I always ask my patients to pay attention to the six Ss—stress, sleep, smoking, sedentary lifestyle, sugar and salt. Less salt and sugar and regular exercise (45-50 minutes) everyday can help manage the disease to a great extent. In India now, pollution, akin to smoking, has also emerged as a big risk factor for heart disease,”says Dr Viveka Kumar, principal director of cardiac sciences and chief of Cath Labs Pan Max Healthcare.</p> <p>&nbsp;</p> <p>Most individuals with stable ischaemic heart disease can be managed effectively with good and evidence-based medical treatment, says Dr Upendra Kaul, chairman, Batra Heart Centre. “This means keeping BP &lt;130/80, blood sugar under control in diabetics, aggressive lowering of cholesterol levels by taking high dose of statins and taking anti-platelet drugs for the long term,”he says. Angioplasty and stent implantation are reserved for patients with increasing symptoms or for persons who want to be physically active for improving quality of life, says Kaul. “The goals of treatment [in chronic stable heart disease] are to prevent a heart attack, sudden death and heart failure. These goals are not achieved better by angioplasty or bypass surgery in stable patients,”he says. “Some patients with angina also get it because of inadequate dilatation of micro vessels well away from the site of major blocks. Such subtle changes can be diagnosed by PET scans and are of academic interest only.”</p> <p>&nbsp;</p> <p>According to Kaul, it is a scientifically proven fact that acute heart attacks do not occur in chronically blocked arteries. The most common cause is rupture of a cholesterol rich plaque that is thin walled; once it ruptures, a clot forms at that site. “This leads to a sudden blockage of the artery leading to a cessation of blood supply to a portion of the heart,”he says. “The size of the heart attack depends upon the size of the artery and its location. This is sometimes also seen in patients who recently had angiography done and were labelled as nearly normal. The control of risk factors is crucial in such patients along with a good lifestyle.”</p> <p>&nbsp;</p> <p>The management has to be lifelong and sustained. All high-risk patients like diabetics, patients of high BP or raised cholesterol levels need this management. Says Kaul: “Optimal medical treatment for stable heart disease is definitely more important than angioplasty or bypass surgery.”</p> Sat Feb 15 18:56:39 IST 2020 have-a-heart-use-brain-too <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>You have probably read or heard the recent news headlines about a trial that showed cardiac stents and bypass not being any better than medications. Like most headlines, this information is only partly true and, unlike what has been touted, not entirely new either.</p> <p>&nbsp;</p> <p>Now before you call your cardiologist or cardiac surgeon and ask for a refund, let me guide you through the fine print—and there is a lot of it. The first being patients who recently had a heart attack or worsening symptoms were excluded. In these patients, stents and bypass surgery definitely saves lives. In addition, the sicker patients, people with weak heart pumps and people with high-risk anatomy were excluded.</p> <p>&nbsp;</p> <p>The ISCHEMIA trial was presented at the American Heart Association. A total of 5,179 patients with stable blockages were treated by either stents and bypass or medications. There was no statistical difference in the groups for major adverse cardiac events at 3.3 years followup—13.3 per cent in the stent and bypass group had adverse events as opposed to 15.5 per cent in the medical group (a 2.2 per cent difference which was considered insignificant).</p> <p>&nbsp;</p> <p>Now for more fine print. Only 80 per cent in the stent or bypass group actually got stents or bypass. Now how is this possible, you may ask. In trials, they use a method called intent to treat. Once assigned to a treatment group , you are counted as receiving the treatment, whether you actually get it or not. I know, I know, it sounds absurd, but welcome to the world of statistics where intent matters. Thank God, it doesn’t hold true for real life, right?</p> <p>&nbsp;</p> <p>In addition, 23 per cent of patients in the medication only arm got stents or bypass during this period as a bailout as they became unstable. A further analysis showed that there was a 30 per cent reduction in heart attacks in the stent/bypass arm. This was an unexpected surprise because we believed that disease of the arteries generally involved all arteries, and stenting one or two arteries would not stop another area from closing off, leading to a heart attack. This reduction in heart attacks, however, did not lead to a reduced mortality rate. The reason: we have gotten better in treating heart attacks. In addition, the patients in the stent/bypass had less chest pain and improved quality of life.</p> <p>&nbsp;</p> <p>Confused? Let me try and break it down. If you have minimal symptoms and a blockage in an artery not supplying a major area in your heart, you should do well with medication, with stents/bypass as an option if you worsen symptomatically. This trial is in line with previous trials that tell cardiologists to definitely hit the pause button before pursuing a more aggressive/invasive strategy. Generally, the sicker you are, the more likely you will benefit from aggressive treatment.</p> <p>&nbsp;</p> <p>Cardiac stenting is big business (around $50 billion big in the US) for companies, hospitals and doctors. There have been cases of hospitals and doctors overusing stents, which has led to a rightful scepticism and bad press associated with stents. This is an area in which we as the cardiology community have been open to regulation, peer review and strict enforcement.</p> <p>&nbsp;</p> <p>The problem with the practice of medicine today is that it is population based. What’s good or bad for a group is considered good or bad for you. While this may be correct in most cases, individuals are unique and have different goals. That is where your doctor comes into the picture. She/he knows you as a person, and can tailor therapy based on what you need as an individual. Don’t believe me? Ask your doctor.</p> <p>&nbsp;</p> <p><b>The writer is chief of staff, Florida Hospital Memorial Medical Center, Daytona Beach, US.</b></p> Sat Feb 15 19:01:47 IST 2020 penning-down-her-demons <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>For the longest time, actor Soni Razdan thought that her elder daughter, Shaheen Bhatt, was acting lazy, delaying school on purpose, locking herself up in the room for no reason and was just being a difficult teenager. Little did Soni realise that Shaheen was dealing with insomnia and depression. “What breaks my heart is that even after being so close to my daughter, I could not have guessed that she was having suicidal thoughts until she communicated the same to me much later,” said Razdan at the launch of Shaheen's book—I’ve Never Been (Un)Happier— organised by Penguin and Landmark Books.</p> <p>&nbsp;</p> <p>The book, which has notes from her journal, is a searing portrait of life with depression. “I feel no good. Like a duck among swans. And somewhere I hate the world for doing this to me. Setting me up to these standards I can’t meet. Making it all my fault. I want to implode, to disappear,” read a journal entry of a 20-something Shaheen.</p> <p>&nbsp;</p> <p>Another entry, from a 13-year-old Shaheen, reveals her constant battle of feeling like a “loser”; how she struggled with the thought that Alia, her younger sister, is “so good in everything she tries”, but she isn’t good enough. “I was feeling very inadequate,” recalls Shaheen, now 32. “That is how everything started for me—with this overwhelming feeling of inadequacy that I had all the time.”</p> <p>&nbsp;</p> <p>Dressed in a bright, flowy dress with flower prints, she is warm and high-spirited the day we meet in the office space of her Juhu house that she shares with Alia. The pristine white walls are painted with cat motifs and cat paws. “That’s how a cat lover’s house would look like,” she says, smiling. Shaheen is overwhelmed, “but in a good way”, with the response that the book is getting. Though she never planned to write a book about her mental health, it was no surprise that she did as she loves writing. “The first journal entry that I have put [in the book] is from the time when I was 12. That is when my depression started to hit. Writing was a means of survival, if I didn’t get it out of my system, I would not have been able to deal with it.” But she struggles to write often. “Putting it on a piece of paper makes it real and I didn’t want to make it real because it was already so bad, so bad in my head,” she says. “I felt I can’t write because I can’t keep dealing with the fact that this is what I am feeling all the time.”</p> <p>&nbsp;</p> <p>And then, in 2016, she made her battle with depression public with an Instagram post. She was tired of posting happy pictures when otherwise she was struggling to live. It was followed by an article in a magazine. “Penguin (publisher) contacted me after that and it seemed like a good idea,” she says.</p> <p>&nbsp;</p> <p>A couple of months into the project though, it started taking a toll. “I was reliving a lot of things, terrible moments that you do your best to avoid thinking about,” she says. She writes about a time she had accompanied her half-sister Pooja Bhatt to a photo shoot along with Alia. She was 12, Alia was six. While Pooja and Alia looked alike, Shaheen saw herself as distinctly different–“newly overweight and tanned” after spending too much time in the sun. After a point, she was excluded from the shoot as her sisters were taken to a better location. She has fought a sense of insecurity ever since.</p> <p>&nbsp;</p> <p>In another chapter, she talks about the time she started seeing suicide as a “route to relief”, finally taking that drastic step in 2006 by swallowing a few pills. The suicidal thoughts came back a couple of months ago. “It was the first time in a very long time that it happened,” says Shaheen. “I couldn’t figure why I was feeling this way. But I am way better equipped emotionally to handle it [now].”</p> <p>&nbsp;</p> <p>Reliving the earlier times has been the hardest thing. “It would [sound] like a cliché, but it has been one of the most cathartic experiences of my life,” she says, adding that most of her life has been about getting through these situations rather than trying to see the silver lining. “Writing the book has been a good experience because I was thinking about what it (depression) has given me. Until then, I was just thinking about what it has taken away from me.”</p> <p>&nbsp;</p> <p>Though depression is not something that can be romanticised, it has given her “the ability now to connect with people that I wouldn’t connect with otherwise”. The diary entries in the book are in her handwriting, and it was her idea. “From the start of doing this, I didn’t see any point of doing it in half measures,” she says. “I can talk about I felt this and I felt that, but this is the easiest way for me to show someone what I felt at that moment by showing them what I had written then. To me, that’s the most real part of the entire book. They are scans of my lowest moments. They are scans of my worse insecurities.”</p> <p>&nbsp;</p> <p>But she finds some of these moments funny, too. Like, the one where she thought being overweight was the root cause of all her problems. “One of the reasons I think I have gotten through depression is because I have a sense of humour about it,” she says. “I just find my situation very funny. I feel like, ‘what a great life and I am just miserable all the time.’”</p> <p>&nbsp;</p> <p>The misery turned her life upside down. She never took studies seriously—she wanted to drop out of school in class 10, dropped out of college and later finished graduation through open university. “In hindsight, I realise I should have cared more about education,” says Shaheen. “Not for any other reason, but it is just a good way to learn about yourself. I am in a very privileged position where my education has not had any bearing on what I have done with my life. For most people, that’s not the case. It prevented me from exploring my likes and dislikes. Now, I know that I like history. Had I continued with college, maybe I would have got a degree in history.”</p> <p>&nbsp;</p> <p>And, she is aware that it is thanks to her privilege that she can talk about her mental health without worrying about repercussions. That is why she does not like being called brave. Also, she wants to bring home the point that despite her privileged position, she has mental health issues. “My privilege has nothing to do with my mental illness in that sense,” she says. “All it does is it gives me a massive ability to deal with it, to tackle it and the luxury to sort of wallow in it, which people don’t have.”</p> <p>&nbsp;</p> <p>Yet, it took her more than five years to tell her parents what she was living with. She opened up to them at 18. She was worried about how her mother would take it, not so much about her filmmaker-father Mahesh Bhatt as he, too, had “to some extent suffered from depression”. But Alia has been her rock—“she has been a bridge between my mother and me, and my father and me,” she says. At the We the Women summit hosted by journalist Barkha Dutt, Alia spoke about how she truly understood what Shaheen was going through only after reading the book. Her actions started making sense to her more, like why Shaheen was changing therapists. Shaheen says she did that initially because she couldn’t find a therapist who understood her or matched her wavelength. “Later, I felt, past a certain point, you get what you could out of one person [and you have to move on],” she says.</p> <p>&nbsp;</p> <p>Shaheen still takes pills for sound sleep, and therapy, she says, is work for her. There are days when she doesn’t want to go for therapy, but she knows she needs it. “The fact that I don’t feel like talking today means that I need to talk. It is pushing through whatever resistance that comes up in me and making sure that I do it,” she says.</p> <p>&nbsp;</p> <p>There have been stories of people being fearful of therapy, and Shaheen understands that fear. “It is daunting,” she says. “You are confronting yourself essentially. It is not going to be easy. It brings up a lot of things that you don’t want to deal with. But the stuff you think is easier to put away, and think by putting away it is going to be fine, it is going to be way worse later. I feel it is a lot easier to deal with the discomfort of sitting with the therapist and talking with them. More than medication, talk therapy has helped me.”</p> <p>&nbsp;</p> <p>With the awareness she has accumulated over the years of dealing with depression, the good phases last longer now. “I know how to look after myself. I know the things that I can do and cannot do. Things that I should and should not do. I don’t beat myself up about it,” she says. She is now working on her second book, also nonfiction, and is busy with Here Comes The Sun—an online campaign to spread awareness about mental illness. “Two of the biggest challenges in treating depression are the stigma attached to it and the lack of awareness and knowledge,” says Shaheen. “Due to this, individuals and their family fail to recognise the onset of depression and sometimes just refuse to acknowledge the problem.” Through HCTS, she wants to “empower society with greater awareness of depression and anxiety, to encourage public dialogue and to promote understanding to ensure timely treatment, through online and on ground campaigns”.</p> Fri Jan 24 16:00:16 IST 2020 need-more-community-based-intervention <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>India’s increasing mental health issues are a subject of alarming concern. According to the data journalism website IndiaSpend at least six crore Indians suffer from mental disorders. A report in The Lancet states that people with mental illness could account for nearly 20 per cent of India’s population by 2020. The numbers are reason enough to sit up and take notice.</p> <p>&nbsp;</p> <p>Despite the growing statistics, our infrastructure continues to remain poor. India, which spends 0.06 per cent of its health budget on mental health care, has an acute shortage of professionals who can help people with mental disorders. To help put this in perspective, there are 0.30 psychiatrists, 0.17 nurses and 0.05 psychologists per 1,00,000 mentally ill patients in the country. We are a young nation. It is imperative that all Indians, especially our young, are given support for them to cope with various life stressors that impact their mental, physical and emotional wellbeing. Unresolved stressors impact the mind and can cause depression, anxiety and stress-related disorders. Furthermore, it is important to note that it is in their youth and productive years that individuals first exhibit symptoms of depression, anxiety and stress-related disorders. If left untreated, it can increase the economic burden on the individual and the community.</p> <p>&nbsp;</p> <p>As the famous proverb goes—an ounce of prevention is worth a pound of cure—it is crucial to reduce the stigma surrounding therapy and mental health so that it is normalised and becomes part of our everyday conversation. Going to a therapist or counsellor needs to be accepted and embraced by the society. This will help us build timely interventions, thereby preventing and minimising the various triggers that cause mental disorders.</p> <p>&nbsp;</p> <p>Social influencers from various walks of life promoting and accepting mental health as an important facet of health care will help break down the strong walls of stigma that are associated with mental health. With India being a collective country with a more group-oriented mindset, we need to borrow the trickle-down effect from consumer goods marketing. This is a model of product adoption that essentially states that fashion flows vertically from the upper classes to the lower classes within society, each social class influenced by a higher social class. In addition, psychologists, counsellors and psychiatrists working in tandem will help aid those already in need of serious intervention. This would mean increasing the engagement between the complementary professions. There have been several cases where a combination of talk therapy and medication has helped clients improve drastically as well as provide the right intervention.</p> <p>&nbsp;</p> <p>It is important to incorporate mental health interventions in smaller cities and towns as well. This can be done by creating model mental health towns by educating and training individuals in basic counselling and listening skills. In the absence of certified professionals, this will bridge the gap and help people who need a listening ear. In this way, we will be engaging and helping both rural and urban communities, thereby creating a more holistic environment for large-scale change.</p> <p>&nbsp;</p> <p>At an intervention level, educating general practitioners in hospitals and clinics on first-level treatment and identifying physical symptoms of mental disorders like anxiety and depression will greatly help prevent further ailments. Hospitals and clinics can also have practising counsellors. This will work on two levels—one, providing access to a counsellor then and there; two, normalising the fact that one can go to a counsellor just as one goes to a general practitioner for fever or cold.</p> <p>&nbsp;</p> <p>India has the highest suicide rate among youngsters as per The Lancet, with an Indian having a nine per cent chance of developing depression. The World Health Organization estimates that depression is the leading cause of disability worldwide. And, world over, mental health is becoming a serious cause for concern. When one sees the numbers stacked up, the time to act is now. We, as a country, can take on the challenges by using a multi-pronged approach. The past cannot be changed, but the future is still in our power.</p> <p>&nbsp;</p> <p><b>The writer is a social psychologist and author.</b></p> Fri Jan 24 15:55:06 IST 2020 head-for-help <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>Manjiri Indurkar from Jabalpur was baffled as she started losing interest in everything she used to love. “I used to be a regular and studious kid. But suddenly I stopped going to school,”recalls the 32-year-old. “I would just watch TV, not leave the house unless pushed and not meet friends. I did nothing. But I still didn’t know what this was.”Her diagnosis of depression happened much later, after she moved to Delhi. ‘’Those days, I was crying all the time. It was rough,’’says Indurkar, who was pushed to get treatment by her friends.</p> <p>&nbsp;</p> <p>Depression is not just feeling sad or being tearful and weepy. The inability to find pleasure from activities one usually enjoys—anhedonia—is also tantamount to depression, says Dr Philip John, senior consultant psychiatrist, Peejays Policlinic, Kochi ( “The other symptoms of depression include insomnia or hypersomnia, feelings of worthlessness or guilt, poor concentration, poor memory, fatigue or lethargy, suicidal thoughts, agitation and change of appetite,”he says.</p> <p>&nbsp;</p> <p>Depression can cause structural changes in the brain, too. “If you experience depression for a long time, your brain cells degenerate. There could even be decreased volume in the prefrontal cortex and hippocampus. A good number of studies show that depressive people lose their grey matter; some lose white matter as well,” says Dr Johann Philip, consultant in psychiatry at Peejays. A study led by Dr Jeff Meyer of the Centre for Addiction and Mental Health in Toronto, showed that people with persistent and untreated depression that lasted more than ten years are found to have significantly high levels of brain inflammation. The study published in The Lancet Psychiatry also throws light on how depression changes the brain over the years.</p> <p>&nbsp;</p> <p>Depression can be triggered by stressful life events, but it has a strong biological and genetic basis, says John. “One of our patients with depression is doing wonderfully well in life. He has achieved all his goals. He has no stress. But at the same time, he goes into recurrent depression,” he says. “It comes from within. Known as endogenous depression, it ultimately comes down to genetic factors and changes in neural networks.” It is caused by a combination of biological, psychosocial and environmental factors. The gene-environment interactions such as parenting or childhood abuse can have a great influence on the genesis of depression, as much as on the outcome of its treatment, says John. According to the World Health Organization, India is the most depressed country in the world—one in five Indians may suffer from depression in their lifetime. Many of them have no one to talk to, and the stigma around mental health and the acute shortage of professionals like clinical psychologists and psychiatrists make matters worse.</p> <p>&nbsp;</p> <p>Dr Bhaskar Mukherjee, senior consultant psychiatrist at ILS Hospitals, Kolkata, considers depression the most severe cause for loss of human productivity and misery globally. It can kill one in multiple ways. Jael Varma, who hails from Sakleshpur, Karnataka, felt suicidal almost every day after she lost her mother to cancer in 2015. What made it worse was that she had, around the same time, come out of a difficult relationship. “I felt I was in a bottomless pit with no hope left,”says Varma. “I imagined my death a million times, wrote eulogies, letters to all my loved ones and even my will. I told my friends what to do with my pets and books in case something happened to me. Once I almost hung myself, well almost.”</p> <p>&nbsp;</p> <p>Looking back, Varma wonders how she survived that dark period of depression when she couldn’t eat or even get up in the morning. “Once I drank coffee 16 times and puked and slept in the bathroom because I was too tired to go to my bedroom,” says Varma, a poet, concept model and an account director at a private firm. “I started losing hair, my skin lost its sheen. I just lost interest in looking after my body. I had lost my self-worth, felt extremely lonely and hated my life. I just could not think positive. I stopped believing in love, in humanity, in dreams, in people, and in the world.” During that period, she fell physically sick for almost four months. She tested negative for all ailments, and doctors said they could not diagnose the reason for her fever, fatigue, body ache and dizziness. “I felt like I lived in a rented body. I was dead within,’’ she recalls.</p> <p>&nbsp;</p> <p>Depression is one of the most complex medical maladies involving several brain circuits and networks. It can cause abdominal problems, too—the gut is referred to as a little brain. Sleep difficulties are also commonly seen in people with depression. Dr S. Kalyanasundaram, a psychiatrist from Bengaluru, says that as depression progresses, patients may feel despondent and it takes a great deal of effort for them to handle daily routines. Patients also tend to skip work. And even if they show up at work, they are not as efficient as before. They end up feeling worthless and useless, leading to suicidal thoughts. Very often, it is caused by mixed anxiety-depressive disorder (MADD), explains Kalyanasundaram.</p> <p>&nbsp;</p> <p>According to a study published in the New England Journal of Medicine, 69 per cent of diagnosed depressed patients had unexplained physical symptoms as their chief complaint. “Children with depression report having tummy pain. Elderly people with depression often complain of headache, back pain, hand and leg pain,”says Johann. “Anxiety, a major accompaniment to depression, activates the autonomic nervous system which, in turn, produces all these physical symptoms. Muscles go into spasm and you can have headache, body ache or pain in the neck or legs.”</p> <p>&nbsp;</p> <p>For Babitha Marina Justin, the depressive spells began when she was writing her novel Maria’s Swamp in 2016. Her depression started with a series of physical symptoms like loss of appetite, panic attacks during sleep, incessant and intermittent crying for no reason, negligence of routine and obsession with hygiene. The same phase recurred every year, with a long and painful spell of depression. “While I was writing, there was a larger chunk of my childhood written in a fictionalised form and it was a painful exercise for me. At the same time, I had immense professional pressure and a relationship crisis,’’ recalls Justin, an academic, writer, and artist based in Thiruvananthapuram.</p> <p>&nbsp;</p> <p>Depression could manifest as anger, too. “In agitated depression, rather than sadness, the primary symptom is hyper-irritability—getting angry easily and throwing things. Many times, such people come for treatment for mood swings and the underlying cause will be depression,” says Dr Sagar Mundada, consultant psychiatrist, Healthspring, Mumbai. Binge-eating can also be a presentation of depression, he says. Another odd presentation is seasonal affective disorder. “In certain seasons like winter, the patient has depressive symptoms which clear once the weather changes,”he says.</p> <p>&nbsp;</p> <p>Sarbari Dasgupta Gomes, 61, a psychotherapist, has had a long battle with depression. For the last four years, she lacked focus and initiative, low self-worth, hyper vigilance over how people were behaving with her or perceiving her, mood swings, lack of enthusiasm about meeting people and taking up new assignments. “What was most damaging was that I started believing that this was who I was and that I could not change and that there was nothing to look forward to in life,”says Gomes. “One day, I woke up from sleep crying and with a huge sense of sadness that was unbearable. There was no external trigger for that symptom.” She realised then that she could not solve this problem with “willpower”and needed professional help. She called a friend, who is a clinical psychologist, and she referred her to a psychiatrist.</p> <p>&nbsp;</p> <p>Rishabh Kumar, 20, is yet to figure out ways to deal with his depression. Counselling sessions help relieve the symptoms to a great extent, he says, but sometimes the fatigue that comes with depression becomes overpowering. But not all patients can manage their depression with counselling alone, says Dr B.N. Gangadhar, director, National Institute of Mental Health and Neurosciences, Bengaluru. “For people with depression, the algorithm is as follows,”he says. “We first see whether the patient is suicidal or not. If he is suicidal, we get him admitted. Secondly, we find out how severe his symptoms are. If the patient is suicidal and has symptoms like retardation and agitation, my preference is to use electroconvulsive therapy (ECT). If the symptoms are manageable, antidepressants will be the standard treatment of choice. Antidepressants give good results in most patients.’’</p> <p>&nbsp;</p> <p>Antidepressants and mood stabilisers help with neuronal repair, says John. “Some of the newer medicines can improve cognition significantly,’’ he says. Patients with major depressive disorder respond well to medication. “People suffering from MDD, especially those with obsessive traits, may become suicidal impulsively. They need to be admitted and put on medication. ECT and medication is a wonderful combination for such patients,’’ suggests John. That said, he adds that bipolar depressives don’t respond to antidepressants, but “to mood stabilisers”.</p> <p>&nbsp;</p> <p>ECT is one of the oldest therapies used for treating mental health issues. While it provides acute relief of symptoms, patients still have to take medicines. Also, ECT carries stigma. And, patients have to be physically fit, too, to be given anaesthesia. “Despite these constraints, ECT is, by far, the best antidepressant therapy known to the world today,” says Gangadhar. Although ECT continues to be the gold standard among physical therapies for the treatment of depression, newer modalities like repetitive transcranial magnetic stimulation (rTMS) are now increasingly being used, says Dr Joel Philip, consultant psychiatrist, Peejays Policlinic. In rTMS, a noninvasive procedure that lasts half an hour to one hour, an electromagnetic coil is held near the patient’s head. The coil generates magnetic pulses that travel through the skull and the soft tissues in the brain, inducing electrical currents that stimulate brain cells. rTMS can be administered with no or minimal side effects, says Dr Shyam Bhat, physician and psychiatrist at Mindfit, Bengaluru. “There is no anaesthesia; it is an outpatient procedure, during which the patient is fully awake.”</p> <p>&nbsp;</p> <p>A lot of research is happening into how deep brain stimulation (DBS) can help treat depression. In the neurosurgical procedure, a neurostimulator is placed in the brain, which sends electrical impulses to specific brain regions. “Controlled trials on DBS have not been put forward. That is one of the limitations of DBS,” says Gangadhar.</p> <p>&nbsp;</p> <p>Then there are other treatment modalities involving ketamine and esketamine for people with severe and resistant depression, says Dr Malay Dave, consultant psychiatrist, Hindu Sabha Hospital, Mumbai. Although initially synthesised as an anaesthetic, ketamine is now prescribed as an antidepressant. “It is useful, in the short term, in reducing suicidal thoughts accompanying a depressive episode,”says Joel. Ketamine is generally administered intravaneously. “Ketamine is currently used only cautiously by psychiatrists owing to its abuse potential, but its efficacy in combating depression has spurred new research for molecules that share the same mechanism of action, with a lowered propensity for misuse,”adds Joel. Esketamine, a derivative of ketamine, can be used as a nasal spray. It gets absorbed instantaneously and helps in the immediate treatment of suicidal thoughts.</p> <p>&nbsp;</p> <p>Another tried and tested therapy is cognitive behaviour therapy (CBT) that Justin is currently undergoing. “My therapist has also taught me certain tricks to be mindful and conscious to manage myself so that whenever I am afflicted by depressive spells I resort to them, and I also try to make them part of my routine,”she says. CBT helped Varma understand herself better. Her therapist introduced her to mindfulness, and she consciously notices her thought and writes down each emotion. “I have become less cynical about my behaviour pattern. I am not angry anymore,” she says. “I have become tender with myself. In a nutshell, I have started treating myself better. It is like a rebirth.” John adds that Varma suffers from recurrent depression and needs medication to prevent relapses.</p> <p>&nbsp;</p> <p>Yoga, too, is increasingly being used in the treatment of depression. “If the person is not severely depressed, I would recommend yoga. It works even as a standalone treatment. I prescribe antidepressants or other modalities, only if they don’t get better with yoga,’’ says Gangadhar.</p> <p>&nbsp;</p> <p>Non-adherence to medication is a major challenge in psychiatric treatment. “Early treatment prevents the degeneration and shrinkage of the relevant brain cells and provides remission. Regular medication for a couple of years also prevents relapse,” says John.</p> <p>&nbsp;</p> <p>Ignorance and myths about psychiatric medication unfortunately abound. For instance, people think that they are addictive and make one drowsy. Some patients avoid them, fearing that they will be on medication for life and that it could damage their brain, liver and kidneys, turning them into a zombie.</p> <p>&nbsp;</p> <p>The paranoia around medication shouldn’t stop patients from following the prescription, says Indurkar. “While I understand the fears, I really think this paranoia does so much damage, especially because I know how my medicines have saved me,” she says. “They have kept my hyperactive imagination in control and stopped me from spiralling into the deeper, darker spaces of my psyche.’’</p> <p>&nbsp;</p> <p>It is also important to stop blaming oneself for the situation. “You are not lazy or lethargic. You just need help, and trust me, you will get it if you seek,” says Varma.</p> <p>&nbsp;</p> <p>Medication, therapies, yoga, exercise, learning and lifestyle changes are pivotal in repairing the brain circuits damaged by depression, she says. Varma now lives her life passionately. “I can tell with confidence, today I feel great, I look gorgeous. I love my life to the brim. Yes, grief does return. I handle it differently. I relish each moment, be it sadness or happiness, without getting attached to it.’’ Her depression has made her more compassionate. “There are a lot of people with depression,”she says. “All I can say is—let's be kind to each other.”</p> Fri Jan 24 15:52:13 IST 2020 i-was-vulnerable-i-was-honest <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>It was in 2015 that I first spoke about depression. Since then, not a day goes by when someone around me does not acknowledge that they have become more aware of their mental health. And that is where I feel great. I was vulnerable. I was honest. And I am glad that my honesty has paid off. I am glad that it has allowed other people to address their own mental health issues.</p> <p>&nbsp;</p> <p>The first step to recovery in cases of mental health, I believe, is acknowledging and accepting. It was really liberating for me. I would do it all over again. Of course, for someone who has been through it, you start identifying the signs and symptoms. And that is the best part. Once it has happened to you, you will always know when it is happening again. It is always easier to identify it and act upon it. Over time, I have started realising what my trigger points are. While working on my recent film Chhapaak, for example, it is just the role that took a toll on me. I could not identify a trigger point, it was the role itself that was a trigger point.</p> <p>&nbsp;</p> <p>My friend and I were chatting the other day. We are so silly sometimes because we know exactly what the trigger points are, but one keeps challenging it because you feel ki ab nahi hoga (it will not happen now), and then boom, one day again it comes back and you are like, “Oh, god! Stupid girl! Why?”</p> <p>&nbsp;</p> <p>When that happens, when I realise that it has spiralled again, I do not hide it. I do not pretend that I am okay. Never. The first thing I do is making people around me aware that I am not okay. And so much has changed now from the time I first started speaking about it. Now, when I tell people, “I am not feeling okay”or “I am not feeling too well”, the first question is, “is it physical or emotional?”It is not taken for granted that it is physical. We are able to differentiate that, which is the best part.</p> <p>&nbsp;</p> <p>Commenting on what helps when you are diagnosed with depression, whether it is medication or therapy, would not be right on my part. I am not an expert. I think it is different for different people. But I feel it is a combination of all the things. I am still on medication. Because you never know what the triggers are, or what suddenly can spiral. I would never want to go back into that place again. Different people get different advice. Some doctors are always trying to wean off their patients. Some recommend them to continue taking medicine. But it is never one thing—it is not just counselling or just medication that helps. When you know it is depression you are living with, your entire lifestyle has to change, which I try and do as much as possible.</p> <p>&nbsp;</p> <p>As a society also we are changing. There are NGOs that are doing their bit to create awareness. With The Live Love Laugh Foundation, we have worked to increase awareness and reduce the stigma associated with mental illness.</p> <p>&nbsp;</p> <p>I think the government has also stepped up. In a couple of sessions that the prime minister has done, especially during exam time, I see him talk about mental health. From an allocation perspective, when you look at the health budget, certainly the overall allocation for mental health can be increased. We are definitely struggling with a demand and supply ratio as far as counsellors and therapists are concerned. Rehabilitation of people struggling with mental health issues is something the government should look into more aggressively.</p> <p>&nbsp;</p> <p>Another aspect that I think is really important is how the insurance companies work around it. They need to relook their policies and see how mental health becomes a part of them. There is a lot of work to be done in that space.</p> <p>&nbsp;</p> <p><b>An actor and producer, Padukone is founder, The Live Love Laugh Foundation.</b></p> <p>&nbsp;</p> <p><b>AS TOLD TO PRIYANKA BHADANI</b></p> Fri Jan 24 18:38:36 IST 2020 next-frontier-is-to-identify-and-use-good-bacteria-to-treat-specific-diseases <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p><b>How did you hit upon the idea of using the synbiotic solution to prevent sepsis in neonates?</b></p> <p>&nbsp;</p> <p>I have been working on neonatal sepsis and necrotising enterocolitis for more than two decades in the US. One thing we saw very early on was that diversity and Gram-positive bacteria (like probiotics) could be protective. One research led to another, including our large-scale surveillance of infection in India, and we gathered enough scientific evidence that friendly bacteria may be used in prevention of sepsis. Since some of our previous studies in India had shown very poor colonisation of probiotic strains in neonates, we added the prebiotics (in combination called synbiotics) to help promote the growth of the administered probiotics; and it worked.</p> <p>&nbsp;</p> <p><b>What was the most remarkable result of your study? Was it the reduction in the rate of lower respiratory tract infection? How would this synbiotic benefit them in adulthood?</b></p> <p>&nbsp;</p> <p>Reduction in respiratory tract infections was definitely unexpected. But, the overall reduction of all infection-related morbidity was remarkable. The synbiotic that helped babies in their first two months of their life may not continue to help them in adulthood (unless there is some epigenetic changes). But, scientists have already started working on discerning the mechanism of such impacts. I am confident new research in children, adults and the elderly will identify new probiotic strains of value in respiratory and other diseases.</p> <p>&nbsp;</p> <p><b>What was the biggest challenge in this study?</b></p> <p>&nbsp;</p> <p>To do a US National Institutes of Health/Food and Drug Administration quality study in India, and that too in the community setting where most babies die. That is why it took us 10 years and close to $7 million of competitive NIH funding to come to the finish line. A lot of energy and time were spent to conduct surveillance of infection (to find out the type and timing of infection), preliminary hospital-based studies, and to prepare the field sites, labs and hospitals and train more than a dozen clinicians and researchers from India.</p> <p>&nbsp;</p> <p><b>In your work, you say that synbiotics could be used as a cheap and highly effective solution in developing countries to prevent sepsis. How has this idea been received by said countries, particularly by India?</b></p> <p>&nbsp;</p> <p>Yes, the cost of probiotics is minuscule compared to antibiotics. Several country leaderships are talking to me on this. I have been invited to speak on this in some developing countries where the need is acute. In 2018, I gave a plenary talk on this at the 36th annual meeting of European Society for Paediatric Infectious Diseases as a '21st Century Milestone in Infectious Diseases'. I have also spoken at the US NIH/FDA and other meetings in the west. From a public health perspective, such preventative therapies could revolutionise how infant infections are handled in developing countries, because that is where 95 per cent of the deaths due to such infections take place.</p> <p>&nbsp;</p> <p>(Although some use probiotics in a solution form in the west, mostly it is used as powder. Otherwise, it is very difficult to keep the bacteria alive. We also used powder reconstituted in a couple of millilitres of dextrose-saline solution when fed.)</p> <p>&nbsp;</p> <p><b>Gut flora of Indians is under-explored. How do you see this changing? Are you planning to collaborate with any research group in India?</b></p> <p>&nbsp;</p> <p>In general, a lot needs to be done in the field of medical research in India, not just gut microbiome. But India, by default, can provide a wealth of information on the gut microbiome. India as one sub-continent has 36 good-sized countries. Each one is different in its food habit and exposures, from socio-behavioural and environmental aspects as well. So, one could consider India to be a global platform to identify different types of microbiota, how they develop and what they do. I collaborate with AIPH University in Odisha, AIIMS, Delhi, Indira Gandhi Medical College and Research Institute in Puducherry and have been talking to the senior leadership and scientists at IMTECH Chandigarh and several others.</p> <p>&nbsp;</p> <p><b>What are your current projects?</b></p> <p>&nbsp;</p> <p>I am busy trying to examine the same preparation in other countries, especially in the sub-saharan African settings where the burden of neonatal sepsis and death is also very high. These efforts are all dependent on funding, especially from overseas.</p> <p>&nbsp;</p> <p><b>I understand you had to stop the study mid-way because the results of the study showed such efficacy that it was “unethical” to deny it to the control group. Could you share the experience from that time?</b></p> <p>&nbsp;</p> <p>When we follow internationally accepted principles of clinical research and trials, it is unethical to continue a trial when you know it is already working because half of your participants get only placebo, no therapeutic intervention. But, once completed and published, it is up to the policy makers to decide if they want to adopt the new frontiers or not. As a scientist, I have done my job. The ethical burden now lies on the policy makers who either use or not use the probiotics to help their babies. Also, to some extent on you, the media that helps disseminate the information, because not every citizen reads medical literature.</p> <p>&nbsp;</p> <p><b>What does latest research say about probiotics and their efficacy? The market is flooded with over-the-counter probiotics that promise to not just restore gut health, but also treat respiratory allergies.</b></p> <p>&nbsp;</p> <p>When I started working seriously on probiotics more than 15 years ago, some called it 'snake oil'—it works in every disease, and probably in no disease. So, how can an informed physician make a decision? They were right. Evidence in its favour was scanty. Now, there has been an explosion of trials and information. But, again compared to how much work has been done in the field of antibiotics or other drugs, it is still at a rudimentary stage. Scientists are just starting to realise that one size fits all will not work and they have to identify specific species and strains for specific ailment in specific populations. Many probiotics available over the counter may have no or minimal effect (if the strains are not chosen based on scientific evidence) and many strains are not even alive in the preparation, because they are not made stable after manufacture and die in the hot climate.</p> <p>&nbsp;</p> <p><b>Ayurveda works on the principle that gut is crucial to good health. Do you feel it is time to revive our ancient heritage, and in what way?</b></p> <p>&nbsp;</p> <p>When our paper on the effect of synbiotics was published in Nature, many major newspapers around the world covered the story. Shailaja Chandra (former secretary of health and family welfare), in response to a tweet by Dr Ravi Mehrotra, then director of National Institute of Cancer Prevention and Research, commented that such type of work should be done in India. I am hopeful that the ministry of AYUSH and the Indian government will be serious about such research. The type of information and clues we have in ayurveda are priceless. It is only very recently that allopathic medicine is recognising the fact that not all human beings are the same and will not respond to a medicine in a similar manner. This is called personalised medicine and is very much practised in cancer therapy now. Ayurveda does not look for a single cause or a pathogen, rather focuses on the host, the person and looks at his/her ailment in a holistic manner and tries to fix the root cause. That is where our ancestors had seen that by changing the gut flora in specific manners many diseases could be treated or prevented. We can go back to the same principles, examine one disease at a time and one intervention of ayurveda with complete understanding of why that was recommended. With all the new molecular and omics tools, many changes in the body can be examined quickly, which was not possible earlier. If done in a systematic manner, ayurveda can provide invaluable insights into our physiology and pathogenesis of different diseases linked to individual physiologies.</p> <p>&nbsp;</p> <p>But, reviving pickles or eating more curd is not the solution. Yes, they are good. More than a century go, Nobel laureate Ilya Mechnikov saw that those eating fermented food were living longer in eastern Europe. That was a pointer for us to do more, and not just be happy with curd. Many countries eat fermented food or milk products. But, there are countries like Ghana where no one consumes curd, and other than babies, milk is not a part of the common diet for a child or adult. But, they are not terribly unhealthy. What do they eat? How do they develop a healthy gut microbiome? What part of their diet contributes to a protective versus a diseased gut flora?</p> <p>&nbsp;</p> <p>Answers to all these types of questions are there in our ayurveda. Why should a leaf or flower be plucked on a moonlit or new moon night (not during the day), and should be taken with certain type of food to experience its healing properties?</p> <p>&nbsp;</p> <p>I sincerely hope that a few young Indians will get vested in ayurveda and bring India to the center stage of medicine.</p> <p>&nbsp;</p> <p><b>Would you say that the work on gut microbiome would be the next frontier of research when it comes to treating or preventing diseases?</b></p> <p>&nbsp;</p> <p>It is difficult to say if gut microbiome will be the next frontier, but definitely one of the frontiers. The reason to support this lies on the fact that the gut is the largest immune organ (size of a tennis court when all villi—a fingerlike projection of the lining of the small intestine—are opened up) in the body, and the number of bacteria residing there is ten times the total number of cells in a human body. We have to examine them to harness their power and use them to our advantage. We live in a very polluted, artificial environment today. Plus, we take antibiotics as chocolates, killing all good bacteria in our body. And, all the processed food and food additives. The rate at which we damage our gut flora or have already damaged, it cannot heal on its own. We need to identify good, powerful ones and use them to restore a healthy gut microbiota and against specific disease conditions. That will be the next frontier!</p> Fri Jan 10 15:46:12 IST 2020 poo-power <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>Poop is the future. It may arouse disgust, but poop transplants are being considered a curative wonder, beginning with ulcerative colitis, for which the treatment has shown positive results.</p> <p>&nbsp;</p> <p>“We have it in plenty. Indians are the second highest poopers in the world, producing about 400g per person per day,” says Dr Avnish Seth, director, gastroenterology and hepatobiliary sciences, Fortis Healthcare, who says he performed the first stool transplant for ulcerative colitis in India in 2014. Since then, Seth says he has done the procedure with 50 other patients, and is conducting a clinical trial for stool transplant with patients with irritable bowel syndrome.</p> <p>&nbsp;</p> <p>The procedure itself is not too complicated, and involves transferring the stool—the richest source of gut microbiome—from a healthy person to the colon of a patient to restructure the gut environment. Stool samples are taken from a donor with a healthy gut environment, which houses a rich, diverse microbial composition.</p> <p>&nbsp;</p> <p>The stool is then churned in the mixer with saline water, run through a soup strainer and transferred to the diseased patient through a colonoscopy. “The best part is that except the colonoscopy, the rest of the stuff can be done at home,” says Seth, admitting that the “yuck” factor might be a put-off for the patients initially. “But once they understand the procedure and experience the benefits, it can be life-altering for some of them.”</p> <p>&nbsp;</p> <p>Agrees Manas Shukla, 50, the first patient to get the treatment. “The ulcers in my colon meant that I would bleed each time I went to relieve myself, which was so often. The bleeding would happen otherwise as well. I was fatigued, could not travel for work, and had lost a lot of weight, too,” recalls Shukla.</p> <p>&nbsp;</p> <p>The Delhi-based businessman concedes that preparing the solution for transplant can be a challenge, but nothing that “cannot be overcome”. “The maximum time that the solution can stay is six hours, within which the solution has to be transferred to the patient through a colonoscopy,” he says.</p> <p>&nbsp;</p> <p>The real challenge though is finding a healthy donor, and then matching the microbial requirements of the donor and the recipient—the microbial composition has to fit like a jigsaw puzzle. “For one, we need to carefully evaluate that the bacteria that are causing the ailment in a patient are not in excess in the [microbiome] of the donor,” says Dr Sharat Varma, senior consultant, paediatric hepatology, liver transplant and gastroenterology, Max Super Specialty Hospital, Saket.</p> <p>&nbsp;</p> <p>In 2018, Varma conducted a first of its kind stool transplant in Asia for a six-year-old boy from Odisha who had a gut disorder (short bowel with recurrent D-lactic acidosis). The disorder was caused because of an excess of the bacteria Lactobacillus, which was producing a toxin that made the boy sick. He had frequent stools, hampered growth, would slip into a “coma like situation” and was extremely dependant on antibiotics to control the bacterial proliferation.</p> <p>&nbsp;</p> <p>“In his case, we considered his parents for donating stool. Before a donor is selected, we have to evaluate their gut microbiome. In this case, we had to be careful that the Lactobacilli population was not too high [in the donor's microbiome] or it would have defeated the purpose of the transplant,” he says. Overall, doctors will evaluate the entire microbial composition so that the delicate balance of microorganisms in the gut is restored, and no disease-causing bacteria are transferred. A “star donor”, says Seth, will have all these qualities.</p> <p>&nbsp;</p> <p>The transplant may be simple and inexpensive, but the “match-making” is an expensive exercise, says Varma, with each genome sequencing test for gut microbiome costing Rs15,000 to Rs25,000. Besides, as Seth points out, at times, not one donor is good enough—a mix of two or three donors may also be required to build the right, effective solution.</p> <p>&nbsp;</p> <p>And then, there is the efficacy of the procedure. Seth says in his trials, about 60 per cent patients have seen positive results, with no side-effects. Good bacteria, of course, do not last forever and the transplant procedure has to be repeated, too. “Besides the transplant, they have to have their medications as well. But, in the case of ulcerative colitis, for instance, they can be taken off the heavier medication such as steroids, which have a lot of side-effects,” says Seth.</p> <p>&nbsp;</p> <p>Shukla, however, is only on one anti-inflammatory drug; he needs to undergo a transplant every six months. “From having heavy steroids and having tried every kind of treatment, to now just one drug, things have improved drastically for me. I have been lucky,” he says.</p> <p>&nbsp;</p> <p>Shukla has been lucky on another count, too. Having an extremely cooperative donor in his brother-in-law. “For the last two years, he has been living in New Zealand. Every six months, he comes down for the donation. And now, I prepare the solution myself. It just takes half an hour,” he says. “There is no need to get disgusted. You don’t have to have it orally; it is put in your colon.”</p> Fri Jan 10 15:42:29 IST 2020 that-gut-feeling <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>It worked like a vaccine of sorts—a sugary solution with a probiotic bacterial strain for newborn babies to prevent sepsis. This was in Odisha, back in 2008. US-based paediatrician Dr Pinaki Panigrahi, who had already been working on sepsis and necrotising enterocolitis (inflammation of small intestine and colon) in neonates for two decades by then, knew enough about good bacteria in the gut and their therapeutic properties.</p> <p>&nbsp;</p> <p>Now, Panigrahi and his team had their task cut out—finding good bacteria for the transfer of the good stuff. After collecting and evaluating several hundred samples of potentially beneficial bacterial strains, both off the market and from babies, the healing bugs were found in the unlikeliest of places— in the babies’ dirty diapers. The bacterial strains were then isolated from the stool, mixed with non-absorbable sugar to enhance efficacy and fed to the babies along with breast milk. The solution worked like a charm—besides preventing sepsis, the babies also reported a drop in several other infections, including respiratory tract infections.</p> <p>&nbsp;</p> <p>For decades, bacteria have been shunned, feared and abhorred for causing everything from tooth decay to epidemics that have wiped out entire generations and, at times, altered the course of history. World over though, scientists such as Panigrahi have found redemption for certain species of bacteria by reporting the crucial role they play inside our bodies in their clinical trials. Research has shown that friendly bacteria that colonise our gut interact with our gut immune mucosa, thereby playing a huge role in making us fat or thin, happy or sad, diseased or healthy.</p> <p>&nbsp;</p> <p>Microbes, we now know, are all over us. Even breast milk, says Panigrahi, once thought to be a sterile medium, has bacteria. Together, these microbes such as bacteria, fungi, viruses outnumber human cells—the human body is made up of 10 trillion cells and 100 trillion microbes. A majority of the microbial population (about 90 per cent, say experts) though resides in our gut; up to 2kg of our body weight is composed of the gut microbial population that holds the key to human immunity.</p> <p>&nbsp;</p> <p>These microbes, primarily bacteria, break down the food we eat, release the by-products into our system, produce vitamins, and set-off complex processes in our body that help us stay healthy, or make us diseased. They can also explain why certain drugs such as antibiotics will not work on us. Experts are trying to understand how these processes can be aided, abetted, or turned around in a bid to find cures and prevent several diseases including depression, Parkinson’s, autism, diabetes and obesity.</p> <p>&nbsp;</p> <p>In India, too, similar efforts are underway, beginning with studying the inhabitants of Indian gut universe—possibly the most diverse in the world. Dr Bhabatosh Das, a microbiologist with Translational Health Science and Technology Institute, Faridabad, has some crucial insights into the Indian gut. Das, 41, is the lead author of a first-of-its-kind study on the Indian gut microbiome, which looked at the gut flora of healthy adults in rural and urban settings. Das, who returned from France—where he had worked on the subject of gut microbiome—in 2012, figured that not much had been done on the gut of Indian people and decided to take it up.</p> <p>&nbsp;</p> <p>After smaller studies on the gut flora of undernourished children, Das and his team started work on the big one—their study was big both in terms of the range of samples and the technique used for studying the bacterial genomes—that was published last year. The researchers collected and analysed samples (faecal matter, richest source of gut bacteria) from three distinct sites—Leh in Ladakh, and urban and rural people in Ballabhgarh in Haryana.</p> <p>&nbsp;</p> <p>The results were striking. “We found that the Indian gut flora is more diverse than, say, that of the Americans or even the Europeans. Indian gut has close to 500 species of bacteria, while the Americans have about 400 species,” says Das.</p> <p>&nbsp;</p> <p>Overall, the study showed the diverse species of bacteria that populate the gut of Indians, reflected the diverse dietary habits, and provided some clues for developing potential cures for a few diseases such as irritable bowel syndrome through faecal transplants or specific probiotics.</p> <p>&nbsp;</p> <p>It also reinforced the fact that urban lifestyles were upsetting the crucial and delicate balance of healthy bacteria and microbes in the gut. The urban gut flora samples were less diverse in their bacterial population than the rural ones.</p> <p>&nbsp;</p> <p>“We also found that the gut flora of vegetarians was more diverse when compared to that of the meat-eating populations,” says Das. In their study, researchers found that dietary habits directly affected the composition of the gut bacteria, from cooking oil to sweet tea, to dairy and meat, the bacterial population changed with specific habits. For instance, the bacteria Collinsella was found to be higher in those who consumed ghee, Sporobacter in those that used mustard oil, and Roseburia in those that used sunflower oil.</p> <p>&nbsp;</p> <p>The study also showed that the Indian gut flora is dominated by Firmicutes, the class of bacteria that ferments carbohydrates and helps extract energy from food to be used by the body or stored in fat cells. “This is higher than in developed countries, primarily because Indians eat a high-fibre diet,” he says.</p> <p>&nbsp;</p> <p>A healthy gut would have bacteria from four phyla—Firmicutes, Bacteroidetes, Actinobacteria and Proteobacteria, explains Das. You would think then that Firmicutes or specific bacterial species such as Collinsella or Prevotella are our friends. The more the better, right? Wrong. Firmicutes have been found in a higher proportion in the gut of obese persons. “In those suffering from undernourishment, Firmicutes are too less,” he says.</p> <p>&nbsp;</p> <p>Prevotella, which is found to be in a relatively higher degree in the Indian gut because of our high-fibre diet, has also been observed in a higher degree in the gut of diabetics, especially those with type 1 diabetes, says Dr Yogesh Shouche, director, National Centre for Cell Science, Pune. The exact mechanism at work between the two though is still being studied, he says.</p> <p>&nbsp;</p> <p>Instead of individual bacteria, it is the “optimal balance” of bacteria that defines a healthy gut, Das explains, lending credence to the grandmother’s advice of eating a diverse diet, based on season, location and even the time of the day.</p> <p>&nbsp;</p> <p>The relationship between diet and gut microbiome though is complicated. “There are studies that have shown that animal-based and plant-based diet promote different microbiomes. However, in India, if we go by the frequency of meat consumption, even the so-called non vegetarians could be defined as vegetarians. It is only specific communities that consume meat on a regular basis,” says Shouche. Genetics, environment and geography also play key roles in shaping the gut environment.</p> <p>&nbsp;</p> <p>Shouche’s own study points to how the gut flora can be affected even by the way we are born—a vaginal birth shows less diversity of microbial species in the infant’s gut, as compared to those born via a C-section.</p> <p>&nbsp;</p> <p>The link between gut bacteria and diseases of the brain such as Parkinson’s, depression, autism and dementia is also being studied. Earlier this year, The New York Times reported on research being do in the University of Chicago on how gut microbes were perhaps releasing a chemical that might be altering how immune cells work in the brain.</p> <p>&nbsp;</p> <p>In November 2019, China gave conditional approval to a drug for Alzheimer’s, which contains a compound known as oligomannate that is derived from marine brown algae. The compound works by “rebalancing” microbes in the gut, including bacteria and viruses. Closer home, Dr Baby Chakrapani P.S. of the Cochin University of Science and Technology is preparing to start work on his latest research project—studying the link between the bacteria in the Indian gut and Parkinson’s disease.</p> <p>&nbsp;</p> <p>The central question Chakrapani will be investigating is this: if the gut is like the “second brain” with all its neural connections, then wouldn’t a change in gut flora help prevent or at least detect brain diseases at an early stage for Indians? “There are 100 billion neurons in the gut. Not so much in the stomach, but in the large intestine where major exchanges take place,” says Chakrapani, who got interested in the project while observing a similar project being done at the University of Chicago. Chakrapani, along with Dr Shyam K. Nair, additional professor, neurology, Sree Chitra Tirunal Institute of Medical Sciences and Technology (SCTIMST), Thiruvananthapuram, has received a Rs1 crore grant from the Indian Council of Medical Research. The duo will investigate this question by taking several samples—faeces, blood, saliva and urine—from patients who will be recruited from the SCTIMST. “What we are assuming is that there are two to three pathways through which the transfer of metabolites from the gut to the brain can happen. Of these, the vagus nerve, the direct connection between the gut and the brain is one,” he says.</p> <p>&nbsp;</p> <p>The vagus nerve is the longest and most complex of the 12 pairs of cranial nerves that emanate from the brain. It transmits information to or from the brain's surface to tissues and organs elsewhere in the body. The vagus nerve sends information from the gut to the brain, which is linked to dealing with stress, anxiety, and fear—hence the phrase 'gut feeling'. These signals help a person to recover from stressful and scary situations.</p> <p>&nbsp;</p> <p>“The transfer could also be happening through body fluids. The exact mechanism of how certain protein aggregates (found in the gut of those with Parkinson’s) reach the brain is what we will be trying to understand over the next few years,” says Chakrapani.</p> <p>&nbsp;</p> <p>Shouche, who is awaiting a nod from the Department of Biotechnology for an approximately Rs40 crore project on studying the Indian gut microbiome of 3,500 persons over two years, says as of now there is no comprehensive study to map the microbiome of different populations across the country. Studying the Indian gut itself is no mean task. “The most important challenge is diversity,” he says. “There is tremendous variation in genetic makeup, diet and geography. That makes it difficult to have a good representative sample to generate any meaningful data.”</p> <p>&nbsp;</p> <p>The challenge, however, is a blessing in disguise, too, says Panigrahi, professor, department of paediatrics, division of neonatal-perinatal medicine and director, International Microbiome Research, Georgetown University Medical Center. “India, as one sub-continent, has 36 good-sized countries. Each one is different in its food habit, exposures, and from a socio-behavioural and environmental aspect as well. So, one could consider India to be a global platform to identify different types of microbiota, how they develop, and what they do,” says Panigrahi, who is credited with the ground-breaking study, published in Nature in 2017, on preventing sepsis through a synbiotic solution in 4,500 neonates in Odisha.</p> <p>&nbsp;</p> <p>Other challenges for studying the Indian gut microbiome are the key issues of technique and funding. It is only in the last five years or so that advances in genome sequencing techniques have made it cheaper to study the gut microbiota. Das says one of the first studies he did on the Indian gut microbiome with merely 20 subjects cost Rs1 crore. “Now a similar study with a bigger sample size can be done in only Rs10 lakh,” he says.</p> <p>&nbsp;</p> <p>The technique of sequencing genomes of bacteria has itself been crucial to the study of gut microbiome around the world. Dr G. Balakrish Nair, who was earlier with the Rajiv Gandhi Centre for Biotechnology, Thiruvananthapuram, says that classical microbiology and its practitioners went only by lab cultures. “Microbiologists believed that what could be seen in a petri dish, cultured in a laboratory, was the only thing that could be studied,” he says.</p> <p>&nbsp;</p> <p>Gut microbes, however, could not be cultured in a laboratory, and therefore were difficult to identify and study. Genome sequencing techniques offered a way out by enabling the microbiologists to study the entire genome structures of microbes. “That came as a huge shift in the way microbiologists worked, and the technique has brought nothing short of a renaissance in the way things were studied,” says Nair.</p> <p>&nbsp;</p> <p>Elaborate studies on the Indian gut microbiome hold tremendous value. For instance, Das’s study has revealed that those from Leh could potentially be ideal donors for faecal transplants, owing to the balance of microbes in their gut. “In faecal transplants, you cannot isolate specific bacteria and so the entire microbiome of the donor is passed on to the recipient. Those in Leh did not have a high population of proteobacteria, which are known to have inflammatory properties, in their gut, and so they could prove to be ideal donors,” says Das.</p> <p>&nbsp;</p> <p>More work on Indian gut microbiome would also lead to manufacture of probiotics with India-specific strains. “We are now working on genetically modifying the bacteria isolated from the Indian samples from our study, and analysing whether they can be used for therapeutic purposes,” says Das.</p> <p>&nbsp;</p> <p>The more we know about specific strains of bacteria in our gut, the better probiotics—a controversial subject—can be developed. “As of now, there are no probiotics with India-specific strains available in the market. The ones that are available are from the populations of developed countries, and will not work for us,” says Shouche.</p> <p>&nbsp;</p> <p>Studying the gut microbiome has never been an urgent and more pertinent exercise to be undertaken by researchers, say experts. “It is the science of the future,” says Nair. “And India, with its diverse gut flora, ought not to be left behind.”</p> Fri Jan 10 15:37:41 IST 2020 best-of-both-worlds <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>Born in Kolkata and raised in Derby, England, she is a true-blue Bengali at heart who indulges in everything sweet and later hates herself for it. A compulsive hoarder, she is a sucker for Bollywood films, loves Ranveer Singh and can watch Shah Rukh Khan's Main Hoon Na over and over again. Her most cherished childhood memories of India include regular visits to the ISKCON temple in Kolkata. And, in her next life, she wants to be born as a reincarnation of Swami Vivekananda. That's Bhasha Mukherjee for you—the 23-year-old who was crowned Miss England on the night of August 2 and who will go on to be the first British Asian to represent England at the Miss World in December. That night, Bhasha changed the perception of beauty pageants forever.</p> <p>&nbsp;</p> <p>Bhasha is the perfect antidote to a competition that has hitherto placed high stakes on female sexuality and outward appearance. She holds dual degrees in medicine, has an IQ of 146 and is fluent in five different languages—English, Hindi, Bengali, German and French. Barely a few hours after her crowning glory and driving home the message that pageant girls are not all airheads or “Instagram models with lip filler”, Bhasha was all set to begin her practice as a junior doctor at Pilgrim Hospital, Boston, Lincolnshire. That's two new titles in the space of 24 hours. A picture of her dressed in fuchsia scrubs and grinning at the camera, clutching a stethoscope in one hand and her crown and sash in the other, soon began circulating on the internet. “Through the beauty pageant, we are trying to showcase to the world that just because we are pretty, it does not end there—we are actually trying to use our reach and influence to do something good,” she told The Sun soon after winning the Miss England title. “It has been really nerve-wracking. I could not tell if I was more nervous about the competition or about starting my job as a junior doctor.”</p> <p>&nbsp;</p> <p>For someone who got bullied for her looks growing up, the title has given her a sense of validation and pride. “I got called Ugly Betty in school,” Bhasha told THE WEEK. “I decided to focus on grooming, and therefore experimented with makeup and got creative. I had my own share of makeup mistakes—Sharpie brows was one of them. I went on a diet and exercised. However, I realised that exterior appearance is something that can be easily altered and eventually I stopped beating myself up over my looks.”</p> <p>&nbsp;</p> <p>The Mukherjees moved to the United Kingdom in 2004 when Bhasha was nine. In school, she was a total nerd, she said. An early memory that still cracks her up is of her stepping on a running treadmill at the school gym and falling flat on her face in front of her mates. “It is a shame it never got filmed,” she quipped. Her parents—Durgadas and Madhumita—encouraged curiosity and creativity and instilled self-confidence in her brother, Arya, and her. “As a child, I had a vivid imagination and was full of questions, whether it be asking existential questions to my grandparents or educational ones in the classroom,” recalled Bhasha. “I would never shut up.”</p> <p>&nbsp;</p> <p>On her tenth birthday, Durgadas gifted her an alarm clock and told her that it would act as a reminder to be always mindful of time. “It was one of my dearest presents at the time,” said Bhasha. “That shaped me as a person, as I am constantly aware of how little time there is in life.” Her upbringing and development in early childhood and adolescence have contributed immensely towards shaping her personality. “My mum was a firm believer in extracurricular activities and finding every opportunity to learn,” said Bhasha. “Every day, after work, she would expect my brother and me to recount how we had spent the day after coming back from school. We got into the habit of being productive early on. And, every evening, it would be a recount of maths sums, creative writing, artwork or reading when mum would return from work.”</p> <p>&nbsp;</p> <p>Bhasha, however, brushes off any mention of genetics being responsible for her having an above average IQ. “Nurture brings out the best in nature,” she said. “I am fortunate that both my parents were educated and clever in their own ways. However, more than genetics, the way this cleverness of theirs helped me was by how they guided me through my own education.” She cites the example of her mother helping her prepare for medical school. “Even through medical school, my mum, despite being a complete novice on medical terminology or knowledge, would always help me revise and be a pretend patient, mostly to let me practise my skills on her,” she recounted.</p> <p>&nbsp;</p> <p>Despite the optimism surrounding her, there are times when negativity creeps in, making her feel vulnerable and lost. “I feel vulnerable every day. I think if I could go back in time, I would add an older sibling before me to my mum's womb,” said Bhasha. Her medical school years were especially quite tough. “There have been several low points in my life as I struggled my way through medical school and battled depression,” she said. “I suffered on and off all the way through medical school. I still suffer with high functioning anxiety.”</p> <p>&nbsp;</p> <p>Bhasha did not always want to be a doctor though. Her first choice was to be an astronaut. Thereafter, she dreamt of being a zillion other things, before settling down to a world dedicated to care and cure. “I realised that medicine is an art and a science and was a perfect mishmash of everything I had to offer—I am a good listener, very much a science geek and I love people,” she said. And then, there was no stopping her—she got a bachelor's degree in medical sciences, followed by another one in medicine and surgery, thereby fulfilling her dream of becoming a surgeon. This, despite someone advising her against it by saying, “Medicine will make you lose all your hair.” Clearly, she didn't give a toss about that.</p> <p>&nbsp;</p> <p>To balance out the monotony and pressure associated with her studies, she continued with performing arts and started her own dance company at 17. That propelled her into the modelling industry. “I carried on modelling all the way through medical school for extra cash,” said Bhasha. “The modelling industry and the pageant industry have much crossover, so I took part in small pageants locally, which unfortunately were rather disastrous. They were scams and I gave up completely on pageantry until 2017.”</p> <p>&nbsp;</p> <p>Bhasha was then scouted by one of the leading Asian bridal magazines to take part in Miss Asian Face of Miss England. But it took them one and a half years to convince her to take part in the pageant. “I finally took part and I won it,” she said. That qualified her for the Miss England pageant and she set her mind to it. “I think pageants certainly do get you places if you are willing to put in the work,” she said. “The numerous success stories from beauty pageants were proof of this and that was part of the reason I wanted to take part. There are far worse things that are overrated in today's day and age, and Miss World or any beauty pageant is not so high on my list of overrated things.” For someone who likes to have something that excites her and keeps her going, she said, “Right now, my job gives me regularity while Miss England gives me the excitement of becoming someone totally different.”</p> <p>&nbsp;</p> <p>But it wasn't a cakewalk to the crown for Bhasha, and initially she had her fears. “I could not sleep for days before the Miss England finals, even though I had no idea or control over its outcome,” she shared on Instagram. “Moreover, I was fearful of both outcomes—the embarrassment of loss and the responsibility of a win. Not to mention the added fear of a new job, moving cities and all that in one week!” But she did overcome her fears. Recounting an incident from the pageant on social media, she said, “The very first round was the 'Bare Face Top Model' round. It was a daunting feat to face a panel among drop-dead gorgeous girls, and that too bare-faced. On top of that, just minutes before I went on stage, I spilt almost half a bottle of water on my jeans. My mind told me to flee but I chose to stay and fight, to walk that stage like it was mine and mine alone. Choose fight over flight.” The very first week after she won the crown and joined the hospital, she was “thrown in the deep end, in the busiest hospital ward during the week followed by three back-to-back 13-hour on-call shifts over the weekend. I was petrified seeing patients by myself, writing drug charts, making decisions autonomously—all so soon into the new job.”</p> <p>&nbsp;</p> <p>Things are now getting hectic for Bhasha, who must juggle her time judiciously between her full-time duty as a doctor, her commitments as Miss England and her preparation for the upcoming Miss World contest. But Bhasha is unfazed. “It is amazing how productive humans can be when under pressure,” she said. “We waste a lot of time on social media and being lazy. If you set yourself deadlines, it is possible. The weeks leading up to Miss World are particularly busy. I have already visited my dress sponsor, who has kindly donated a full wardrobe of 10 dresses to wear at Miss World. I have taken some time off [from the hospital] to prepare for the physical aspects of Miss World with my trainer at Torpex Sports, the gym group in Derby. While I was still working [at the hospital], I tried to schedule Miss England commitments on weekends and off days.”</p> <p>&nbsp;</p> <p>While each day brings in a set of different commitments, a typically busy day in Bhasha's life could begin at 6am, starting with getting hair and makeup done, travelling to another city, event appearances in the morning, a shoot in the afternoon and another event in the evening. “I also now have to fit in fitness training with the gym group for the Miss World sports round,” she said. And seeing how she has sashayed her way to the crown and through medical school, Bhasha has no qualms about walking that extra mile. “All I have had to do is step up my game, get even more efficient and not waste time,” she said. Amid all this, she also finds time for her organisation—The Generation Bridge Project—which connects the younger generation with the older one by visiting care homes for the elderly. But she is also responsible, which is why she took a month off before the Miss World pageant. “It is always important to recognise what is and isn't within your capacity to achieve, and go at a sustainable pace,” she said.</p> <p>&nbsp;</p> <p>But balancing acts come with sacrifices, and Bhasha has had to give up on her social life. “I see my friends almost never for just socialising. Even our meet-ups revolve around working out together or planning charity events. I also don't go clubbing, nor do I drink or smoke. So socialising isn't much fun if I am around,” she said, laughing. But she does indulge in some 'me time', either reading, writing poems, dancing or boxing.</p> <p>&nbsp;</p> <p>Though her schedule went for a toss after winning the Miss England title, she has found a routine and is sticking to it. “I am not particularly picky about food but focus on portion control and calorie restriction by intermittent fasting,” she said. “In terms of fitness, my aim is gaining strength rather than weight loss.”</p> <p>&nbsp;</p> <p>Bhasha isn't quite attuned to sports. In the Miss England sports round, her performance was “pretty low”. In an Instagram post, she wrote how “it shook her confidence and turned her into an emotional wreck. My anxiety was so bad I was struggling to fall asleep for almost a month, my limbs felt weightless and numb and I felt a constant sickness in my stomach.” And, then she found boxing. “I actually saw a growth in myself, where my punches got stronger and stronger,” she said. “So, I may be horrendous at bikes, but won in the area I enjoyed.”</p> <p>&nbsp;</p> <p>Bhasha is essentially a desi at heart. For the talent round at Miss England, she swayed gracefully to the 'Ghoomar' song from Padmaavat. She calls herself a filmi keeda who loves all Indian films and music. Her love for Hindi films comes from her parents. “So I am well versed in Indian classical and Bollywood music, starting from the 1930s, and even regional music and films,” she said, but cautioned: “Don't test me though.” Her last visit to India was in 2016 and she absolutely loves the masaledar Indian dal. She felt super proud to be an Indian in the UK when Slumdog Millionaire released. “We watched it in school, where A.R. Rahman's music blared through the speakers. I felt super proud then,” she said. She, however, regrets not watching Baahubali. Her greatest regret though is not demanding the respect she deserved for the work she did for years as a model.</p> <p>&nbsp;</p> <p>Today, she is more forthright, and no longer reluctant to voice her opinions. Brexit, she says, is a “gangrenous leg”. “We have been anticipating this for so long, we may as well go ahead and chop the damn thing off,” she said. “Let's just move forward. It is no fun being in limbo.” She thinks the #MeToo movement has been phenomenal but is sad that the wave is dying down. “We need to keep the fire burning in all of us and fight such social injustices,” she said.</p> <p>&nbsp;</p> <p>As the performer, poet and protagonist of her own story, Bhasha's state of mind is “a strange one”. She is engaged in the process and preparation of Miss World, “but at the same time I feel a sense of detachment. I fleet between feelings of caring too much and not caring at all about the outcome.” And what if she doesn't succeed? “My faith and spirituality have aided a lot in giving me that inner strength,” she said. “I don't believe in winning. I believe in surviving failures and getting back up on my feet every time.”</p> Fri Dec 06 16:07:36 IST 2019 tackling-the-tumour <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>Fibroids are one of the more common maladies affecting women in their reproductive years. Doctors say that fibroids—the slow-growing, non-cancerous tumours of the uterine muscle—can be small or large, few or several in number, deep-seated, in the middle or outside the uterus wall. For most women, these benign tumours can lie dormant through their lives; for others, they can cause significant pain, discomfort and heavy bleeding, and require surgery, too.</p> <p>&nbsp;</p> <p>“About 40 per cent of women have fibroids in their uterus. Some aren't even aware of their presence, and the fibroids get discovered only during routine checkups. Majority of them don't require treatment,” says Dr Ranjana Sharma, senior consultant gynaecologist, Indraprastha Apollo Hospitals, Delhi. The growth of these tumours is dependent on oestrogen and progesterone hormones and typically they start to shrink after menopause. Doctors say genetics plays a role in their growth and there isn't anything you can or cannot do to prevent them. “We are seeing a trend of girls hitting puberty earlier than usual. Now, they are getting their periods at nine or ten, which means that there is a longer period between attaining menarche and menopause,” says Dr Rishma Pai, consultant, gynaecology, Lilavati Hospital and Research Centre and Hinduja Healthcare, Mumbai.</p> <p>&nbsp;</p> <p>For Renuka Nair, 51, the fibroid came as a shock. She says she had been “healthy” all her life, and her menstrual cycles had run like clockwork. In 2016, while undergoing an annual checkup as part of her husband's health care plan, she found out about the “four kilo” tumour growing inside her uterus.</p> <p>&nbsp;</p> <p>“During the sonogram, the doctor said that I had a large fibroid, about 18.5cm, that had been growing inside of me this entire time,” recalls Nair, who works at a travel agency. “It was hard to believe since I had had no symptoms ever.” Besides a stray comment from a friend about her tummy looking “bigger than usual” in those days, she says she had no forewarning about the large mass inside her.</p> <p>&nbsp;</p> <p>Pai, who treats several fibroid cases in a month, says these tumours can be asymptomatic for many patients. But for those who have symptoms, the suffering can be pretty serious. “Most women land up at the doctor's when they have heavy bleeding or menstrual pain, or have symptoms such as the fibroid creating pressure on the bladder,” she says. “It may also give them a feeling of heaviness. At times, the bleeding caused by the fibroid can be so bad that women end up feeling extremely weak, fatigued, and are unable to cope.” Many women also end up turning to the doctor if they have had trouble during pregnancy, or have had frequent miscarriages or repeated abortions, says Dr Suneeta Mittal, director and head, obstetrics and gynaecology, Fortis Memorial Research Institute, Gurugram.</p> <p>&nbsp;</p> <p>There are four kinds of fibroids—intramural, subserosal, submucosal or pedunculated. Intramural fibroids are those that grow within the muscle tissue of the uterus; subserosal ones grow outside of the uterine wall into the pelvis; submucosal ones generally develop in the middle muscle layer of the uterus; and pedunculated fibroids grow from outside of the wall of the uterus or into the uterus cavity and are attached to it by a narrow stalk.</p> <p>&nbsp;</p> <p>Treatment options for women suffering from fibroids usually depend on the woman's age, location of the fibroids, their size and numbers. In some cases, there have been 60-70 fibroids even, says Mittal. Doctors describe their size as ranging from that of a coin to that of a coconut or a watermelon.</p> <p>&nbsp;</p> <p>One of the priorities for determining the treatment modality is whether the woman has “completed her family”. If the woman is in her 30s or early 40s, and may be considering having children in the future, removing the fibroid and saving the uterus would be the doctor's key concern. “We also need to map these fibroids to find out where they are located, how many of them are there and the severity of the woman's symptoms. Usually, it is the ones that lie inside the uterus that give rise to several symptoms,” says Pai.</p> <p>&nbsp;</p> <p>Today, doctors say that options for treatment are many—using drugs or blocking the arterial blood supply of the uterus to shrink the tumours, an MRI-guided focused ultrasound that works by burning off the fibroids, and surgically removing the tumour, or, in some cases, the uterus as well. “Until three years ago, we didn't even have drugs to deal with the issue,” says Pai. “But now, drugs can shrink the fibroids, albeit temporarily, as fibroids tend to recur.” Drugs are also used as a temporary solution for those who are unfit for surgery, says Dr Sonia Naik, Max Hospital, Saket.</p> <p>&nbsp;</p> <p>The other option is the procedure of uterine artery embolisation (UAE), which is performed by an interventional radiologist using a small needle hole. A flexible catheter is inserted and guided to the vessels supplying blood to the fibroid. Through the catheter, small particles that block the blood vessels and deprive the fibroid of nutrients are injected. This results in shrinkage of the fibroid. “The UAE procedure may, however, affect the ovarian reserve, and trigger symptoms of early menopause,” says Mittal.</p> <p>&nbsp;</p> <p>The downside of the procedure is also that blocking the blood supply of a fibroid will render it dead. “The dead tissue inside the body might take time to get absorbed. The patient can get high fever, and would need to be counselled on these aspects. Also, for those who are trying for pregnancy, we wouldn't recommend this,” says Sharma.</p> <p>&nbsp;</p> <p>A more recent procedure is the MRI-guided high intensity focused ultrasound procedure, which delivers a series of targeted ultrasonic pulses or sonications to treat the fibroids. “The heat burns the fibroids, and since the ultrasonic pulses are targeted, the healthy tissue is not harmed,” says Pai. The heat generated by the high-intensity focused ultrasound, says Sharma, will melt up to 40-50 per cent of the tumour. “A 10cm tumour would be reduced to 5-6cm, but it would still be present in the body. If reduction in size of the fibroid relieves the patient's symptoms, then it can be a very attractive minimally invasive treatment,” she says.</p> <p>&nbsp;</p> <p>However, not everyone is an ideal candidate for that treatment. “The eligible patient would have a tumour that is not too big in size, and its position must be accessible for the beam to act on it and there should be no bowel in the way,” says Sharma. “Besides, one needs to be cautious if the patient intends to be pregnant in the future, though there have been successful pregnancies after the procedure.” The procedure was launched at the Apollo hospital in 2012, but has been discontinued because of the mismatch between the high cost of the machine and the patient load.</p> <p>&nbsp;</p> <p>In case of a submucosal fibroid though, surgery is the only option. Nair says she was first advised open surgery, but was “apprehensive” about it. “I felt more comfortable with a laparoscopic surgery,” she says. Her uterus had to be removed because the fibroid was “too large”. “My daughter is now 21. Not having a uterus and ovaries were not something that bothered me,” she says. “My ovaries were removed because my mother is a breast cancer survivor. After the procedure, many women are given hormone replacement therapy. But in my case, since I had an active lifestyle, I wasn't given one.”</p> <p>&nbsp;</p> <p>At times though, the removal of the uterus can result in a dilemma—some women might equate the uterus with “femininity” or “womanhood”, say doctors. “That is a myth, and people ought to know that the uterus has no role in producing hormones. It is the ovaries that produce the [sex] hormones,” says Naik.</p> <p>&nbsp;</p> <p>For Nair, the hysterectomy “hasn't changed a thing”. “I am still as active,” she says. “In my mother's case, post hysterectomy, she got diabetes. But I haven't had any issues yet.”</p> Sat Nov 16 14:35:07 IST 2019 to-the-brink-and-back <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>Her vulnerability echoes in her words and in her latest music, too.</p> <p>&nbsp;</p> <p>You could sense it in Anoushka Shankar's recent revelations about her struggle with fibroids, painful periods and the hysterectomy. It also resonated in her 2017 Instagram post on “pain” that was followed by the news of the end of her seven-year marriage with British director Joe Wright.</p> <p>&nbsp;</p> <p>Sitarist, composer and daughter of the legendary sitar maestro Ravi Shankar, Anoushka says her latest single, Lovable, that released on October 11 is all about “heartbreak” and “loss”. “It is the voice of that raw, aching vulnerability inside us, the one we rarely articulate,” she tells THE WEEK in an exclusive conversation from her home in London. “It is nice to see people appreciating it; they are saying it is an emotional song, invoking sad, vulnerable type feelings in them.”</p> <p>&nbsp;</p> <p>And, Anoushka, 38, is not one to shy away from her own vulnerabilities. This August, she took to social media to post her “gynaecological CV”. “As of last month, I no longer have a uterus,” she writes. In the following pages, Anoushka details a painful account: getting her periods at the age of 11, “bleeding for ten days every 20-25 days”, and suffering from excruciatingly painful menstrual cramps, the ones that make you “roll on the floor in pain”. “Like everyone else, I tried everything... the usual stuff... from the prescription stuff to the natural stuff [to ease the discomfort]. I did take magnesium supplements; not many people know that these can help,” says Anoushka, adding that she had been practising yoga for two decades.</p> <p>&nbsp;</p> <p>In the elaborate post, she opens up about her suffering because of fibroids—the slow-growing, non-cancerous tumours that grow out of the uterine muscle, affecting, as some studies suggest, close to half the women in their reproductive years. Doctors say that for a majority of the women, the fibroids won't show symptoms or even require any treatment. For others though, there will be symptoms such as heavy bleeding, cramps and abdominal bloating.</p> <p>&nbsp;</p> <p>Anoushka says that she had a myomectomy (surgical removal of fibroids) once, after which she had two children. But earlier this year, when she was diagnosed with a fibroid that made her uterus appear as if it were “six months pregnant”, she was advised to undergo hysterectomy, a procedure that doctors advise depending on the severity of a woman's condition and whether she plans to have children in the future. In her case, says Anoushka, it was made “quite clear” that there was no option other than the surgery. The immediate fallout of it was “short-term depression”, and apprehensions about how it would affect her “womanliness”, how it may affect her sex life, her fears of dying during the procedure—all of which she details in her post.</p> <p>&nbsp;</p> <p>It was while dealing with the news and reaching out to her family and friends to “prepare emotionally” for the surgery that Anoushka realised that many women around her had undergone the surgery but never spoke about it.</p> <p>&nbsp;</p> <p>While reflecting on that and her own struggles with her gynaecological issues, Anoushka said that she realised how she, too, had “internalised” the stigma and ended up following the convention that women must keep mum about such issues and continue to suffer. “It struck me that something that affects half the population in the world is never spoken about. I also realised it is more common than I had thought it would be, and what I went through is hardly unique. Many women go through this and even worse,” says Anoushka. The decision to share her story on social media stemmed from this realisation. “I guess I just had a hunch that I needed to speak about this. Of course, I wanted to wait until I was feeling better, had recovered a bit,” she says.</p> <p>&nbsp;</p> <p>Now on the road to recovery—Anoushka also had an abdominal tumour surgery, which, she says, has complicated her recovery somewhat—the six-time Grammy nominated artiste says the reaction to the post has been quite “brilliant”. “Men and women have responded,” she says. “The women were able to relate it to their own struggles, while the men told me that the women in their lives went through similar situations and were now prompted to seek the doctor's advice. Articles were written about the issue, medical type of articles, telling women this is what the issue is and here's what you can do, that kind of stuff, which was really brilliant.”</p> <p>&nbsp;</p> <p>You wonder how hard it is for someone like her to say these things, given the compulsions of being a celebrity. But Anoushka, who has had a rather unconventional upbringing, is comfortable being in the public eye, something she has “grown up with”. When it comes to speaking about contentious issues, she has always tried to be “straightforward”, and has not been concerned with “projecting an image”. “I feel blessed to have a voice, and to know that people will hear me,” she says. “So, when there is something I feel the need to speak about, I just do it.”</p> <p>&nbsp;</p> <p>It is something she did in the aftermath of the December 16, 2012, gang rape in Delhi, too, when she revealed she was sexually abused as a child by a “trusted friend” of her parents. “After the gang rape in Delhi, women started talking about their pain, and it was like there was all this collective trauma,” she recalls. “Some people, however, were unable to accept it saying that the outrage about Jyoti Singh was so because she was a middle-class person, someone like us. They were just unwilling to accept the scale of the problem. I just felt I had to say something to highlight the issue.”</p> <p>&nbsp;</p> <p>Women, says Anoushka, just cope. “I mean, it is not like women would take a day off every month or even disappear for days on end if they are having these health issues,” she says. She adds that women ought to talk about it and reach out for support, instead of just suffering in silence. Anoushka, who battled “heartbreak, domestic upheavals and health issues” in 2018 and 2019 did so and more—she wrote and sang about it, too.</p> Sat Nov 16 14:36:08 IST 2019 the-wings-of-desire <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>‘<b>ITHAKA’, A POEM BY</b> Constantine P. Cavafy, offers a panacea for modern ills. The Greek poet tells us not to hurry the journey of life and reminds us how important it is to pause, to satiate our senses and gain knowledge and experience. The journey, he says, is more important than the destination.</p> <p>&nbsp;</p> <p>I had something of an epiphany while reading the poem. Caught up in our everyday lives, we tend to forget what we had been and what our fondest childhood dreams were. But some people manage to reconnect with their passions, despite the challenges life throws at them. The doctors featured in this package belong to that group.</p> <p>&nbsp;</p> <p>Take, for instance, Dr Shobhit Chawla from Lucknow. An eye surgeon, he cooks like a man possessed once he gets back home. Chawla loves to cook Kashmiri Pandit cuisine—Kashmiri kofta, dum aloo, lal paneer, phirni and rogan josh. “I find cooking meditative,” he says. “Avoiding eating what I have cooked is a great exercise in self restraint!”</p> <p>&nbsp;</p> <p>Dr Jagdish Chaturvedi, a nose and sinus surgeon at Fortis Hospital, Bengaluru, finds fulfillment in standup comedy, which not only breaks the monotony in his life but also serves as an alternate source of income, making him less dependent on his primary profession. Having a hobby can be truly rewarding, says Chaturvedi. “I get a lot of patients from the audience. Sometimes people come to me after the show to take a selfie and then they pull out a CT scan and ask for consultation,” he says. “One patient who came and consulted me after the show got operated on a few days later for sinus. My shows are cheaper than my consultation fee. So, it is a win-win situation for both the parties.”</p> <p>&nbsp;</p> <p>Rock climbing is more than just a hobby for Dr Sanjay Dhawan, director and head of ophthalmology, Max Healthcare, Delhi and Gurugram. “While profession is like fuel to the engine, passion is like oil,” says Dhawan, who thoroughly enjoys his lizard-like climbs. “Hobbies are required for smooth running. Else there will be friction, heat and breakdown.”</p> <p>&nbsp;</p> <p>Pursuing a hobby is a way for doctors to maintain their sanity. Doctors are often consumed by their work and deal with stressful life-and-death situations. “A hobby can help them lead a balanced and emotionally healthier life,” says Dr Shyam Bhat, psychiatrist-physician and head at Mindfit, who used to do standup comedy earlier.</p> <p>&nbsp;</p> <p>However, a hobby could add to a doctor’s stress, if he is not good at managing time. Dr Arvind Bhateja, a cycling globetrotter and neurosurgeon based in Bengaluru, has had to make a lot of sacrifices to follow his heart. “The biggest sacrifice I make is on my social life. And then you have to wake up early to get your workout done while the rest of your colleagues are fast asleep. Maybe you will have to give up on eating sweets during the festivals. Your training demands that,’’ he rues. However, Bhateja confesses that his hobby means the world to him.</p> <p>&nbsp;</p> <p>It is observed that doctors who actively pursue hobbies are more happy overall and are more productive at work. Here, a few doctors tell us how they balance their passions with their profession.</p> <p>&nbsp;</p> <p><b>JOKE'S ON YOU</b></p> <p>&nbsp;</p> <p><i>A man walks in with his mother who is unwell, looks at me, and says, “Ready kar ke dey.” I look at him and ask, “Should I home deliver her to you once she is ready?’’</i></p> <p>&nbsp;</p> <p>Dr Jagdish Chaturvedi’s comedy revolves around themes he is angry about.</p> <p>&nbsp;</p> <p>“I am basically an angry man. [Doing] standup helps me de-stress and convert my anger into comedy,” he confesses. His jokes on Bengaluru’s parking and traffic problems and doctor-patient violence are hugely popular.</p> <p>&nbsp;</p> <p>His childhood experiences—“I was a problem child. I would get into trouble a lot.”—too, made their way into his comedy, especially in his ‘F for Failure’ standup set. “There was no dearth of ideas while writing the one-hour comedy script,’’ says Chaturvedi. He did the show in cities across the country and the proceeds from it went to NIMHANS for a campaign on raising awareness on depression.</p> <p>&nbsp;</p> <p>The inner child in him still asks annoying questions. “I never understood the concept of studying important questions before the exams,” says the 35-year-old. “I mean if there are important questions, why are they teaching us unimportant things?” Our restaurants are as weird as our classrooms, he says. “Restaurants treat your home food as 'outside food'. They write it in capital letters—OUTSIDE FOOD NOT ALLOWED.”</p> <p>&nbsp;</p> <p>Chaturvedi juggles the demands of a challenging career and an all-consuming passion with ease. “Surgeries are done during the day and standup comedy happens over the weekends or at night. So, there is not usually a schedule collision,” he says. “It helps both the domains. A lot of people see my comedy and then come to me for treatment because they think I am a friendly person.” But managing family and standup is more challenging, he says. Most of the time, though, they fall in place and help each other.</p> <p>&nbsp;</p> <p>His eponymous YouTube channel features skits and cartoon sketches, besides his standup acts, and has more than 1,20,000 subscribers. He is now working on a web series—Starting Troubles—to be launched in November.</p> <p>&nbsp;</p> <p>Doctors have an amazing sense of humour, says Chaturvedi. To encourage doctors to do comedy, he has started a movement called #DoctorsDoComedy. “We are providing a platform for medical students and doctors to do comedy after undergoing a one-day workshop,” he explains. “So far, we have done these shows in Bengaluru, Hyderabad, Mumbai and Delhi, where we have had ten medical professionals try out comedy. All these shows were housefull.”</p> <p>&nbsp;</p> <p><b>CROWNING GLORY</b></p> <p>&nbsp;</p> <p>Dr Deepanjali Pathak Mundada believes in the power of dreams. Everybody should have a dream and make it come through, she says.</p> <p>&nbsp;</p> <p>Originally from Meerut, Mundada drew inspiration from Rhonda Byrne’s The Secret while preparing for the Mrs India Pride of Nation contest, organised by Glamour Gurgaon. “I would visualise myself winning the crown, and that filled my mind with positivity. Our thoughts can impact the whole life we are experiencing,’’ says the 33-year-old consultant diabetologist based in Mumbai. She was the second runner-up in the contest, and won the Miss Beautiful Smile subtitle.</p> <p>&nbsp;</p> <p>Around 7,000 women took part in the Mrs India Pride of Nation auditions in 2019. Mundada got selected from the Mumbai region. Being a beauty queen is not as easy as it seems, she says. The finalists had to attend grooming sessions. “We had a workshop on catwalk, where we were taught how to walk in six-inch high heels—something I was not used to,” she recalls. “Then there were sessions on etiquette and personality development, besides the ones on how to do your makeup and hair. Some of these sessions would go on till midnight.”</p> <p>&nbsp;</p> <p>What does it take to be a good model? “I think first and foremost is confidence,” she says. “It is not just about beauty. You should have confidence in yourself and be open to new things.”</p> <p>&nbsp;</p> <p>Mundada considers the Mrs India contest a platform to interact with a large number of people and create awareness on health issues. “I am doing campaigns on breast cancer awareness,” she says. “I want to emphasise on how women can remain healthy. When it comes to diseases like cancer, early diagnosis and treatment are crucial. Women often tend to put themselves at the end of their to-do lists and end up paying a huge price for it.” Her breast cancer campaign comes from a personal experience—her mother, who, she says, is her biggest inspiration, had breast cancer. Early diagnosis and timely treatment coupled with her willpower and positive attitude helped her fight the disease.</p> <p>&nbsp;</p> <p>Every doctor should have a hobby, says Mundada. “I always wanted to do more apart from my professional life. We are not born just to live our routine lives,” she says. “A doctor spends about 12-13 years of her life studying hard. We are so much into academics that we don’t get to celebrate festivals or attend family functions. So it is extremely important that we pause and do something for ourselves amid our hectic schedules.’’</p> <p>&nbsp;</p> <p><b>RIDING HIGH</b></p> <p>&nbsp;</p> <p>Cycling on Maui island in Hawaii is an almost surreal experience, says Dr Arvind Bhateja, neurosurgeon and spine surgeon at Sita Bhateja Speciality Hospital, Bengaluru. “There is a 60km mountain climb that starts at a beach and goes to the top of Haleakala, a dormant volcano, which is 10,000ft above sea level,” says the avid cyclist.</p> <p>&nbsp;</p> <p>Bhateja, who has cycled up Pass Stelvio, one of the highest mountain passes in the Alps, believes that cycling is the best way to get to know a new country. “When you are cycling, you tend to choose roads that have less traffic. In European countries, typically those would be country roads. They are off the highway and through villages,” he says. “When you stop for a meal or for refreshment, you actually interact with the locals and you get to see the real countryside. It is clearly the best way to see a country.”</p> <p>&nbsp;</p> <p>Bhateja, 50, has thus explored Hawaii, Italy, Singapore, Indonesia and Thailand on his S Works cycle. His fitness journey—mostly working out in the gym—began in 2003. He wanted to run the half marathon, but couldn’t as his knees had started troubling him. That is when he took to cycling. “I went and test rode a bike in 2009 and there was no looking back after that,’’ he recalls. He has also taken part in cycling races like the Giro delle Dolomiti in Italy. He took part in the 2016 edition of the Tour of Nilgiris after an injury and yet was able to finish first in the veterans category.</p> <p>&nbsp;</p> <p>Bhateja says one can cycle at any age. In international events, it is not uncommon to see people who are in their 50s or 60s. “You see a lot of women who are really fit and strong in these events. That has been a real eye-opener for me,’’ he says.</p> <p>&nbsp;</p> <p>Cycling abroad has its own set of challenges. “Exporting the bike is a fairly big challenge in itself,” he says. “Sometimes, the bike has technical issues once it lands at the destination. Sometimes you forget to pack something or some accessories are missing and you end up looking for help at the last minute.’’ A crash abroad is one of the worst things that can happen. One has to be prepared for all these eventualities, says Bhateja.</p> <p>&nbsp;</p> <p>Usually, when people hear about India, the first thing they ask Bhateja is how he manages to cycle in all that traffic. One thing Bhateja loves about Italy is the respect they give to cyclists. “You’ll always find a long trail of cars behind you—they won’t overtake you unless the opposite side is clear and it is safe for them to overtake,” he says.</p> <p>&nbsp;</p> <p><b>ROCK STAR</b></p> <p>&nbsp;</p> <p>As a child, Dr Sanjay Dhawan, 57, was fond of hiking and climbing mountains. But little did he know that he would continue to enjoy it in his adulthood. “A few years ago, I came across a book by Mohit Oberoi that details all rock climbing spots in Delhi NCR. That really helped,’’ recalls Dhawan, who specialises in cataract and refractive surgery.</p> <p>&nbsp;</p> <p>Rock climbing is the best sport for those who love the outdoors, mountains and climbing. However, it is no child’s play, says Dhawan. “To be able to do rock climbing, one needs to be physically fit. If you are not fit, you won’t enjoy it and may even end up with injuries. So, overall fitness is required,” he explains.</p> <p>&nbsp;</p> <p>Endurance and strength training workouts go a long way in terms of increasing muscle mass, strengthening bones and preventing injuries. Running and cycling, too, help Dhawan stay fit. “I would recommend yoga and stretches also for those who are into rock climbing. You need to have strong upper limbs and hands to be able to hold on to the rocks,’’ says Dhawan, who is a regular at Climb Central Delhi. Rock climbing helps burn calories as well. “With one hour of climbing, you can get rid of enough calories to enjoy your food,” he says.</p> <p>&nbsp;</p> <p>So how does he deal with the fear of heights while climbing? “My fears are all controlled by logic,” he says. However, the first time he attempted a free climb—climbing without any harness or rope—he got stuck in the middle of the pitch for a good amount of time and almost panicked. The instructor had to come up to rescue him, or he could have fallen and broken his bones as there was no pad below. Dhawan learnt his lesson—one shouldn’t be reckless or foolhardy when it comes to rock climbing.</p> <p>&nbsp;</p> <p>Dhawan, who is also into photography, music, writing and books, says that profession and passion should go on hand in hand to keep a person lively. Almost every time he has gone climbing or hiking, he has either held an eye camp or provided informal medical service to the villagers en route.</p> <p>&nbsp;</p> <p><b>READY FOR THE LONG RUN</b></p> <p>&nbsp;</p> <p>Running happened by chance, says Dr Gurmeet Soni Bhalla, a paediatrician and allergist who works with RxDx Clinic in Bengaluru. “Since I was a fitness enthusiast, someone asked me to sign up for Sunfeast 10k marathon in 2009. I did reluctantly, and found myself on the podium. And, I was hooked,’’ she recalls. Since travelling is another passion, Bhalla tries to run races wherever she goes for vacations with her family.</p> <p>&nbsp;</p> <p>This year, Bhalla, 50, became a member of the Seven Continents Club, which enrols runners who have run the full marathon on all the continents. The Athens marathon was her first full marathon. Another memorable experience was the Prague Marathon, thanks to which she saw the beautiful city on the run. The Inca trail in Peru, she says, is rightly known to be the hardest marathon. Running in rarefied air at 17,000ft in the Khardung-La Challenge in Ladakh was an ethereal experience, she says. And, the Antarctica Marathon was both challenging and exotic. “While in the Antarctica, we got caught in a blizzard and it took seven days for a special cargo plane to fly us out of there,” she recalls, adding that she bonded with 50 runners from 13 countries while stranded on the continent.</p> <p>&nbsp;</p> <p>With not many women participating in races, she says she finds herself on the podium often. “It is really motivating, even though I run for the joy of running,” says Bhalla, who is originally from Jammu and Kashmir. She has started enjoying ultra marathons, too. They bring you closer to nature and also test your endurance, she says.</p> <p>&nbsp;</p> <p>Running can be time-consuming and hence Bhalla tries to manage her time well. “I start my day early, say, 5am, get done with my run by 7am, finish household chores and then head to work,” she says. “It does take discipline and motivation to stay on track. I have to cut down on social commitments to adhere to my training schedule.”</p> <p>&nbsp;</p> <p>Bhalla follows a 16-week programme to train for a full marathon or an ultra marathon. It comprises four days a week of running, besides strength training twice a week. “I am mindful of what I eat so I don’t have to make too many adjustments except to increase my protein intake when my running mileage increases,’’ she says.</p> <p>&nbsp;</p> <p>Her husband runs, too, and they take vacations with the family around the marathon schedule. “My teenage children respect my passion for running and help me with chores,’’ she says.</p> <p>&nbsp;</p> <p>For Bhalla, running has been a gratifying and enriching journey. According to her, the perks of running include fitness, friendships, travel experiences and a chance to give back to society by mentoring and sometimes coaching friends.</p> <p>&nbsp;</p> <p><b>REEL TIME</b></p> <p>&nbsp;</p> <p>Being a doctor has helped him be a complete filmmaker.</p> <p>&nbsp;</p> <p>Dr Biju's film Birds with Large Wings depicts how endosulfan, a synthetic pesticide, wreaked havoc in Kasargod district in Kerala, leaving people crippled for life. Having a solid grasp on the effects of pesticide on humans, Biju could delve deep into the issue.</p> <p>&nbsp;</p> <p>For Biju, films are a catalyst for social change. His movies like Kaadu Pookkunna Neram, Perariyathavar and Veyil Marangal deal with the lives of the marginalised. They draw heavily on his experiences as a doctor. “As a government doctor, I often interact with people belonging to the lower strata of the society. A large part of my work involves improving the health of the tribal communities,’’ says Biju, who was at the forefront of the rescue and relief operations during the tsunami and last year's floods in Kerala.</p> <p>&nbsp;</p> <p>Biju’s favourite locations include the Himalayas, Sikkim, Ladakh and Andaman and Nicobar Islands. “Once while shooting in Ladakh, someone in the crew had altitude sickness. I gave him medication and he could continue with the shoot,” says Biju, currently a district medical officer at Pathanamthitta. A homoeopath, he always carries his medicine pouch, especially while shooting in remote places.</p> <p>&nbsp;</p> <p>A self-taught filmmaker, Biju, 48, has become a name to reckon with in Indian cinema. He started his journey with Saira, which was screened at the Cannes Film Festival in 2007 as the opening film in the world cinema section. A three-time national award winner, Biju has also won international awards like the Golden Goblet for Outstanding Artistic Achievement at the Shanghai International Film Fest in 2019 for Veyil Marangal. His movies have been screened at various international film fests, like the ones in Montreal, Tehran, Cairo, Telluride and New York. He was also part of the 2015 Oscar selection jury for the best foreign language film from India and was on India's National Film Award jury in 2012.</p> <p>&nbsp;</p> <p>Sound of Silence was his first non-Malayalam film—it was in Pahari, Tibetan and Hindi. The success of Sound of Silence encouraged him to do Painting Life, a film in English.</p> <p>&nbsp;</p> <p>Though not a regular at cinema halls, he still manages to watch over a hundred movies every year. “I take part in all major film fests in different countries. I watch around 150 movies a year,’’ says the director and scriptwriter who is a huge fan of Satyajit Ray and Majid Majidi.</p> <p>&nbsp;</p> <p><b>EYE ON FOOD</b></p> <p>&nbsp;</p> <p>Dr Shobhit Chawla loves everything about food, from its tantalising aroma to its mesmerising taste. “I even like to talk about food and recipes and to visit supermarkets and gourmet stores with their fascinating range of ingredients,’’ says the 57-year-old medical director and cofounder of Prakash Netra Kendra, Lucknow. Culinary shows that combine cooking with travel are his favourite. “They broaden your outlook about food and cuisine, expose you to interesting ingredients,’’ he says.</p> <p>&nbsp;</p> <p>Chawla, who specialises in diseases of the retina and the vitreous body, has donned the chef’s hat thrice, that too in five-star hotels on invitation. “Once, it was an evening buffet as part of a home-cooked food festival. I did a full dinner buffet, including two desserts,” he says. “I chose to do a Kashmiri Pandit [cuisine] for the buffet. It was a sellout.” He has twice taken part in contests on innovative cooking, one of which he won.</p> <p>&nbsp;</p> <p>Chawla does a lot of Italian food, like gourmet pastas. A perfectionist, he makes his own pasta. “It is a bit cumbersome but I don’t believe in buying the packets. I use fresh ingredient,” he says. His friends vouch for his carbonara. His other specials include the Thai steamed fish, paneer dishes made in Kashmiri Pandit style and Awadhi dishes. He loves experimenting with traditional recipes, hunting them down from old Lucknow families and giving them a twist. “I do my own innovations like mango salsa with roasted chicken and drunken prawns with cooked peaches. I am now enjoying innovating a lot of healthy salads, adding flavour and punch to healthy dishes,” he says.</p> <p>&nbsp;</p> <p>Chawla has had his share of culinary failures. “Once I put fish in the oven to steam and my guests arrived and I forgot about it. It was overdone, charred and leathery and I had to quickly cook akuri for them, as the main course was not edible,’’ he recalls.</p> <p>&nbsp;</p> <p>Medicine and cooking, it seems, are in his genes. “My mother was an excellent cook and a baker, besides being a gynaecologist,” he says. “Our neighbour Manglik, an English professor, and my mom would do a lot of interesting western dishes together. These influences initiated me into cooking.’’</p> <p>&nbsp;</p> <p>So who cooks at home? Usually, it is his wife, who emphasises on healthy food. Twice a week, Chawla takes control of the kitchen to ladle up some comfort food.</p> <p>&nbsp;</p> <p><b>HEALING MOVES</b></p> <p>&nbsp;</p> <p>Dr Kanishka Das, 53, fell in love with dance while in middle school. “My elder sister, Tapaswini, was a disciple of Guru Kelucharan Mohapatra. I would accompany her to the dance class and soon found myself fascinated by the moves and the mudras,’’ says Das, professor and head of paediatric and neonatal surgery at the All India Institute of Medical Sciences, Bhubaneswar.</p> <p>&nbsp;</p> <p>His parents were aghast when they came to know of his newfound interest. Back then, male dancers were not that common. Das, however, refused to give up his passion; soon, they gave in.</p> <p>&nbsp;</p> <p>He started his formal training in Bharatnatyam while he was studying medicine. He says dance helped him excel in medicine. “I felt refreshed to imbibe the difficult medical texts after a dance session, notwithstanding the physical exhaustion,” he says. He practised and performed the most while doing his masters in surgery at Post Graduate Institute of Medical Education and Research, Chandigarh. While he was a faculty at St John's Medical College, Bengaluru, he would squeeze in time for dance practice either early in the morning or late at night. The practice would be particularly intense before performances, and he continued to practice both Odissi and Bharatnatyam.</p> <p>&nbsp;</p> <p>His most memorable performances have been at the Yadavindra Gardens, Pinjore (Odissi), in front of the sanctum of the Jagannath Temple, Chandigarh and on a winter evening at the Odissi centre of Guru Gangadhar Pradhan at Konark (both Bharatanatyam).</p> <p>&nbsp;</p> <p>Looking back, he says the journey has been tough but gratifying. “I have carried the art form with me and it has kept me sane through mad times,’’ says Das. He says that being a dancer endears him to the patient, shatters his demigod image and cements the trust between him and the patient in intangible ways. “On discovery, my patients are pleasantly surprised, often amazed, that the knife-wielding hands can bring forth a flowering mudra,” he says. They appreciate that there is a soft side to their apparently strict healer and they open up further in communication. These are things central to the healing profession.”</p> <p>&nbsp;</p> <p><b>WALK WAY</b></p> <p>&nbsp;</p> <p>Take a leisurely walk in a forest, and immerse yourself in its sights, sounds and scents.</p> <p>&nbsp;</p> <p>The Japanese believe that just being in nature and connecting with it will help keep diseases at bay. Shinrin-yoku, the Japanese practice of forest bathing, is now gaining popularity.</p> <p>&nbsp;</p> <p>Dr Rohit Shetty, vice chairman, Narayana Nethralaya, Bengaluru, was introduced to shinrin-yoku when he visited Japan ten years ago. A co-passenger, who worked as an environmental science professor at a university in Tokyo, got Shetty interested in forest bathing. Forest Bathing: How Trees Can Help You Find Health and Happiness, written by Dr Qing Li, a professor at Nippon Medical School in Tokyo, gave him more insights into the practice.</p> <p>&nbsp;</p> <p>“Shinrin-yoku means taking the atmosphere of the forest with you,” explains Shetty, 43. “All you have to do is walk for an hour quietly in a forest. Breathe mindfully. This will help boost immunity and bring down your stress hormone levels.’’</p> <p>&nbsp;</p> <p>Shinrin-yoku is considered as the foundation of preventive health care in Japanese medicine, and is part of Japan’s national public health programme. Connecting with nature can work wonders for children with attention-deficit/hyperactivity disorder, says Shetty. “It improves intuition and cognition,” he says. Forest bathing has prompted numerous scientific studies that throw light on the health benefits of getting back to nature, which include reduced blood pressure and improved concentration and memory. Phytoncides, a chemical released by trees and plants, can boost the immune system.</p> <p>&nbsp;</p> <p>One of the most beautiful forest walks Shetty had was during his trip to Kyoto in Japan. “Practising forest bathing in the bamboo forests of Arashiyama in Kyoto had a huge influence on my thought processes. I have done forest bathing in Machu Picchu in South America, too, where there is a trek that leads up to the ruins.’’ While in Karnataka, he practises it twice or thrice a month. “We have an estate at Shiroor in Udupi that has a beautiful forest area. It is perfect for forest bathing,” he says.</p> <p>&nbsp;</p> <p>Shinrin-yoku is becoming increasingly popular in countries like England. Kate Middleton, the Duchess of Cambridge, is a huge fan of nature therapy. “Shinrin-yoku is not trekking; it is not jogging either,” says Shetty. “It is very quiet walking with mindful breathing.”</p> Fri Nov 01 15:44:01 IST 2019 a-disease-with-no-drug <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p><b>IN 2014,</b> a nine-year-old resident of Santa Cruz, Mumbai, was brought to P.D. Hinduja Hospital, Mahim, by her parents. Initially, the patient suffered malaria-like symptoms—high fever, altered sensorium (inability to think clearly or concentrate) and muscle weakness. However, it further developed into peripheral paralysis (involving hands and legs), which eventually ended up with the patient battling paralysis and severe respiratory problems. The symptoms were suspected to be of a mosquito-borne disease called Japanese Encephalitis (JE).</p> <p>&nbsp;</p> <p>JE is a viral disease that infects animals and humans. It is caused by a flavivirus transmitted by mosquitoes in humans, causing inflammation of the membranes around the brain. Generally, infections caused by JE virus are mild (fever and headache) or without apparent symptoms. Recently, the disease has been in the news for outbreaks affecting children in Uttar Pradesh, Bihar and West Bengal.</p> <p>&nbsp;</p> <p>The Mumbai resident was among the first few cases of JE in 2014. However, we couldn’t jump to conclusions without evidence in the form of reports. The patient underwent multiple tests, such as CT or MRI scan of the brain. Samples of the patient’s cerebrospinal fluid were sent to a private laboratory and Pune’s National Institute of Virology in the first week of hospitalisation, but they turned out to be negative for JE. During the third week of her treatment in the ICU, however, the results of the samples turned positive.</p> <p>&nbsp;</p> <p>My team and I were trying our best to bring the patient to normalcy, despite the impaired neurological functions and paralysed extremities in the hands and legs. In cases of JE, 30 per cent of the patients die and the ones who survive the disease suffer from neurological problems. Although the patient survived, unfortunately, the disease affected her with long-term disorders. I met the patient a year ago. There has been a whole lot of shift in her lifestyle in the aftermath of the disease. However, rehabilitation therapies have helped her regain physical, mental and cognitive abilities.</p> <p>&nbsp;</p> <p>To date, there is no specific treatment or cure found for JE. Once a person has the disease, only hospitalisation and supportive treatment can regress the symptoms.</p> <p>&nbsp;</p> <p>As they say, prevention is better than cure. It holds true for JE, too.</p> <p>&nbsp;</p> <p><b>The writer is a consultant paediatric neurologist, P.D. Hinduja Hospital, Mahim, Mumbai.</b></p> Fri Oct 04 19:07:02 IST 2019 knowledge-is-key <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>Just four months before her first birthday, Ipsa Valvi underwent a complicated liver transplant surgery. Weighing just a little over four-and-a-half kilos, she became the youngest and lightest baby in west India to undergo a successful liver transplant. As the baby recovered and regained her health, her family and medical team including doctors and nurses celebrated her first birthday at Mumbai's Global Hospital, where the surgery was performed.</p> <p>&nbsp;</p> <p>Ipsa was born healthy in Vyara, a small town in Tapi district of Gujarat, but her weight remained the same even after two months. Her parents, Suchitra and Krunal Valvi, both homeopathy practitioners, observed that Ipsa had stopped growing. Investigations revealed that she suffered from biliary atresia, a childhood disease of the liver in which the bile ducts are absent. Bile is a bitter greenish-brown alkaline fluid secreted by the liver that aids in digestion, but in biliary atresia it becomes stagnant and causes permanent liver damage and cirrhosis. “This is a very rare disease that affects only one in 20,000 children. The only treatment option left to save the baby was a timely liver transplant,” says Dr Anurag Shrimal, paediatric liver transplant surgeon, Global Hospital, who operated on Ipsa.</p> <p>&nbsp;</p> <p>Ipsa could have just had a surgery, but a delay of three months in diagnosing the disease left the doctors with no option but to do a transplant. This is what happens with rare diseases, says Dr Anil Venkitachalam, consultant neurologist, Nanavati Super Speciality Hospital, Mumbai. “The diagnosis of a rare disease is late most of the time. This, despite visits to multiple clinical centres, involvement of a number of specialties and investigations,” he says. “One major reason for delayed diagnosis is lack of awareness on the part of doctors and medical practitioners handling the case. Demystifying a disease that is rare involves a lot of time and effort, which unfortunately is not easy to come by, and leads to frustration and emotional and financial burden for the patient.”</p> <p>&nbsp;</p> <p>Biliary atresia is one of the 6,000 to 8,000 rare diseases that exist in the world at present. These are defined as health conditions of low prevalence that affect a small number of people compared with other prevalent diseases in the general population. Even though they are rare, most of these diseases are life-threatening and chronically debilitating and collectively affect a considerable chunk of the population of any country, which according to generally accepted international research is between 6 to 8 per cent. These are genetic diseases, rare cancers, infectious tropical diseases and degenerative diseases. Eighty per cent of rare diseases are genetic in origin and hence disproportionately impact children.</p> <p>&nbsp;</p> <p>However, the definition of a rare disease differs from country to country. While the World Health Organization defines a rare disease with a prevalence of one or fewer per 1,000 population, the United States defines it as a disease or condition that affects fewer than 2,00,000 patients in the country or 6.4 in 10,000 people. The European Union considers a disease to be rare if it affects no more than 5 in 10,000 people. According to the document released by the Ministry of Health and Family Welfare's expert committee on rare diseases in 2017, India currently has no standard definition of rare diseases and no data on prevalence. Since there is no epidemiological data, there are no figures on burden of rare diseases and morbidity and mortality associated with them. “If we apply the international estimate of 6 per cent to 8 per cent of population being affected by rare diseases, we have between 72 to 96 million people affected by rare diseases in the country, which is a significant number,” says the report.</p> <p>&nbsp;</p> <p>So far, only about 450 rare diseases have been recorded in India from tertiary care hospitals and the most common rare diseases include haemophilia, thalassemia, sickle-cell anaemia and primary immunodeficiency in children, autoimmune diseases, lysosomal storage disorders (LSDs), cystic fibrosis, hemangiomas and certain forms of muscular dystrophies.</p> <p>&nbsp;</p> <p>Manish Sachdev, owner of a general store and the only son in a family of six daughters in Mumbai, died of muscular dystrophy in his mid thirties. A rare inherited disease in which the muscles that control movement progressively weaken, it can appear in infancy up to middle age or later, and is characterised by severe muscle weakness and wasting as happened in Sachdev's case. It all began in his early teens when the family observed that he was not running or climbing stairs like other children, and would often fall while walking. After consulting numerous doctors and undergoing hundreds of tests, he was diagnosed with limb-girdle muscular dystrophy, which meant that over a period of 10 to 15 years, his lower limbs would give up completely. “He became dependent on a help for his movement and daily ablutions and had to be frequently admitted to the hospital for infections resulting from falls,” explains his sister Minakshi, who now runs the store. “It was disheartening to know that at the time there was absolutely no cure for the disease. But now advancements in science, including gene editing, are making it possible for patients to hope for not just treatment, but also for a cure.”</p> <p>&nbsp;</p> <p>Rare diseases are just coming to light in the last seven years in India, says Ratna Dua Puri, paediatrician and chairperson, Institute of Medical Genetics and Genomics, Sir Ganga Ram Hospital in New Delhi. “Our focus until now has been on other communicable diseases, malnutrition and such, so rare diseases never really got the attention they need,” she says. “Now because of increased awareness, availability of tests and technology, we are able to diagnose these better.” Also, there are now support groups for patients with rare diseases and their kin, she adds.</p> <p>&nbsp;</p> <p>Shashank Sathe, a retired government employee, is part of one such group known as the Lysosomal Storage Disorder Support Society. The society was started by parents whose children fell victim to the rare, genetic, life-threatening LSDs. Sathe's son Suyog was diagnosed with Gaucher's disease when he was six. Gaucher's is a rare, inherited disorder resulting from a buildup of certain fatty substances in the spleen and liver, causing them to enlarge and affecting their function. It is one of the 45 LSDs caused by deficiency of certain enzymes in certain compartments of the cells.</p> <p>&nbsp;</p> <p>“After he turned three, we noticed that his spleen was becoming enlarged and his health was deteriorating day by day,” recalls Sathe. “At the time, no doctor was able to diagnose him correctly. They simply experimented and suspected leukaemia initially. But that turned out to be negative. Much later, a paediatrician diagnosed him with Gaucher's after his blood sample was sent abroad for testing.”</p> <p>&nbsp;</p> <p>Suyog was then put on enzyme replacement therapy, in which each vial of 400 units costs Rs70,000—he would need about four to five vials to be administered intravenously every two weeks. Today, Suyog is 25 and an engineer. He plays cricket, drives a car and talks well. About three years ago, the IV was replaced with an oral pill, which he must consume once a day. “Fortunately for us, the treatment was all free—as it was a rare disease, the company forewent the charges. But unlike Gaucher's, patients suffering from other LSDs aren't as lucky,” says Sathe.</p> <p>&nbsp;</p> <p>Venkitachalam says that most rare diseases remain unidentified or undiagnosed because people in India are not so keen on genetic testing, which can help experts identify the problem in the first place. “People don't know whether they have the disease or not and don't want to undergo genetic testing in the face of social stigma and fear of ostracism,” he says.</p> <p>&nbsp;</p> <p>Union Health Minister Harsh Vardhan recently directed ministry officials to expedite the process of formulating the National Policy for Treatment of Rare Diseases. The policy was announced by the government in 2017 with a corpus of Rs100 crore to provide financial aid to patients suffering from rare ailments. “Increasing awareness and government proaction can help so many of us,” says Prasanna Shirol, cofounder and executive director, Organization for Rare Diseases India. “Most patients with rare diseases remain undiagnosed for a long period of time—average time to diagnose a rare disease is around seven years.”</p> Fri Oct 04 19:04:42 IST 2019 dying-with-hope <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p><b>THE TRUTH IS</b> that no one knows everything, but that’s not really the problem. The problem is that, for some things, no one knows anything, nothing is being done to change that, and sometimes medicine can be frankly wrong.</p> <p>&nbsp;</p> <p>I still believe in the power of science and medicine. And I still believe in the importance of hard work and kindness. And I am still hopeful. And I still pray. But my adventures as both a doctor and a patient have taught me volumes about the often unfair disconnect between the best that science can offer and our fragile longevity between thoughts and prayers and health and well-being.</p> <p>&nbsp;</p> <p>This is a story about how I found out that Santa’s proxies in medicine didn’t exist, they weren’t working on my gift, and they wouldn’t be delivering me a cure. It’s also a story about how I came to understand that hope cannot be a passive concept. It’s a choice and a force; hoping for something takes more than casting out a wish to the universe and waiting for it to occur. Hope should inspire action. And when it does inspire action in medicine and science, that hope can become a reality, beyond your wildest dreams.</p> <p>&nbsp;</p> <p>In essence, this is a story about dying, from which I hope you can learn about living.</p> <p>&nbsp;</p> <p><b>Excerpted from <i>Chasing My Cure</i> by David Fajgenbaum—Copyright © 2019 David Fajgenbaum.</b></p> Sat Oct 05 17:04:21 IST 2019 know-very-well-that-this-fight-is-not-over <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p><b>What is the one quality of David that you admire?</b></p> <p>&nbsp;</p> <p>One quality that I admire about David is his drive and passion for the work that he does. When David decided that he was going to make it his life's mission to find a cure for Castleman disease it was never a question; he put his head down and ploughed through the obstacles that were standing in his way.</p> <p>&nbsp;</p> <p><b>Were you part of his decision-making process when he decided to try new drugs on himself or go to business school?</b></p> <p>&nbsp;</p> <p>When he decided to try a new drug on himself it was a game-time decision. All his research thus far had led him to make the most educated decision. It was pretty terrifying for the both of us that there were no other patients on this drug for his illness, but I was supportive if he and his doctors thought this was the right path to take. I was also part of his decision to attend business school. He had realised that while he was sick it wasn't only the doctors that make an impact on your life, but also the role that the drugs play. He felt that attending business school would bring his medical background to a new light and help him in finding his cure.</p> <p>&nbsp;</p> <p><b>What was your thought process during his relapses? Were you terrified?</b></p> <p>&nbsp;</p> <p>I handled each of his relapses a little differently. One in particular I can remember feeling like we were heading into war. He had been through this before and could get through it again with no problem. I felt confident and knew he was going to come out of this. The last relapse five and a half years ago was difficult. We were engaged at that point and things felt a bit more 'real'. He wasn't bouncing back as quickly as he had in the past and I knew something wasn't right. Thankfully, he pulled through, but it was a bumpy road.</p> <p>&nbsp;</p> <p><b>You were with him throughout and so you have seen him go through quite a bit. How did you get through those years?</b></p> <p>&nbsp;</p> <p>I would not have been able to get through this without my family and friends. My parents were a constant support system for me. My mom came out to Little Rock, Arkansas, to be with me and to support Dave. My close friends called or texted me constantly to make sure I was doing okay, and I was so thankful for that.</p> <p>&nbsp;</p> <p><b>What are your thoughts on the book?</b></p> <p>&nbsp;</p> <p>I am very excited for the book to be released and for Dave's story to be heard by more than just our family and friends. It is an inspiring journey and one that I hope will inspire readers to reflect on their hopes/prayers/wishes and then turn their hopes/prayers/wishes into action, like David did with identifying a treatment for himself. The process of writing the book was a whirl of emotions for me. I had to dig back into my memories that I had tried so hard to tuck away. With David being in remission, I try to stay positive and look forward to the future, knowing very well that this fight is not over and there is still lots of work that needs to be done.</p> Fri Oct 04 17:59:01 IST 2019 when-a-doctor-chases-his-cure <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>During the years as a talk show host discussing medical research, I have had the opportunity to meet some awesome people and hear stories that inspire and motivate. Dr David Fajgenbaum’s is one of the most compelling ones that I have heard.</p> <p>&nbsp;</p> <p>David has written a book—Chasing My Cure: A Doctor's Race to Turn Hope into Action—documenting his crazy decade-long battle with his disease and more recently developing a drug that he is using himself. With his book out in September, I cannot but reminisce about our chat.</p> <p>&nbsp;</p> <p>“When I started medical school at the University of Pennsylvania, the first two and a half years of medical school were fine,” started off David. “I never had any medical issues and I was planning to become a clinical oncologist. I had lost my mom to cancer a few years before and I knew I wanted to be a doctor to treat cancer patients.”</p> <p>&nbsp;</p> <p>However, things suddenly changed for David. He went from being this totally healthy third-year medical student to being sick in the intensive care unit with night sweats, weight loss and abdominal pain. His liver and kidneys began to shut down and bone marrow stopped functioning properly. And, he was hospitalised in the same intensive care unit at the University of Pennsylvania that he had previously worked in as a medical student.</p> <p>&nbsp;</p> <p>He got sicker and sicker by the day with no diagnosis!</p> <p>&nbsp;</p> <p>“It was absolutely terrifying to really lose grip on life, without knowing what it was that was making me so sick,” said David.</p> <p>&nbsp;</p> <p>Fortunately, over the course of several weeks, David’s condition improved without any explanation. He regained consciousness and some of his organs began to work again, but still no diagnosis.</p> <p>&nbsp;</p> <p>The relief was short-lived and David found himself back in the ICU with liver failure, kidney failure, bone marrow failure and in and out of consciousness. In fact, he was so sick the second time around that his physicians encouraged his family to say their goodbyes and a priest came in to administer the last rites.</p> <p>&nbsp;</p> <p>But right before that, an important diagnostic test was done—a lymph node biopsy. A review of his lymph nodes indicated that he had a disease called idiopathic multicentric Castleman disease. This is a rare and deadly inflammatory immune system disorder, where your immune system gets out of control and begins to attack your healthy vital organs.</p> <p>&nbsp;</p> <p>Castleman disease has been known since the 1950s but has remained largely a mystery. A hallmark of the condition is enlarged lymph nodes, and most people with the disease have a form that affects just one part of the body and can usually be cured through surgery.</p> <p>&nbsp;</p> <p>The form ravaging David’s body—multicentric Castleman disease—is rarer and deadlier. Only about 1,200 to 1,500 people are discovered to have it every year in the United States. It defied classification, occupying a no man’s land between cancer and immune disease. Doctors weren’t sure of the cause in patients like him: some believed it was a type of cancer, while others thought it was an inherited genetic disorder, or was triggered by a virus.</p> <p>&nbsp;</p> <p>One thing was clear: the disease was deadly.</p> <p>&nbsp;</p> <p>Armed with this diagnosis, David’s doctors decided to start him on a form of chemotherapy to help turn around the disease. The first dose of chemotherapy kept him alive, but relapses began to happen needing more intensive regimens, including seven-agent combination chemotherapy. Finally, after six months in and out of hospital, David returned home and began to improve. He returned to medical school and back to his mission to treat cancer patients.</p> <p>&nbsp;</p> <p>And then everything came to a halt again!</p> <p>&nbsp;</p> <p>About one year later, David had another relapse of all of his previous symptoms, all of his previous organ failures and was back in the hospital. He was once again administered seven different chemotherapies. During this hospitalisation, he also learned that that there were no other drugs that were in development for Castleman.</p> <p>&nbsp;</p> <p>This time when he returned to medical school, he wasn't back on the same track he was on before. This time he returned on a mission to take on Castleman disease.</p> <p>&nbsp;</p> <p>He began conducting laboratory research in the lab at Penn, and decided to create a foundation called the Castleman Disease Collaborative Network (CDCN) to try to bring together researchers from around the world to push forward Castleman disease research.</p> <p>&nbsp;</p> <p>“Research that really makes a difference needs to work across institutions. It needs to work across countries and needs to be highly strategic. We needed to all work together,” explained David on the need to set up CDCN. He then attended the Wharton Business School to pick up some skills. “You need to think really critically about what is the most important next step,” he said. “How do you utilise the resources available to you, whether they are financial or tissue samples or data? And a lot of those sort of decisions and ways to think about things are really not taught to you in either medical school or in PhD programmes. Those sort of operational decisions and strategic decisions are really kind of the bread and butter of the business world. And so, I felt that it would make sense to focus some time and do an MBA to try to pick up some of those skills.” And, it helped. “I really do think that that has had an important impact on the approach CDCN has taken to research,” said David. “We spend a lot of time thinking really critically about how to perform our research studies and how to make sure we are making the most of every dollar that we raise for research.”</p> <p>&nbsp;</p> <p>Since he received the diagnosis, David had been collecting weekly blood samples and keeping track of his immune system, tabulating results. This time when the disease returned, he persuaded his doctors to remove a piece of a lymph node, test it and save it for future research.</p> <p>&nbsp;</p> <p>After a round of chemotherapy, he improved enough to be discharged and started looking into what the tests might reveal. He observed that his immune system seemed to have started gearing up for a fight even though there was no apparent threat. His T cells, a key weapon in the body’s immune system, had started activating and he had started producing a protein call VEGF (vascular endothelial growth factor) in excess. This protein instructs the body to make more blood vessels.</p> <p>&nbsp;</p> <p>He hypothesised that probably the problem was with one of the body’s communication lines, triggering overproduction of VEGF and T cell activation. If he could get his body to shut down that communication line—known as the mTOR pathway—he might be able to stop his immune system from overreacting and prevent a relapse.</p> <p>&nbsp;</p> <p>He and his doctors explored existing drugs that were known to shut down the mTOR pathway. They discovered Sirolimus, also known as Rapamune, commonly given to kidney transplant patients to prevent their bodies from rejecting the organ. The drug had been on the market for years and was known to have a few serious side effects, but had never been used for Castleman disease.</p> <p>&nbsp;</p> <p>David chose to become his own test subject.</p> <p>&nbsp;</p> <p>“I had recently graduated from medical school and was certainly very early in my career,” he recalled. “But I made what was probably the most important decision of my young life to try this drug that had never been used before to treat Castleman disease.”</p> <p>&nbsp;</p> <p>David, assistant professor at Penn Medicine's Translational Medicine and Human Genetics division, continues to lead research efforts of his own disease, and hopes to help raise awareness about Castleman disease through his work. He recently celebrated five years in remission. During this time, he got married. “And then my wife, Caitlin, and I had our first child, Amelia, who has brought us so much happiness in these first six months,” said David. “It was something that certainly when I was on my deathbed I never thought that I would see. It has been the most amazing experience of my life to be a father.”</p> <p><b>Priya Menon is scientific media editor at TrialX/Applied Informatics Inc. She manages and hosts CureTalks, an international online radio talk show on cancer research and health care.</b>&nbsp;<i><br> </i></p> Sat Oct 05 17:06:42 IST 2019 training-your-child-in-safety <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>This incident happened a few years ago. My children were 4 and 6 and I was playing with them in the park across my home. I suddenly noticed that one of the maids was being verbally abusive to an almost eight-year-old who was on the swing and threatened to hit him if he did not get off. When I confronted the maid, she told me off, saying it was none of my business. I found it hard to let the matter go and reached out to the child's family. I recounted the park incident to them and that led the parents to question the maid. The parents found out that the reliable maid, who had been their children’s primary caregiver for the last three years, had been hitting their children (aged eight and ten) while they were at work and threatening to take away their privileges if they divulged this to the parents.</p> <p>&nbsp;</p> <p>It was mind-boggling to me that these children, studying in elite private schools and being raised by well-to-do, educated parents, never brought these instances of hitting or threatening behaviour to the attention of their parents.</p> <p>&nbsp;</p> <p>In hindsight, that is not very surprising.</p> <p>&nbsp;</p> <p>Research suggests that one in three children who are sexually abused do not tell anyone about it. There are several reasons for this:</p> <p>&nbsp;</p> <p>● Fear of retaliation from the perpetrator because in most cases it is a person the family knows.</p> <p>&nbsp;</p> <p>● Children hold themselves responsible and feel that somehow they are at fault.</p> <p>&nbsp;</p> <p>● Children do not have the vocabulary to express their feelings of discomfort or cannot find a safe space to vent.</p> <p>&nbsp;</p> <p>Unfortunately, the issue of safety and security of children is not limited to home, park or even school; it pervades into the online world that children of today inhabit with as much ease as the physical world. There are countless dangers and threats lurking in cyberspace. A study by i-Safe foundation found that more than half the teens have been victims of cyber-bullying and most children do not tell their parents when cyber-bullying occurs. Suicide games like the Blue Whale Challenge have claimed the lives of several children.</p> <p>&nbsp;</p> <p>Given the scary statistics and the risks associated with any such incident, it is imperative that parents proactively take charge of the safety and security of their children. ACT—awareness, communication and tracking—is a simple three-letter mantra to keep your child safe.</p> <p>&nbsp;</p> <p><b>Awareness:</b> The first step in keeping your child safe is to stay connected and create a few safe spaces and times when there can be free flowing communication—dinner table conversation, bedtime routine, playing together or a walk in the evening. As a connected parent, your antenna will be able to catch the signal of a distressed or upset child. This holds true as much for a toddler as for a teenager. It is critical that parents stay plugged into the websites or apps that their children frequent. It is equally important to know the friends or adults that your child is spending time with.</p> <p>&nbsp;</p> <p><b>Communication:</b> Have an explicit conversation with your child about good touch and bad touch and the meaning of consent. Teach your child that it is okay to say no to anyone—adult, child, grandparents—if their touch makes them feel uncomfortable. Vividly elaborate on the dangers of sharing any information or interacting with strangers online. It is a well-known fact that children of parents who have had an explicit conversation about keeping themselves safe are much more likely to bring it up to them if and when they experience anything disturbing. Books like No Means No by Jayneen Sanders and Amazing You by Gail Saltz can be good conversation starters.</p> <p>&nbsp;</p> <p><b>Take action:</b> A supportive response from a parent is one of the most important factors in helping stem any abuse that might be happening in a child’s life and aid recovery. A child needs to get a consistent message that you believe what he or she tells you and will take the necessary action. In the case of my neighbours, they let the maid go that same night.</p> <p>&nbsp;</p> <p>As your child grows older, they will spend more and more time away from your persistent and careful watch. The best personal safety lesson you can impart to your child is to trust his or her own instincts and develop a good judgement. And for that you will need to ACT. Stay aware, communicate frequently and take action if you find something amiss.</p> <p>&nbsp;</p> <p><b>Goyal, chief strategy officer with KLAY (Kids Learning And You), is an educator and a serial entrepreneur.</b></p> Sat Sep 14 16:51:30 IST 2019 teaching-young-minds <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p><i>Give me a dozen healthy infants, well-formed, and my own specified world to bring them up in and I will guarantee to take any one at random and train him to become any type of specialist I might select—doctor, lawyer, artist, merchant-chief and, yes, even beggar-man and thief—regardless of his talents, penchants, tendencies, abilities, vocations and race of his ancestors.</i></p> <p>&nbsp;</p> <p><b>- John Watson, founder of modern behaviourism</b></p> <p>&nbsp;</p> <p>No doubt, Watson overstated his point. While genes and environment contribute to a child’s overall development, studies in the last three decades have shown the significant role of environmental stimulations of early years in the development trajectory of human life. You cannot do much about genes but you can surely provide the right environment for your child's growth and development. It is during the first eight years that children develop the cognitive, physical, social and emotional skills that they need to lead a healthy life. The responsibility, therefore, lies on the shoulders of parents and teachers.</p> <p>&nbsp;</p> <p>Evolution-based studies highlight that young children are most receptive to significant adults—parents, teachers, and caregivers—probably because of their high dependence on them for physical, social and emotional needs. Moreover, the brain development is happening at a rapid speed in children in the early years. By the age of six, 85 per cent of human brain development is complete.</p> <p>&nbsp;</p> <p>In addition to that, human development is a holistic endeavour. Development in one particular domain is actually a result of multidisciplinary actions. For example, chewing food by an infant is physio-motor development but is rooted in various functions of the brain, like cognitive. Therefore, the best development of children happens when they are given optimal stimulation in every developmental domain.</p> <p>&nbsp;</p> <p>Apart from family atmosphere, the most crucial agent in holistic and healthy development of young children is preschool. The most obvious impact of schooling and teachers is seen in intellectual and cognitive growth of children. But the most important offering of formal schooling is the social stimulation given to children through group settings.</p> <p>&nbsp;</p> <p>During the last quarter century, there has been a significant change in the social system of urban India. There is a clear shift from joint family system to nuclear family. Cars are getting bigger and homes are getting smaller. Recent social studies of urban India indicate 88 per cent homes have four members with no senior citizens and just 11 per cent homes in metros have more than two children. In this dearth of child-to-child interaction at home, preschool teachers and peers are the saviours. The art of socialisation is learnt in community dining and group activities in classrooms.</p> <p>&nbsp;</p> <p>The first and foremost way to develop healthy individuals and rightfully cater to young minds is to understand the significant role that teachers play in children’s lives. Teachers need to be well aware that their professional efforts are impacting the future of the country. It is not just a job, but it is actually building the nation. Teachers are today’s heroes who are shaping tomorrow’s heroes. And to carry out such a consequential task on a daily basis, teachers need to invest in their own physical and emotional health.</p> <p>&nbsp;</p> <p>Studies have shown that children need to learn basic life skills like self-control, behaviour management and emotional regulations in the early years to be “successful” in later years. Self-regulation lays a foundation for a child’s long-term physical, psychological, behavioural and educational well-being. Academic success and higher order brain functioning are very much a result of a stress-free mind. And to develop stress-free minds in classrooms, teachers need to cater to their own emotional health. So the mantra for significant adults around young children is: self-care is not selfish. Rather, invest in yourself before you invest in others.</p> <p>&nbsp;</p> <p>Children learn best in stress-free and playful environment. Be it home or in classroom, the brain best functions in cheerful and stimulating environment. Moreover, to provide the right kind of exposure to curious minds of young children, teachers need to hone their skills at regular intervals. Like any other profession, it is important for preschool teachers to stay abreast with latest developments in the field of early childhood care and education. Teachers in India need to develop a strongly connected network and should share best practices with each other. Thought leaders and policy makers of our country need to join hands in providing such platforms to early childhood professionals.</p> <p>&nbsp;</p> <p>In today’s world, there is a growing momentum for investment in early childhood care and education across the globe, and India is no exception. The significance of early years in healthy development of human life is beyond debate now. It is high time that as a nation we focus on developing healthy children who will define the health of the country in coming years.</p> <p>&nbsp;</p> <p><b>A child psychologist and family counsellor, Yadav is head of training and development at KLAY (Kids Learning And You) schools.</b></p> Sat Sep 14 16:52:17 IST 2019 gain-some-lose-some <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>As a high school teacher and an author of a self-help book for Indian mothers, I get to be in constant touch with parents. My interaction with them has led me to believe that Indian parenting is in a state of conflict, unable to define itself and struggling to resolve its challenges.</p> <p>&nbsp;</p> <p>Fifty years ago, parenting was centred around children and whether they would grow up to be healthy and wealthy. The narrative around parenting was kept simple and straightforward, probably because shepherding one’s young was viewed as something fundamental to existence. Today, however, parenting in India has acquired a complex narrative of which two features stand out.</p> <p>&nbsp;</p> <p>First, parenting has become a spectacle. Parents make a big deal out of what gets done by them and their child (their sacrifices or their children's achievements) and others make a big deal about what is not getting done.</p> <p>&nbsp;</p> <p>In effect, parenting has turned into a giant scorecard, with parents, grandparents, teachers and friends doubling up as judges, commenting on every progress and mistake.</p> <p>&nbsp;</p> <p>Second, parenting in India has become an act of great contrasts.</p> <p>&nbsp;</p> <p>More women are opting for maternity hospitals with cutting edge facilities to birth their babies, while others are choosing midwife-assisted home births. App-assisted learning is hugely popular, but gurukul and homeschooling have their own takers. More parents are shopping for toys around the world or at the nearest Hamleys, while others are making their kids spend time on farms, picking up a life skill or learning to care for nature. Mum's no longer the word for Indian mothers—they openly admit that it is mind-numbing and spine-breaking to cater to children all day long. But a 2018 report from the World Economic Forum shows that Indian parents spend 12 hours a week helping their children with homework. This is twice the global average and the highest in a list that featured 29 countries including the UK, Vietnam, Brazil and Japan.</p> <p>&nbsp;</p> <p>As you can see, the contrasts run deep and wide. Perhaps, they are bound to as:</p> <p>&nbsp;</p> <p><b>Value systems have changed:</b> Indians have become more westernised in the last 30 years than ever before. A parent who lays down the rules of decorum in a house is no longer seen as a hypocrite if he or she is seen drinking.</p> <p>&nbsp;</p> <p><b>Economic situations have changed:</b> Mothers have stepped out; fathers are stepping in. Economic empowerment has led to role reversal in homes and where it hasn’t, friction is palpable.</p> <p>&nbsp;</p> <p><b>Social structure has changed: </b>Single child, single parents and working grandparents are all a part of this reality.</p> <p>&nbsp;</p> <p>In such a changing dynamic, can parenting be defined? Can good parenting be distinguished from neglectful parenting? Maybe yes, especially if you dig deep and look closer for parallels between now and parenting patterns back then.</p> <p>&nbsp;</p> <p>For some mothers today, becoming a parent has meant giving up on their jobs, becoming redundant in a fast-paced economy. But women of the past made sacrifices, too. Dreams were crushed not just when they became mothers, but even earlier when they became wives. A lot of women had to discontinue with their education or jobs because they were getting married or having a child.</p> <p>&nbsp;</p> <p>Today's women depend on cooks, maids, nannies and gadgets to juggle everything that they try to achieve. Back then, women had aunts, uncles, grannies and extended family—multiple hands and eyes to take care of the baby. No one set of mother or parent has it easier. It is not without reason that they say it takes a village to raise a baby.</p> <p>&nbsp;</p> <p>Yes, many women work very stressful jobs today, but women in the past performed gruelling tasks, too. It is just that the nature of the tasks is different.</p> <p>&nbsp;</p> <p>And yet, some contrasts remain. Let’s face it, not everyone can afford help today or have the luxury of a family support. More young mothers are raising babies alone because they are what I call ‘married but single’ with husbands working Indian jobs, which is to be on call 24x7. Motherhood in many nuclear families has become excruciatingly isolating.</p> <p>&nbsp;</p> <p>Today’s mothers also get judged all the time. If they are working, then obviously they are not doing a good job in keeping house or raising children. If they are not working, they are treated with condescension and seen as non-contributory to the family. No wonder parenting seems so hard to pull off.</p> <p>&nbsp;</p> <p>But there is comfort in the thought that millions do it and that most children eventually get independent—perhaps the primary goal of parenting.</p> <p>&nbsp;</p> <p>It could cease to become confusing and a spectacle if we stop looking for results; cherish those baby steps into parenting; learn from mistakes; stop judging ourselves or others; and smile when parents make mistakes. Remember, we all make them.</p> <p>&nbsp;</p> <p><b>Lakshmy Ramanathan is the author of For Bumpier Times: An Indian Mother’s Guide to 101 Pregnancy &amp; Childcare Practices.</b></p> Sat Sep 14 16:53:12 IST 2019 diy-parenting <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>Arianna Huffington said it best: “If you look at the best research on parenting, what it comes down to is who you are.” You are their first role model, their first teacher and the only person they ever want to be like, until, of course, they meet Superwoman.</p> <p>&nbsp;</p> <p>When I look back at my childhood, I have great memories of not what I had but a lot of time with my parents and cousins, unstructured time with my peers, my mom’s home-cooked food and homemade delicacies to ring in every festival. Both my parents worked and a cold lunch at 2pm was ready when I came back from school. What has stayed with me are not the presents and its memories, but the values, the grit and the perseverance they taught me.</p> <p>&nbsp;</p> <p>We were never taught gender equality through books but by watching and observing. I remember my dad teaching us science and maths after coming home from work at 9pm or taking us to Marine Drive to talk about tides, the moon and the beautiful almond flowers that dropped there as we walked. He helped my mom dress us up each morning, put our tiffins in our bags, dropped us at school and even delivered our lunch on his way to work.</p> <p>&nbsp;</p> <p>My parents never spelt out their duties, but worked to make us their priority. The strongest memory of my childhood was that my parents were there for me despite working, and I felt secure. I cherish the holidays we took as a family because that meant unlimited hours of treks, table tennis, carrom and playing cards with my dad. The destination was never at the forefront.</p> <p>&nbsp;</p> <p>The presents were few, but we had abundance of their presence. They had little time, given that they both worked, but we stayed in a joint family and perhaps with fewer distractions, there was always more time.</p> <p>&nbsp;</p> <p>Today as busy parents we fill our child’s time slots with gifts, education and entertainment that money can buy versus what we actually need to give—our time. The time we have today is limited, given that both parents must work to make ends meet and live their ambitions. I have never shied away from being a full-time working mom and never want to blame my kids for giving up on my dreams.</p> <p>&nbsp;</p> <p>Let’s look at a few things that make it exciting, harder and empowering for us millennials versus our parents.</p> <p>&nbsp;</p> <p><b>We want to be equal and break stereotypes:</b> I know how parents resonate with us when we share quotes on our Instagram feed like, “When dads watch their kids, it’s called parenting and not babysitting.” We expect equality.</p> <p>&nbsp;</p> <p><b>We are more than parents:</b> We want to pursue our passions whether it is a hobby that turns into a career or fitness or travelling. We want to be more than parents and that is okay. We are not a generation of people that wants to make sacrifices or have regrets either.</p> <p>&nbsp;</p> <p><b>Paradox of choice:</b> Anything that you throw at Google, like why does my child have a rash, even at 2am, gives you a billion results in 0.12 seconds and it is adding to the confusion you already have. If you need a baby monitor, there is one with audio, video, soft voice, with lullaby and without one and with phone access and without. Without a doubt, we are raising a generation of empowered and informed parents. But with all this information and choice, we need to, as parents, not forget our intuition and know our child. We need to understand that there is a far stronger connection and bond that technology may fail to create.</p> <p>&nbsp;</p> <p><b>Risk takers: </b>Millennial parents are not scared to take risks, whether it is experimenting with a way of upbringing, like going off an essential food product like dairy and raising vegan kids, trying a different method of education altogether, letting kids pursue their passion like sports and pulling them out of conventional day schools and choosing sports schools or even risking their own set jobs to pursue their passion or embark on entrepreneurship.</p> <p>&nbsp;</p> <p><b>Perfecting the art and the urgency to fix:</b> If you are often caught using the phrase “but our generation was so diligent and hardworking”, it is because as millennials we are born to be perfecting every piece that we own and our work is our pride. When these perfect people want to raise perfect kids who are just as diligent as they are it may be hard because kids are not projects and there is no syllabus to achieve the perfect score. When we struggle to ‘fix’ them, it causes a lot of anxiety.</p> <p>&nbsp;</p> <p><b>A distracted juggler:</b> As millennial parents, our aim is to perfect the art of multitasking and then pay up for a session of mindfulness. We are a breed that takes pride in sending that important client email while the kids are howling in the background and we give them an iPad to quickly get done with the email only to snatch it back the moment we press 'send'.</p> <p>&nbsp;</p> <p><b>Templates and spreadsheets:</b> Our life as kids and most of the life skills we learnt were not from structured play but playing with cousins who were older and bullied us fondly or with peers and friends in the building. Our childhood missed the structure and perhaps there were no templates to download back then to make it perfect. I must share here that when I had my little one, and I downloaded a breastfeeding app, my mom almost laughed at the fact that I keyed in the amount of time I nursed and how the app helped analyse it. She urged me to take a nap or do my laundry instead and just feed on demand. Practical and simple advice!</p> <p>&nbsp;</p> <p><b>Raising a Vitamin D3 deficient generation:</b> We find these deficiencies strange only to realise that a lot has changed and I am guilty as charged. With my kids on a four-week D3 supplement, I sit and wonder where did I get mine from? Perhaps because my mom screamed and begged me to come up each evening while I was playing in the building. I am equally thankful for the sachets, all the substitutes and especially the advanced medical care that we have as millennials. Kudos to our paediatricians who are available on call or WhatsApp 24/7.</p> <p>&nbsp;</p> <p><b>Out of the closet:</b> We are privileged to find out about symptoms and signs earlier on to ensure we provide our child with the best care versus letting them suffer through their lives. We are not afraid to ask for help or take our less-abled child in public for the shaming that comes with it. We are more empowered and more connected to know that this too can be addressed.</p> <p>&nbsp;</p> <p><b>Value the intangible:</b> In the quest to give the best and provide the best, we have started accumulating all that we don’t need and then we get caught in a hamster wheel where we need a bigger house because we can't fit everything in. We value the number of likes and followers and spend hours of family time to take that perfect picture to please people who we’ve never met.</p> <p>&nbsp;</p> <p><b>The perils of a sandwich generation:</b> The millennials definitely have a tough job and I am sure every generation went through this, but it means taking time out to nurse your ailing parents and take care of your kids, too.</p> <p>&nbsp;</p> <p><b>Tick tock: </b>Not the new Chinese app that’s getting people crazy but time is precious and millennial parents have the least of it. For my mom, when I came home and shared my stories of the day, I know she was looking forward to each one of them. But I know when I call my kids at 2pm during lunch, my next statement after “Hey, how was your day?” would be a series of instructions and a job list that needs to be accomplished before I am home. I also realised that for my mom, I was a priority, just like it is for our kids, a moment of being fully present because for them there are no distractions like us.</p> <p>&nbsp;</p> <p><b>Fit in:</b> Millennial parents are constantly trying to fit in with their social setups, from the classes their kids take, to the school their kids make it to, to the summer holiday destination they picked and whose guest list they made it to. All our decisions are largely governed by the circle we would fit into than what our child really wants to do or what is right for them. We as millennial parents are alpha parents and we need to be in control.</p> <p>&nbsp;</p> <p><b>Ease the addiction:</b> Do you ever remember our parents discussing screen time at every opportunity they would get with their friends? No, they had better things to discuss. But for us we are all so intimidated by the screen time concept and how others are getting it right. As a kid, I remember just watching two shows one of which was Dekh Bhai Dekh and one was One Minute Games. And I am on your side here before you dismiss me and say, but our times were different. Absolutely we have more OTT apps today than we had shows to watch as kids. But what did matter and is a constant is that we watched those shows as a family. And today, when I watch movies or shows, I watch it with my kids. It’s a conversation starter for us. If you want to ease the addiction just let it be the start of engagement for you and your child.</p> <p>&nbsp;</p> <p>While we may turn to the internet for everything, there are certain aspects that unfortunately need expert advice and cannot be outsourced or shared on social media.</p> <p>&nbsp;</p> <p>As an early millennial parent, I perhaps miss the trial and error of parenting with the art of having a sure-shot answer to every solution. We rely more on technology to give us answers and they seem to pacify us more than what our parents tell us. The phrase—Mom, you don’t know because your times were different—is a stronger part of our narrative than any other generation. I am keen on seeing how we do as parents and how this generation that is raised by so many different hands—the biggest one being technology—turns out to be.</p> <p>&nbsp;</p> <p><b>Zaveri is founder and CEO of</b></p> Sat Sep 14 16:53:59 IST 2019 the-millennial-mode-of-parenting <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p><i>I decided to slot only two days a week for anything junk, including wafers and cakes, but my mother-in-law just gives in to my daughter's demands every time she asks for a packet of chips.</i></p> <p>&nbsp;</p> <p><i>My 10-year-old has been demanding to watch Netflix, and I have had to delete the app altogether. Now, nobody watches it.</i></p> <p>&nbsp;</p> <p><i>We spent almost a fortnight looking for the right alternative and experimental school for our three-year-old.</i></p> <p>&nbsp;</p> <p><i>My pre-teen just asked me if he could explore the dating site Tinder.</i></p> <p>&nbsp;</p> <p>These are some of the voices that echo on the timeline of a parents' WhatsApp group that I am part of as a new, working mother. Posts keep streaming in through the day, and sometimes even late night when parents ask for tips on handling a colic baby, on the never-ending school project or simply for company as they stay awake with a sick child. To a large extent, this group, like several others across different social media, feed on the shared anxieties of young, new parents who come together to vent, advise, suggest, share and, at times, scare each other about everything related to parenting. It is rather parenting by millennials—the cohort born between 1980 and 2000—who are doing things differently from any other generation before them.</p> <p>&nbsp;</p> <p>As per the US tech company Winnie, in 2017 millennials made up for 90 per cent of all new parents, thereby turning into a powerful force shaping the future of parenting. Experts attribute certain characteristics to the new-age parent: they are well-educated and constantly struggle to balance their own ambitions with parental duty, don't mind waiting until they are ready to have kids, enjoy documenting their kid's lives on social media to the extent of giving their kid her personal hashtag and YouTube channel, take to the internet for everything under the sun and beyond, unfalteringly check food labels with a micro lens, and are more involved in their children's lives than their parents were.</p> <p>&nbsp;</p> <p>Dr Anupam Sibal, group medical director, Apollo Hospitals, says, “The problem with the present group of parents is that they cannot figure out how to say no to their children, how to have the children listen to them in the face of a technology clatter, and how to instil traditional values while at the same time opening them up for the ever-evolving modernism.” It is not just the millennials who have evolved to be smarter, informed and resourceful; their children have, too. And so, the conventional parenting rules do not apply anymore, says Sibal, a paediatrician and author of Is Your Child Ready To Face The World?. He explains with an anecdote: “My friend's seven-year-old son once told his grandfather who is 80-plus, 'Dadaji, you are wrong.' My friend was aghast because he never as much as raised his eyebrow in front of his father. When confronted, the son replied, 'Dad I am not like you who won't call out his father when he is wrong.'”</p> <p>&nbsp;</p> <p>All experts concur that parenting has always been a challenge across generations and, in that respect, its nature has stayed the same. However, the milieu changes over the years bringing on a new set of challenges and conflicts for every new generation. Priya Krishnan, founder and CEO of KLAY Schools, says that parenting in an urban setup is a lonely journey. “The famous saying—it takes a village to raise a child—stands true no matter what time and age we are in. But this concept currently just doesn't exist, given the degree of urbanisation and the absence of a parental structure on which parents of today have been raised on,” she explains. She cites how parents turn to Google for something simple like how to treat colic instead of asking the elders in their own family. “In the absence of this framework, there is a lot of peer-based parenting, comparisons between parents and children and exchanging of notes happening,” says Krishnan. “Like, your toddler says good morning, while mine bangs her head against the wall. Now both these behavioural traits are perfectly normal for the age group, yet millennials will fluster over it.” This kind of behaviour, she says, has given rise to the notion of helicopter parenting, wherein a parent constantly hovers over every aspect of their child's life.</p> <p>&nbsp;</p> <p>Manna Jaiswal, mother to a chirpy six-year-old in Gorakhpur, narrates how being too possessive and protective of her daughter affected her. “I would constantly monitor her and would tail her wherever she went,” she recounts. “Even in case of a common cold, I would call my mommy friends and take their advice instead of heeding to the advice of my own parents. Sometimes, it did work, but it put me in a situation where I found this control to be too suffocating.” She, however, agrees that there are parents who are at ease with the notion of 'letting go' and let the children thrive among a community of people than being under constant control.</p> <p>&nbsp;</p> <p>New-age parents especially struggle to balance their need to be hands-on parents and their urge to carve their own identities outside home. This April, Maithilee Dange, mother of three-year-old Reva, decided to climb Mount Everest as a way of “coping with the stress of being a mother and rediscovering her lost self-esteem and self image”. Dange, a training and development consultant, had taken a sabbatical of three years to take care of her baby. By the end of it, she says she began to feel sorry for herself. “I was suffering from depression and would just cry at random, thinking how useless I appeared to others. Everest was a way to self-discovery,” she says.</p> <p>&nbsp;</p> <p>Parenting can take a toll on marriage, too, like in the case of Disha Lal (name changed), 34, mother to a teenager. “Parenting in a way created rifts between me and my husband and that, in turn, has affected our son's psyche,” she confides. “We, as a generation, are not as tolerant as our parents were and are ready to be charged at the slightest provocation. So, between the two of us, there is no equal division of household duties, which has led to frustration. Soon, it will lead to our eventual separation.”</p> <p>&nbsp;</p> <p>Most parents believe that a constructive role of the father has assumed significant importance in this day and age. Tarun Sakhrani, a banker who lives in London with wife Kathleen Gaile, a photographer, son Kian, 3, and two-month-old daughter Trisha, says the lack of time is eating into his relationship with his family. But it has taught him to manage time better and draw boundaries. “When I leave office and come home each evening, I make it a point to leave the office behind,” he says. “For those few hours in the evening, I will dedicate my time to just my kids, their meals, their bedtime and, most important, our nightly ritual of story time. Once they are down for the evening, I may then pick up work for a short period of time to catch up on any emergencies or key deadlines. And if, after that, there is some time, then I will dedicate it to myself—be it watching some telly, reading a book or simply meditating. Again, with only 24 hours in a day, many a time, I feel that I need to sacrifice on that me time to make sure I am being a good dad and a good husband.” Both Sakhrani and Gaile bring in different parenting styles, as he is from India and she from Manila. But both struggle to get their son away from Peppa Pig on his favourite device and on to the playground. Another difference in millennial parenting is the constant fear of everything, but he tends to be a bit flexible, says Sakhrani.</p> <p>&nbsp;</p> <p>Communication and control on one's impulses are two sure-shot ways to good parenting, says Dr Avinash D'Souza, consultant psychiatrist based in Mumbai. And, it is here that the concept of rubber-band parenting comes into the picture. Parents are required to wear three simple rubber bands on the right wrist as a reminder to praise their children throughout the day, starting each morning. Every time you praise your child, you move a rubber band over to your left wrist, with the goal of ending the day with all three bands on the left wrist. The US version has five rubber bands moved to the other wrist whenever one loses patience. But to gain the bands back, one must do five positive things with the child, be it to dance, sing, read, or play chess. These concepts help in furthering the family bond while creating mindful parents.</p> <p>&nbsp;</p> <p>According to D'Souza, changing family structures have a lot to do with changing patterns of parenting. We have moved from joint families to nuclear families and single parenthood, leaving young parents with more responsibilities, he says, and the anxiety of good parenting becomes all the more pronounced in the case of a family with an only child vis-a-vis one with siblings.</p> <p>&nbsp;</p> <p>For Lakshmi and Milind Wankhede, both photographers, striking a balance between too much pampering and ensuring their five-year-old Myrah doesn't become selfish or lonely is a challenge. While both parents try to be hands-on parents, there are times when Milind has to stay away from Myrah for days on end. “There have been days when Myrah has cried for almost three hours at a stretch and developed a fever because her father was leaving her back home,” says Lakshmi. “She is quite attached to both of us, but we know where to draw a line when it comes to showering our love on her.”</p> <p>&nbsp;</p> <p>In his book, Keys To Parenting The Only Child, author Carl Pickhardt talks about the many ways in which young parents can give their child the benefit of their mature understanding, as sharing of this kind allows the only child an opportunity for learning from the wisdom of parental experience. Reflecting on what he or she has been told, the child can learn to constructively manage his or her growth. The three thumb rules that parents of today must follow are: not to be judgmental, not to expect their children to live their dreams and not to compare their children with those of their peers. These three thumb rules hold true, irrespective of whether it is a parent from the millennial, Gen X or baby boomer generation.</p> <p>&nbsp;</p> <p>Apart from dividing time and making room for a breather in the face of demanding duties, millennials, unlike previous generations, are doing a “great job by allowing their children to play a pivotal role in decision-making at home,” says Krishnan. They are also striving hard to equip their children with unique skills, be it music, dance or sports. In Sakhrani and Gaile's household, children are being raised to understand, accept and respect varied cultures, languages and religions. “In our household, Christmas is celebrated with as much joy and pomp as Diwali. When it comes to languages, Kathleen speaks to the kids in Tagalog; I use English and occasionally throw in Hindi and Sindhi words in our daily conversations.”</p> <p>&nbsp;</p> <p>D'Souza, who specialises in the area of children and adolescence behaviour, says there are several parenting aspects where millennials are doing a better job than their predecessors. “Already, the kids of today are more well aware than their parents were at their age. So now parents have no choice but to mould themselves in ways that will suit the rapidly growing personality of their ward,” he says. “In the area of academics, these new moms and dads will encourage their child to learn from his mistakes than admonishing him over his marks or grades.” Also, new-age parents are more open to talk about sexuality and relationships. “These examples represent the entire psyche and thought process of the millennial parent, which is that he or she will not do what was done to them,” says D'Souza. “Rather, they would make the world a much better, safer, calmer and fun place to live for their children.”</p> Sat Sep 14 16:50:54 IST 2019 double-trouble <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>Dhairya Soni, five, looks like any other boy his age. He runs around, plays and cycles with friends and dances to Bollywood music. But, unlike others, being active and in control does not come naturally to him. It takes 13 units of insulin every day and a strict diet plan—no ice cream or chocolates—to keep him happy and energetic. This is because the Mumbai boy has type 1 diabetes—an autoimmune condition in which the beta cells in the pancreas lose the ability to produce insulin, the hormone that keeps the body's blood-sugar level in check. Dhairya's mother monitors his sugar level several times a day and makes sure he plays for at least two hours so that the excess sugar in his body gets used up. She also takes him for regular eye checkups and blood tests.</p> <p>&nbsp;</p> <p>It all began two years ago when a toilet-trained Dhairya began wetting his bed. “We were stunned to see how his body was changing all of a sudden,” says his grandfather Girish Soni. “Despite feeling excessively hungry and eating more than usual, he would be fatigued and listless all the time and was also losing weight rapidly.” Unexplained weight loss, frequent urination and excessive hunger and thirst are the first symptoms of type 1 diabetes in children, which often strikes them after the age of three.</p> <p>&nbsp;</p> <p>The excess sugar that builds up in a child's bloodstream pulls fluid from the tissues and makes him lose water more than usual. In the absence of insulin, which can help in the conversion of sugar into energy, the child's muscles and organs lack energy, thereby triggering intense hunger. “Type 1 diabetes is one of the most common paediatric endocrine illnesses,” says Dr Prasanna Kumar from Bengaluru, whose research on type 1 diabetes got published in the Indian Journal of Endocrinology and Metabolism. “It affects nearly five lakh children. Of these, over half live in developing nations, with India being home to an estimated 97,700.”</p> <p>&nbsp;</p> <p>These children must be on a lifetime of insulin supply to manage the lack of insulin in their bodies and to prevent hyperglycaemia (excess glucose in the bloodstream), hypoglycaemia (deficiency of glucose in the bloodstream), ketoacidosis (a buildup of acids in the blood) and other complications.</p> <p>&nbsp;</p> <p>“Unfortunately, science has not been able to explain the cause of this autoimmune condition,” says Dr Pradeep Gadge, a diabetologist in Mumbai. “It has nothing to do with genetics, family history or even an improper lifestyle. The body itself shuts down the pancreas from making insulin. It is the sheer misfortune of those children who fall prey to this beast.”</p> <p>&nbsp;</p> <p>Priyanka, a state-level topper who is studying to be an electronics engineer in Bengaluru, was the first in her family to be diagnosed as diabetic, at the age of seven. “We were shocked,” says her father Ravindra Kumar. “Nobody in our family suffered from diabetes at the time. Initially, we blamed ourselves for it but then were told that there was no real explanation for it and no external factor had caused it. And to know that there was nothing we could do about it but to keep her on insulin for her entire life was extremely disheartening.”</p> <p>&nbsp;</p> <p>The parents made a strict daily schedule for timely injections and a low-carb, high-protein diet with loads of fruits and vegetables—a habit that has remained with her even today. “It has been 11 years since I was diagnosed with type 1 diabetes, but I really never felt inconvenienced in any way,” says Priyanka. “This is mainly because the dietary discipline that my parents have put me through is so ingrained in me that I never feel the need to cheat. As per plan, I must never miss my injections, limit desserts to once in a fortnight and exercise every day.”</p> <p>&nbsp;</p> <p>According to experts, diabetes has a huge psychosocial impact on children, especially as they face discrimination for carrying the insulin kit and injecting themselves at regular intervals. “I have had instances when children have approached me with an earnest request for shifting their insulin doses to after-school timings as they felt shy and embarrassed to take insulin in the presence of their friends and classmates,” says Gadge. “In such cases, we mostly write a letter to the school requesting them for full cooperation. I do not advise the child to keep her diabetes a secret because it can cause problems when her body experiences dizziness and fatigue due to sudden lowering of blood sugar. Diabetes self-management is a continuous job.”</p> <p>&nbsp;</p> <p>Parents are also educating children on disease management using storybooks, videos and counselling. “We have also been to camps where doctors counsel parents and children on multiple aspects of living with type 1 diabetes, including self-injection techniques, awareness about hypoglycaemia, managing simple hypoglycaemia, and knowing the essentials while travelling, at school and during holidays,” says Mehul Thakkar, father of Niket, 12, who has type 1 diabetes.</p> <p>&nbsp;</p> <p>While type 1 is the more common form of diabetes among children, doctors have lately observed an increase in type 2 diabetes in children and teens. “Until now, we all believed that childhood diabetes invariably meant type 1 diabetes,” says Dr Phulrenu Chauhan, endocrinologist at P.D. Hinduja Hospital in Mumbai. “That is how it was until a few years ago. Then we noticed that a lot of children were coming to us with type 2 diabetes, which is essentially an adult form of diabetes generally seen after the age of 40. One primary reason for this is decreased physical activity, increased screen time, uncontrolled consumption of junk food and obesity.”</p> <p>&nbsp;</p> <p>Agrees Dr David Chandy, consultant in endocrinology at Sir H.N. Reliance Foundation Hospital, Mumbai. He says that it is primarily a disproportionate increase in the belly fat among children aged eight to 10 that renders the insulin ineffective and exposes them to type 2 diabetes. “About 10 years ago, there must have been hardly one patient suffering from type 2 diabetes below the age of 20 in my clinic,” he says. “But now, I see about five such patients in three months. The darkening of skin behind the neck of children is an early sign of insulin resistance and parents must check for this at regular intervals. It is called acanthosis and literally means a black, velvety carpet. It means that the body's insulin is losing the fight and gradually the child will have diabetes.”</p> <p>&nbsp;</p> <p>Another aspect that almost all doctors agree on is the need to counsel parents so that they do not experiment with different treatments for their children. Sticking with insulin is the best way, say doctors.</p> <p>&nbsp;</p> <p>Moreover, the advances in blood-sugar monitoring and insulin delivery have improved the daily management of the condition. In terms of technological advancements for children with type 1 diabetes, the latest is an insulin pump that works very well for a child above the age of seven. Its advantage is that it continuously gives insulin and has a sensor that will stop the process when needed. “But the cost is Rs3 lakh to Rs5 lakh for the device and a monthly expense of about Rs10,000 to Rs15,000,” says Dr Chauhan. “Also, one has to be tech savvy to actually help the child use it.”</p> Sat Aug 24 15:33:26 IST 2019 reclassification-will-help-us-improve-treatment <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p><b>Interview/ Dr Chittaranjan S. Yajnik, director, diabetes unit, King Edward Memorial Hospital and Research Centre, Pune</b></p> <p>&nbsp;</p> <p><b>Q/ The European study published in The Lancet identifies five subgroups of adult-onset diabetes.</b></p> <p>&nbsp;</p> <p>A/ What we really need to study is how our types differ within our own population and from westerners. That is the purpose of our study. This research has been on for the last 30 years but this [latest] description from Sweden gives it a direction. As luck would have it, we have already got a grant for collaborating with the same group. It is an Indo-Swedish grant given by the department of science and technology and the Swedish medical council. The people who have written the paper in The Lancet about the five subtypes of diabetes are our collaborators, and even before the paper was published we were planning to do this. So we will now expand our ideas of the characteristics of Indian diabetic patients by comparing them with Europeans, especially Scandinavians.</p> <p>&nbsp;</p> <p><b>Q/ Tell us about the concept of the 'thin-fat Indian' and how Indian diabetics are different.</b></p> <p>&nbsp;</p> <p>A/ For 30 years, we have been doing research to find out why diabetes is so common in India. We have found that Indian diabetic patients have different characteristics from European patients. We have described this for many years in terms of Indian patients being shorter and thinner. But we showed in our research that when you measure the body fat with a special technique, Indian patients, though they look thin, are fat. And, they are fatter than Europeans. This is called the thin-fat concept and is named after me as I described the concept of a thin-fat Indian a few years ago.</p> <p>&nbsp;</p> <p>Though not obese by international criteria, Indians are adipose—that is they have a high body fat percentage. Therefore, because diabetes is linked with excess fat in the body, we get it even though we look thin, and we get it at a younger age. In our research, we showed that Indians develop this thin-fat characteristic in the mother's womb. So we contributed to the idea called foetal programming of diabetes. We showed that the mother's nutrition is an important contributor to all this. India has had a history of undernourishment, famines and environmental stress, going back many hundreds of years. So Indians were used to living in difficult conditions with less food, less money and poor hygiene. All these things were part of our lives for years and our bodies are programmed to deal with these conditions. And suddenly, in the last 50 years, there was social and economic development, which brought about this epidemic of diabetes. We are now in a situation of relative plenty. Therefore our type of diabetes will be somewhat different from what has been described in Europe.</p> <p>&nbsp;</p> <p><b>Q/ How will reclassifying diabetes help?</b></p> <p>&nbsp;</p> <p>A/ Diabetes complications can cause economic and human loss, and must be treated effectively. Hence, if we are able to identify any sub types that are specifically predisposed to, say kidney damage, then it will be useful because we can treat them early. Those who already have diabetes need to be treated properly, and when we find different types and which treatment will be effective for them, it will help us improve treatment. The most common ones are type 1 and type 2, of which the latter is a very heterogeneous condition. Now, because of measurement of certain chemicals in the blood, we are going to be able to classify them.</p> <p>&nbsp;</p> <p><b>Q/ Will individuals fall exactly into one of the categories?</b></p> <p>&nbsp;</p> <p>A/ Never. Each person is an assembly of characteristics that are unique. This is a modern attempt at a systematic understanding of the disease. It will be put to test in clinical studies. Even in the WHO classification, there are probably 10 different types. But what we are saying is that the most common variety is the type-2 diabetes. We will try to reclassify it with more confidence into separate groups.</p> <p>&nbsp;</p> <p><b>Q/ What do you think will be the conclusion of the study?</b></p> <p>&nbsp;</p> <p>A/ There is a long way to go. Either we will conclude that our groups are similar to Europeans or they are not. And there is a hope that we will be able to personalise the treatment depending on the classification. But it will need to be clinically tested.</p> <p>&nbsp;</p> <p>The Swedish classification is relevant to us, but if 10 per cent of Swedes have type A, 30 per cent of our people might have that. And something that is related to gross obesity in old age will be less common in Indians because our population is not that obese.</p> <p>&nbsp;</p> <p>We will see a few thousand diabetic patients and will enrol them in the study. We will study what complications are common in groups 1, 2, 3, 4 and 5, depending on whatever number of groups we find. Then, we start analysing it and decide whether we want to classify every patient the first time, put him into subgroups and treat him from the previous experience to prevent certain complications. Then, we will see after five or ten years if we have really achieved something. It is not just one cross-sectional report. We will also have to do a clinical study and trial to see whether such a classification is of any use to direct treatment, prevent complications and improve the quality of life.</p> Sat Aug 24 15:36:06 IST 2019 diabetes-redefined <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>A 30-year-old working woman with no family history of diabetes, a 57-year-old obese man and a 19-year-old lean girl with an unhealthy lifestyle have entirely different physiological and structural makeup. When placed under the scanner for diabetes diagnosis though, they are clubbed together and labelled as type 2 diabetes patients. This is now set to change.</p> <p>&nbsp;</p> <p>According to scientists and medical researchers in India, there may be as many as seven subgroups of type 2 diabetes according to which patients can be provided a focused and personalised treatment.</p> <p>&nbsp;</p> <p>Last March, Swedish professor Leif Groop published his research in The Lancet, suggesting five new subgroups to type 2 diabetes after studying almost 15,000 newly diagnosed diabetics in southern Sweden. He used measurements such as age at diagnosis, body mass index, long-term glycemic control, insulin resistance and presence of auto-antibodies associated with autoimmune diabetes. He claimed that in the case of Europeans, adult-onset diabetes or type 2 diabetes can be further classified into severe autoimmune diabetes (SAID), severe insulin deficient diabetes (SIDD), severe insulin resistant diabetes (SIRD), mild obesity-related diabetes (MOD) and mild age-related diabetes (MARD). According to researchers and doctors in India who joined the study a few months later, the classification of diabetes stands true for patients in India, too, which reportedly is the diabetes capital of the world with more than 50 million people suffering from type 2 diabetes. “Type 2 diabetes actually consists of several subgroups and we have found that each has significantly different patient characteristics and risk of complications,” says Dr Chittaranjan Yajnik from Pune's KEM hospital who is leading the Swedish project, All New Diabetics in Scania (ANDIS), in India in collaboration with the Swedish Council. “Diagnosis cannot only be based on levels of blood sugar. A number of factors contribute to accuracy in diagnosis and this further classification will help doctors in prescribing accurate and personalised treatment options.”</p> <p>&nbsp;</p> <p>Experts agree that diabetes is the fastest growing disease worldwide, and as per a report published in The Lancet, the amount of insulin needed to effectively treat type 2 diabetes, in particular, will rise by more than 20 per cent worldwide over the next 12 years. Dr Shaival Chandalia, a consultant in diabetes and endocrinology at Jaslok hospital in Mumbai, says that patients with SIRD or SIDD have the most to gain from the new classification, as they will get precise treatment. “Present classification in type 1 and 2 is quite broad and does not give us complete clarity on the choice of treatment for patients, each of whom has inherent physical, biological and physiological differences,” he says. “Almost 98 per cent of all diabetes cases we see are of type 2 variety.”</p> <p>&nbsp;</p> <p>The attempt at classification of the disease is not entirely new though. Doctors say that they have always been classifying their patients into varied types, according to cause, duration and prognosis, but only in their heads. “Until now, we mostly used our intuition to treat type 2 patients,” says Chandalia. “For example, if somebody is overweight, her insulin resistance must be high. A tablet such as metformin or pioglitazone will help in reducing the resistance. That is how we have been working. But with developing research, scientists are laying stress on going to the root to understand the type of pathophysiology that is responsible for the particular type of diabetes so that we can determine the cause of the disease as well as the type of medication to be used.”</p> <p>&nbsp;</p> <p>The ANDIS project classification, however, is a European classification for Scandinavians and Caucasians. Dr Shashank Joshi, president of Indian Academy of Diabetes, says an Asian diabetic is different from a Caucasian one. “The Asian phenotype of type 2 diabetes is quite distinct,” he says. Type 2 diabetes in India, says Joshi, is hotchpotch and heterogenous and the most complicated of all, whereas in Europe it is quite homogenous. “We, in India, see type 2 in thin people, those with normal BMI range but abdominal fat, and also among overweight and obese people,” he says. “And, the subgroups, as suggested by the Swedish team, are only applicable to the type 2 population of Scandinavia, not for that of India. We need to do our own stratified sampling of our phenotype and Yajnik is certainly not doing that.” He explains that in India there are more than 10-12 variants of type 2 diabetes, with two major peaks, one that comes during adolescence and the other that comes in later life. Also, type 2 diabetes varies with topography. “We have state-specific diabetes, too, such as Kerala diabetes and Odisha diabetes, both mostly due to malnutrition. There is MODY (maturity onset diabetes of the young), too. So, with such heterogeneity, it is not possible to classify type 2 into five subgroups only.”</p> <p>&nbsp;</p> <p>According to a 2009 study, among 16,000 patients from eight regions of Maharashtra, type 2 diabetes came with problems of hypertension and lipid profile abnormality, and the common thread between all of them was the abdominal circumference. Joshi explains that if one's waist circumference is more than 90cm in men and 80cm in women, it can lead to the twin problem of blood pressure and diabetes. “It is a triad of blood pressure, diabetes and cholesterol coming together,” he says.</p> <p>&nbsp;</p> <p>Nonetheless, the five subgroups are a starting point in understanding and managing type 2 diabetes better.</p> <p>&nbsp;</p> <p><b>SEVERE AUTOIMMUNE DIABETES</b><br> This type essentially corresponds to type 1 diabetes and LADA (latent autoimmune diabetes in adults), and is characterised by onset at young age, poor metabolic control, impaired insulin production and the presence of glutamic acid decarboxylase antibodies (GADA). A year ago, 17-year-old Shivani Chavan was diagnosed with juvenile diabetes—a chronic condition in which the pancreas produces little or no insulin. A random blood test revealed that her sugar level had shot up to 490mg/dL. Normal sugar levels range between 85mg/dL and 120mg/dL. She was then prescribed a high dose of insulin—about 40 units of Actrapid and Lantus—which she continues to take five times every day without fail. “It was quite difficult initially to prick myself so many times. And, I have to strictly abide by the timings because otherwise the sugar levels would spike and I would feel dizzy and low,” says the resident of Bhayander, a Mumbai suburb.</p> <p>&nbsp;</p> <p>Chavan, a mechanical engineering student, gained weight—from 57kg to 64kg—within six months of taking insulin. The initial months were too much to take, says Chavan, who ended up on the college's defaulters' list because of the many leaves she took for undergoing a battery of tests. But now she is used to her condition. Her sugar levels are under control, she says, thanks to diet and exercise. “It is below 200 now and my HbA1c (haemoglobin A1c) is 8.9 at present, while upon diagnosis it was 13,” says Chavan, who is now busy prepping for her exams. To keep her sugar levels under check, she will have to take insulin all her life.</p> <p>&nbsp;</p> <p>“Initially, when Chavan came to us, it was not easy to actually identify which category she would fall in—type 1 or type 2. When such patients who are in their teens and are obese or overweight come to us, we get into a dilemma because they can fall into either categories,” says Dr Pradeep Gadge, a diabetologist in Mumbai. Type 1 diabetes is where the patient must be put on a lifetime of insulin as the production of insulin in the body stops, while type 2 diabetes is more related to lifestyle habits and genetics. “Upon conducting the GAD antibody test, indicating autoimmunity, which came back positive, we could figure that she was a type 1 diabetic. So, there was no point in trying to give her oral medications because such patients require insulin only,” says Gadge. “So, the sub-classification that the ANDIS project seeks to do will help practitioners like me in deciding the line of treatment, not experimenting with oral medications where they would not work, identifying the autoimmunity early on and in establishing the long-term prognosis of the treatment.”</p> <p>&nbsp;</p> <p><b>MILD OBESITY-RELATED DIABETES</b></p> <p>This subtype includes obese patients who fall ill at a relatively young age. “Most people who are obese eventually develop diabetes because the body can produce only that much of insulin for an ideal body weight,” says Dr Mahesh Chikkachannappa, senior consultant, general laparoscopic and bariatric surgery, Aster CMI Hospital, Bengaluru. “And nowadays because of the lifestyle we lead, this particular subtype may be more common among the middle age group. In turn, it is also true that diabetes leads to obesity because of decrease in metabolism and storage of fat and cholesterol in the body. Roughly, I would say about 60 to 65 per cent of obese people in India have diabetes and hyper cholesterol and blood pressure issues.”</p> <p>&nbsp;</p> <p>When Chitra Mane (name changed on request), 38, visited Aster hospital, she weighed 110kg with a BMI of 43. A BMI reading between 19 and 25 is considered to be an indicator of healthy body weight, while a BMI reading above 30 indicates obesity. She had been overweight since her teenage years and post two pregnancies, she gained even more. “She found it very difficult to lose weight and whatever she lost would bounce back quickly. The excess weight led to obesity and a nagging pain in the knees and the back,” says Chikkachannappa.</p> <p>&nbsp;</p> <p>He, along with his team of doctors, suggested that Mane undergo a sleeve gastrectomy—a keyhole bariatric surgery in which the stomach is reduced to a fraction of its original size by surgical removal of excess portion. Five months post the surgery, she lost 35kg, “felt lighter and better” and has stopped taking medicines to control her blood sugar because now the body does not need high dosage to keep the insulin level in check. “Mostly we bracket obese or overweight diabetics under the type 2 bracket, which is quite a heterogenous group. These patients start with oral medications and then eventually move on to insulin. But if uncontrolled diabetes persists and BMI goes above 34, we advise bariatric surgery,” says Chikkachannappa.</p> <p>&nbsp;</p> <p>A classification of type 2 diabetes into a class of diabetes that is more prone to obesity will help in prescribing focused treatment, says Chikkachannappa, which will at most times be bariatric surgery. “But that is also because until now there are no novel medicines or tablets to take care of obesity-related diabetes,” he says. “Most of the available [medicines] come with side effects.”</p> <p>&nbsp;</p> <p>Agrees Dr Ramen Goel, a bariatric surgeon at Wockhardt Hospital, Mumbai: “Patients who have insulin resistant diabetes are generally good candidates for bariatric surgery because this surgery reduces insulin resistance immediately after surgery to the extent of 90 per cent. So, depending on the case, these subgroups also kind of overlap.”</p> <p>&nbsp;</p> <p>He cites the example of Priti Shardul, 65, who was first diagnosed with diabetes at 40. She initially took Glycomet 500mg twice a day, but switched to insulin eight years ago because of increased weight. Last year, she underwent bariatric surgery when she was a little short of 100kg. “I would fall down frequently as my legs would not be able to take the weight of my body. My blood sugar level went over 250mg/dL and I was on 70 units of insulin every day,” says Shardul. Today, she is slimmer by 30kg.</p> <p>&nbsp;</p> <p>“The best thing about the reclassification or subgrouping of type 2 diabetes is that it will help in early diagnosis and focused treatment,” says Goel. “For example, in the case of Shardul, had we known at the start that her diabetes had a predisposition towards obesity, the treatment would have been prescribed accordingly.”</p> <p>&nbsp;</p> <p><b>MILD AGE-RELATED DIABETES</b></p> <p>This subtype covers a large part of India's population, in which many elderly patients suffer from diabetes. Dr Sonal Dalal, nephrologist from Ahmedabad's Sterling Hospital, cites the example of a 65-year-old patient who has been under her care for seven years. “He will soon undergo dialysis because his kidney function has reduced to less than 15 per cent,” she says. “The primary cause, of course, has been MODY diabetes, which is essentially age-related. He never opted for regular checkups and was caught unawares when his creatinine had shot up to 1.6mg/dL. Since the past few months, his creatinine is around 7mg/dL.” Normal creatinine levels range from 0.6mg/dL to 1.2mg/dL. Early identification of a subtype of diabetes prone to kidney damage will help in giving timely treatment and, in the best case scenario, prolong dialysis by five to seven years, says Dalal. “Also, we can provide patients with renal protective drugs if we know well in advance that her type of diabetes is prone to renal damage,” she says.</p> <p>&nbsp;</p> <p>Diabetic kidney disease, says Dalal, is reversible only in very early stages. Once the creatinine levels start moving up, it becomes difficult to bring the disease under control. O.N. Boni, 79, suffers from type 2 diabetes that has severely impacted the function of his kidneys. He might have to undergo dialysis next month, but Boni, who was diagnosed with diabetes at 45, hopes he can delay it with his dietary precautions and daily strolls. His breakfast is usually rice bhakri and meals that consist of boiled vegetables. “I have also considerably reduced my salt intake and I keep my sugar levels under check,” he says.</p> <p>&nbsp;</p> <p>Knowing that a certain type of diabetes is prone to kidney damage, it is possible to delay the progression of the kidney disease even if one cannot entirely stop it. Dalal says a patient's sugar levels, HbA1c and microalbumin levels must be checked every six months. Albumin (blood protein) in the urine is one of the first proteins to leak when kidneys get damaged.</p> <p>&nbsp;</p> <p><b>SEVERE INSULIN-DEFICIENT DIABETES AND SEVERE INSULIN-RESISTANT DIABETES</b></p> <p>SIDD is characterised by high HbA1c, impaired insulin secretion and moderate insulin resistance, say doctors. “A patient with severe insulin deficiency would be someone whose pancreatic beta cells are not performing at all. This means that no oral tablets will work because most of them work primarily through the pancreas. Hence, these people will most likely require insulin sooner rather than later,” says Dr Sandeep Gulati, a Delhi-based nephrologist.</p> <p>&nbsp;</p> <p>Even someone who falls in the category of type 1 juvenile diabetes can be classified under SIDD because she will require insulin for survival, says Gulati. “But even those who have been type 2 diabetics for about 15 to 20 years, who were on tablets earlier but have moved on to insulin, fit the definition of SIDD,” he says.</p> <p>&nbsp;</p> <p>As against this, SIRD is characterised by obesity and severe insulin resistance. It is also said to be the group with a very high incidence of kidney damage. “Here we have patients who weigh 120kg to 150kg and their insulin requirement is very high. It can go up to 100 to 200 units per day and even in countries like the US the insulin requirement can go up to 500 units per day,” says Dr Ashutosh Goyal, senior consultant, department of endocrinology and diabetes, Paras hospitals, Gurugram. The high insulin requirement, says Goyal, is because such patients are more obese and are less physically active, so insulin resistance is more in them. “So, we need to administer high doses of insulin externally. If a patient requires more than two units of insulin per kilo of body weight per day... then it is a case of SIRD,” he says. While such patients have always been there, says Goyal, classifying them into a focus category is new and welcome, too. “This classification will be helpful in the future,” he says, “as it will enable us to determine the exact course of action or give precise medicine as per the condition.”</p> Sat Aug 24 15:38:48 IST 2019 shore-up-your-core <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>Source: Wanitha Ashok, fitness expert, Bengaluru</p> <p>Model: Wanitha Ashok</p> <p>Photos: Bhanu Prakash Chandra</p> <p>Graphics: Sumesh C.N.</p> <p>&nbsp;</p> <p><b>SINGLE LEG STANDING CORE EXERCISE</b></p> <p>Stand with your feet hip-width apart</p> <p>Lift one leg backwards to hip level; knees straight; arms outstretched, and body parallel to the floor</p> <p>Contract your abs and hold the position for 30 seconds to one minute</p> <p>Repeat on the other side</p> <p>&nbsp;</p> <p><b>SIDE BALANCE CRUNCH</b></p> <p>Lie down sideways on a mat, legs extended</p> <p>Bring the floor-side elbow directly under the ceiling-side shoulder</p> <p>Lift your hips off the floor and touch the ceiling-side elbow to the ceiling-side knee</p> <p>Repeat four to five times</p> <p>&nbsp;</p> <p><b>GLIDER SLIDING PIKE</b></p> <p>Place a glider or folded napkin under both your feet</p> <p>Get into a full plank</p> <p>Glide both your legs forward, knees straight, and lift your back to form an inverted V</p> <p>Glide back. Repeat eight times</p> <p>&nbsp;</p> <p><b>PLANK TAPS</b></p> <p>Place a bottle in the front of you and get into a full plank</p> <p>Tap the bottle with one hand without sinking or lifting your lower back</p> <p>Do the same with the other hand</p> <p>Repeat 10 to 12 times</p> <p>&nbsp;</p> <p><b>KNEE TUCK USING A BALL</b></p> <p>Sit on a mat with your knees bent and your back straight</p> <p>Place a soft ball between your knees</p> <p>Raise your hands towards the ceiling</p> <p>Hold for 30 seconds to one minute and repeat two to three times</p> Fri Aug 02 17:09:35 IST 2019 core-asset <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>Staying in good shape is a must for fashion models, for you never know when you could be called for a bare body shoot, says Prathamesh Maulingkar. Having won the Mister Supranational 2018, the 28-year-old Goan cannot take part in pageants for the next five years. But that hasn't kept him from gruelling core workouts. “You have to be ready all the time. That's what keeps me going,” says Maulingkar, an avid footballer and cricketer who got into modelling after an injury kept him from sports for a long time. “Also, for a tall person, strengthening the core is all the more important. You tend to get a lot of injuries if your core is not strong.”</p> <p>&nbsp;</p> <p>If you want to get a defined core with your abs popping out, try weighted crunches, suggests Maulingkar. “This involves holding dumbbells or a plate while doing your crunches. It is more difficult than normal crunches as there is weight involved. But it can work your muscles more and make your abs bigger,” says Maulingkar, who won the Mr India title in 2017.</p> <p>&nbsp;</p> <p>His favourite exercise is the plank, which is suitable for both youngsters and senior citizens. “That's the most important core exercise one can do,” says Maulingkar. “Full-body plank burns a lot of calories. It is like using your whole body to keep yourself up. The main plank combined with the side plank and back plank can keep your core strong from all sides. Nowadays, people are coming up with variations on the plank to jazz up their workout sessions.”</p> <p>&nbsp;</p> <p>Core muscles are the unsung heroes of our body. Anatomically, the core is the middle portion of the body. “The core is the central trunk of the body and [includes] the muscles in the abdominal area, lower back, hips and around the pelvis,” explains Grand Master Akshar, founder of Akshar Yoga. “If the core is strong and well developed, it gives the individual added stability and controlled flexibility in his or her movement.”</p> <p>&nbsp;</p> <p>Ever wondered how a boxer generates power for his power-packed punches? It is generated from the core, not the arm. “It passes through the core set of muscles and builds into a powerful punch. There is something called a boxer muscle, which is part of your core,” says Rishabh Telang, fitness expert at, headquartered in Bengaluru. “The arm is a small muscle. One can't generate so much power from the arm.”</p> <p>&nbsp;</p> <p>Similarly, one can't do weightlifting just by using their arms. A weightlifter leverages power from the glute. The glute muscles that make up the buttocks are also part of the core; they are the most powerful muscles in our body. Weightlifting might seem like an upper body movement, but you need to have strong glute and abdominal muscles to do weightlifting, says Telang.</p> <p>&nbsp;</p> <p>If your core is weak, you may have trouble doing everyday activities. Even getting up from the chair or picking up a grocery or vegetable bag requires core activation. However, most of us take note of our core only when we experience pain or stiffness in the back.</p> <p>&nbsp;</p> <p>The best way to build a stronger core is by enhancing the muscles that make up the trunk. Core strengthening exercises are essential for everyone, from the athletically inclined to those who lead sedentary lives. A strong core reduces pressure on the limbs for various body movements. If your core is weak, it results in inefficient movements. A person having a weak core may experience calf pain or have weak ankles. “It is important to strengthen your core, for it will improve your strength and stamina,” says Nishriin Parikh, a 53-year-old bodybuilder and fitness trainer.</p> <p>&nbsp;</p> <p>Sunaina Raju, a forensic science student at Jain University in Bengaluru, would agree. The 20-year-old from Thanjavur swears by core drills, a staple in her workout session. “They keep your body in an erect, upright posture. They also tone abdominal muscles, and as I am a gymnast, core exercises reduce the risk of injury,” says Raju, whose favourite core exercises include stomach vacuums and dragon flags. Stomach vacuum is a breathing exercise, wherein you contract your deepest abdominal muscle—transverse abdominis. Dragon flag, on the other hand, involves lying on a flat bench, with both the hands holding its edge behind the head, and lifting your legs, with only the upper back in contact with the surface. A micro influencer on Instagram, she encourages her followers to try these exercises.</p> <p>&nbsp;</p> <p>Core exercises are gaining popularity like never before, says Telang. “When you go to a place where there are good coaches, they will help you work on your core, with weights or movements that require more engagement of your core,” he says. “Coaches have become more knowledgeable, and they have started educating people about the importance of the core. So a lot of people engage in core activation now.”</p> <p>&nbsp;</p> <p>For people who prefer working out at home, Cult, a workout space, has come up with fitness apps. “We have 10- to 15-minute videos featuring core exercises that people can do at home,” says Telang. The entire philosophy of Cult is around body weight and equipment. “We use equipment, but we don't use machines,” he says. “While using a machine, you don't have to engage your core unless you are doing it consciously. At Cult, you are forced to activate and engage your core much more because your body is doing the entire job. The core plays an important part in whatever we do with our body. Doing bodyweight exercises strengthens the core and helps you with consistency.”</p> <p>&nbsp;</p> <p>Core exercises like animal flow and primal movements have become quite a rage these days. “They are effective and are being done by many to get the best results,” says Mustafa Ahmed, celebrity fitness trainer and cofounder of AKRO fitness studio in Mumbai.</p> <p>&nbsp;</p> <p>Sitting is the new smoking. Even the best workplaces in India do not offer standing desks to their employees. Stand-up meetings are yet to gain popularity here. Jag Chima, an internationally renowned fitness entrepreneur, prescribes core exercises for everyone with a desk job. “Core exercises are essential, especially for people with back problems. I tell people, 'You don't need to have a gym membership. You can do these exercises at home',” says Chima, who has worked with actors like Hrithik Roshan, John Abraham and Arjun Kapoor. “Strengthening the core will help you get a better posture and avoid lower back pain. If you are in a desk job, my suggestion is that you do these exercises three times [a day] and you will see a huge change in your core strength.”</p> <p>&nbsp;</p> <p>Most of us shy away from core workouts, thinking they are intense, strenuous and time-consuming. But these exercises can be done anywhere and anytime, even while standing in queues, brushing your teeth or at work, says Wanitha Ashok, 52, who could easily pass off as a 30-year-old.</p> <p>&nbsp;</p> <p>A finalist at the Gladrags Mrs India Contest in 2009, Ashok offers some simple exercises for people who cannot make time to exercise. Tuck your stomach in, hold it for ten counts and release. It engages your core muscles. You can repeat this exercise throughout the day. Standing core exercises are great for the young and the middle-aged. Try this easy-to-do exercise: Lift one leg up and balance on the other leg. Hold it long enough to activate the core. Repeat with the other leg. This workout should be avoided if you have lower back, knee and balance issues, warns Ashok.</p> <p>&nbsp;</p> <p>One of the easiest ways to exercise your abdominal muscles is by taking a deep breath. “When you hold your breath, pull your navel inwards towards the back of the spine for a few seconds. This is a great way to engage your abdominal muscles or 'abs'. This simple exercise can activate your core all through the day, even when you are sitting in a chair or standing or lying down,” says Parikh, who secured fourth place in the World Bodybuilding Championship in 2018. Women having urinary incontinence should do core exercises, she adds. “They can strengthen the pelvic muscles,” she says.</p> <p>&nbsp;</p> <p>Leg raises are good for burning abdominal fat. “I love leg raises and recommend them for beginners,” says Maulingkar. “To start, you can do single leg raises, followed by double leg raises. Slowly, you can start adding weights. You lie down, grab the dumbbell with the insides of your feet and then lift your legs. I do leg raises with weights. They make my workout very tough and help me burn those extra calories.”</p> <p>&nbsp;</p> <p>Running, swimming, skipping and cycling are effective core workouts, too. “Cycling strengthens lower core and legs,” says Yusuf Jerrin, 19, from Lucknow. Jerrin was introduced to core workouts at the age of 10. “I was a huge fan of Bruce Lee and Jackie Chan. I dreamt of being like them and joined Taekwondo training. There, I was taught core exercises like leg raises, jumping jacks and sidelocks as warmups, before training to fight,” recalls Jerrin, an undergraduate student at St Joseph's Evening College, Bengaluru. “I quit Taekwondo after achieving my first dan black belt but continue to do the core exercises. I focus more on strength now.”</p> <p>&nbsp;</p> <p>Jerrin's core workout regimen starts with crunches and leg raises, followed by Roman sit-ups, which are done on a declined bench. “It is a complete workout where you lie down on the bench and go up and down, as in crunches,” says Jerrin. “Roman sit-ups are helpful for both lower and middle core.” Jerrin loves twisting crunches, where you rotate your upper body towards one side as you lift up and then rotate it back to the centre as you go down. It is good for the stomach, he says.</p> <p>&nbsp;</p> <p>Jerrin does the hanging knee raise religiously whenever he goes to the gym. The workout done using a pull-up bar is known to be a favourite among those wanting to build six-pack abs. “I don't aim for a six-pack,” clarifies Jerrin. “I do have abs, but not hardcore abs. Natural hardcore abs are gained after three years of regular diet and workout.”</p> <p>&nbsp;</p> <p>Functional training helps strengthen the core, too. It involves doing things your body has been designed to do, including resistance, in terms of your body weight, and engaging more than one muscle or joint. Functional training can be done using equipment like dumbbells or a resistance band. “Many people don't realise that you can work your core to its maximum potential by doing movements like squat, deadlift, push press and bench press. Adding these movements can help in developing a strong core,” says Ahmed.</p> <p>&nbsp;</p> <p>Namratha Sunil, 35, from Bengaluru, has had an amazing fitness journey. A mother of two, she was genetically blessed with a lean body structure. However, to keep up with the trend then and for the fun of it, she tried Zumba, but her interest in it died down soon. As time passed, Sunil went through a medical challenge and was advised to be active. So, she took up structured aerobics as her fitness regime. Gradually, fitness became her lifestyle, and she started doing core exercises. “Along with everyday cardio, I do core workouts, focusing on the abdomen, the lower abdomen, the oblique, stabilising the spine and back muscles as well as the butt,” she says. “These workouts make the muscles work together properly to maintain balance, agility, posture and movement and to help the body move efficiently and prevent injuries.”</p> <p>&nbsp;</p> <p>Her favourite core exercises include plank variations, single-legged core workouts and reach throughs. “Plank jacks are my favourite. It super challenges my core,” she says. Plank jacks are easy to do and can be performed in the comfort of your home without any fitness equipment. “You begin in a plank position, with your hands on the floor and body parallel to the ground. Your arms will be right beneath your shoulders and feet together. Hold your body up on your forearms and toes, and then jump your legs out to the sides and jump them back together. Do this as many times as you can in a minute. Take a short break and then repeat the exercise,” says Sunil. Plank jacks are a great way to tighten and contract all of your core muscles, she adds. “Spider crawl and Superman walk are my other core options. Core exercises give good results. I have got fit like never before,” says Sunil.</p> <p>&nbsp;</p> <p>Ashok does a lot of single-legged core exercises and yoga to challenge her core. “I use gliders to do various planks to super challenge my core; a napkin can double up as a glider, too. These exercises offer other benefits like strengthening the weight-bearing leg, improved balance, focus and concentration. I also do core stabilisation exercises like variations of floor planks and bridges and cobra,” says Ashok. For youngsters, she recommends core workouts like TRX (total resistance), suspension workout, yoga, functional fitness, kickboxing, pilates and piloxing.</p> <p>&nbsp;</p> <p>“Yoga has become very popular when it comes to activating or strengthening the core,” says Telang. “Yoga might come across as something not very intense, but when you go and do it, holding an asana for a long period, it challenges the muscles that have not been worked over for long.”</p> <p>&nbsp;</p> <p>Yoga has a splendid repertoire of asanas that enhance various muscles of the body core. “We practise them regularly, for their benefits begin with the external muscles and reach the internal organs as well,” says Akshar.</p> <p>&nbsp;</p> <p>Dhanurasana (bow pose) is a simple pose that can strengthen the core. “Lie down on your stomach. Hold your ankles tight with your palms. Lift your legs as high as you can. Hold the posture for a while and then release,” he explains.</p> <p>&nbsp;</p> <p>Regular practice of asanas will help one tone and strengthen the core and provide relief from back pain. “Forward bending asanas such as Paschimottanasana help strengthen the spine, stimulate the nerves, and increase vitality. Similarly, backward-bending asanas such as Bhujangasana give a stretch to the abdominal muscles and strengthen the spinal muscles. Vakrasana and Ardha Matsyendrasana, which involve the twisting of the spine and trunk, stimulate the spinal nerves,” says Dr Rajeev Rajesh, chief yoga officer, Jindal Naturecure Institute, Bengaluru.</p> <p>&nbsp;</p> <p>Listen to your core when you perform every activity. Do not ignore those cramps and pains in the lower back when you bend down. It is possible the core has weakened over a period of time. Lower back pain is an increasingly common problem. A strong core is needed to maintain a strong back. Lower back problems sometimes manifest when you lift weight or take part in sports. It may not be the exercise but a weak core that is causing the pain. Even bad postures over a period of time can lead to issues like spine degeneration and disc bulge, which translates into lower back pain.</p> <p>&nbsp;</p> <p>Strengthening the core is an uphill journey that starts from within.</p> Sat Aug 03 14:13:12 IST 2019 musty-floral-or-like-the-trash-can-how-do-you <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>I have never had an interviewee sniff my armpit before, but I suppose there is a first time for everything. “Really, it is fine. We can do it now. You just need to pull your top up,”coaxes the capable-looking Belgian microbiologist Dr Christopher Callewaert, while making a discreet shirt-lifting gesture.</p> <p>&nbsp;</p> <p>We are in the serene canalside common room where Callewaert, 32, and his fellow academics at Ghent University’s renowned Faculty of Bioscience Engineering come to relax with a Mars bar and watch the swans glide by. Or, if the piano by the window is anything to go by, to knock out a sonata or two.</p> <p>&nbsp;</p> <p>Bioscience is a bewilderingly broad church, comprising investigations into pretty much everything that is alive, and Ghent University is an international frontrunner when it comes to parlaying its research into advances with the potential to change the way we live. Callewaert nods to a colleague a few tables away who is “converting urine back into drinkable water”on behalf of the European Space Agency. Right now, disappointingly, he is eating a sandwich.</p> <p>&nbsp;</p> <p>Analysing body odour is Callewaert’s thing and he is very good at it, to the point of being able to identify different types of human scent straight off the bat, which is to say, straight off the pit. The axillae, to give armpits their scientific name, are the sweaty engine rooms of pong aboard the good ship Homo sapiens.</p> <p>&nbsp;</p> <p>“There is fishy; there is faecal-like; there is oniony; there is sour; there is even a bit floral, a bit soapy even,”says Callewaert, managing to sound measured and professional, as if he is itemising varieties of vinyl flooring. “Those last two are the good ones. Then there is what I would describe as a boar-like animal odour, which is pungent and grasping. It catches the back of your throat. There is a cannabis-like smell as well and a sulphurous one.”</p> <p>&nbsp;</p> <p>I am suddenly bashful, concerned about the effect my half-hour, polyester-clad power walk from Ghent’s central station may have had on my underarm. So, rather than submit to Callewaert’s impromptu sniff test, I ask if I might be referred to one of his famed odour panels instead.</p> <p>&nbsp;</p> <p>The odour panel, as Callewaert reminds me, comprises “eight specially trained people—four male, four female—who are served anonymised samples of underarm odour, which they grade based on intensity and hedonic value. In other words, whether they smell good or not.”</p> <p>&nbsp;</p> <p>There are plenty of machines that can analyse a sample for the presence of a given substance—gas chromatography-mass spectrometry is the standard laboratory method. “But none of them can say if a sample stinks, which is what I need to know,”says Callewaert.</p> <p>&nbsp;</p> <p>As it happens, the latest round of Callewaert’s olfactory X Factor is due to take place tomorrow, which is why I spend the rest of my time in Ghent with a cotton pad taped under my left armpit. After a few hours, the damp swab is dropped with tweezers into a glass “goblet”(in reality, the kind of jar you might use to preserve chutney) and sealed for the odour panel’s delectation... or disgust.</p> <p>&nbsp;</p> <p>This suits me just fine. If my armpits reek of stoned, rotting kipper, I would rather find out via email.</p> <p>&nbsp;</p> <p>As the younger brother of two sisters, one of whom died in a car accident when he was ten, it was expected that Callewaert would take over the family farming business in his native Flanders, “growing lettuces and tomatoes in a greenhouse”. Accordingly, his parents enrolled him at a secondary school that specialised in agriculture and biotechnology.</p> <p>&nbsp;</p> <p>Young Callewaert soon decided that he “did not like getting up early to dig in the dirt”, but he was nevertheless fascinated by the processes of life. Later, as he neared the end of his undergraduate degree in applied biosciences at Ghent, there came a (metaphorical) roll in the hay that led to his first breakthrough.</p> <p>&nbsp;</p> <p>“It is an embarrassing story, but I got body odour after a one-night stand when I was a 21-year-old student here,”he says. “Before that night, I had never had any trouble with odour whatsoever. Then suddenly, I stank, without any other change to my routine.”</p> <p>&nbsp;</p> <p>Was it faecal, I ask, trying to sound detached and scientific. Fishy?</p> <p>&nbsp;</p> <p>“Part sour and a bit dirty,”says Callewaert, looking slightly haunted. “Even today, I would be able to pick it out from among thousands, that dirty bacterial smell.”</p> <p>&nbsp;</p> <p>Despite fastidious washing and copious deodorant use, things got so bad that Callewaert became convinced that he “must have some kind of disease”. Still, his doctor gave him a clean bill of health.</p> <p>&nbsp;</p> <p>Perplexed, Callewaert began to speculate that the night of passion had done something profound to the make-up of his microbiome, the community of bacterial flora that live on the body, specifically in the armpit, which Callewaert refers to as a microbiological “piece of mystery”that is home to more bacteria than there are humans on Earth.</p> <p>&nbsp;</p> <p>Those bacteria are sustained by the “warm, moist and nutritionally rich conditions”of the armpit, where a wide range of lipids, salts and proteins are secreted through a high concentration of sweat glands. Callewaert is fond of quoting the New Zealand microbiologist Mary Marples, who compared the ecology of the skin to that of our planet: “The forearm is the desert, the scalps are the cool woods and the armpit is the tropical rainforest.”</p> <p>&nbsp;</p> <p>Callewaert began to think that “if a transfer is possible in a bad way, it must also be possible in a good way. If you can contract bad body odour via bacteria, then you must also be able to contract good odour, right?”</p> <p>&nbsp;</p> <p>He pitched the idea—a little more than a hunch at the time—to his professors, who deemed it a winner. “Then I applied for a couple of grants from the Belgian government, and I got them,”he says. “That is how the whole story started.”</p> <p>&nbsp;</p> <p>The first task for Callewaert and his small team at Ghent University’s Laboratory of Microbial Ecology and Technology was to recruit a 53-strong sample of armpit owners and try to establish whether or not there was a discernible difference between the microbiome of those whom the odour panel found to be fresh as daisies and those who smelt like they were pushing them up. To identify possible patterns and correlations, subjects were asked for extensive information about their daily lives.</p> <p>&nbsp;</p> <p>Conveniently, Callewaert’s bout of curiosity corresponded with the coming of nifty, next-generation DNA sequencing technology that could break down molecular structures with unprecedented accuracy and sophistication. He describes this development in terms that suggest it was the laboratory equivalent of Bob Dylan going electric.</p> <p>&nbsp;</p> <p>“Before that, microbiology was like Siberia, you know? Nobody wanted to choose it because all you could do was gram staining, which is growing bacteria on a plate and looking at them,”he says. “Since sequencing technology advanced in 2010, we have had unprecedented information about the enzymes, the biochemical pathways and so on. We have the full biochemical understanding of what’s going on and the possibilities are now endless.”</p> <p>&nbsp;</p> <p>The evidence from his first peer-reviewed study, published in the PLOS journal in 2013, was overwhelming. The dominance of one particular type of bacteria, staphylococcus epidermis, seemed to correlate conclusively with pleasant-smelling or inoffensive armpits, whereas a different kind of microorganism—corynebacterium—was the uncontested mack daddy in pits that smelt rank.</p> <p>&nbsp;</p> <p>At any point in time, billions of bacteria of all stripes are feasting on you like it is coupon day at the buffet. But it is the corynebacteria that have a peculiar and nefarious effect on the output of the apocrine sweat glands peculiar to the armpit and turn secretions into “volatile”(aka smelly) compounds. They leave the restaurant in a right old state, whereas staph bacteria are much more considerate.</p> <p>&nbsp;</p> <p>In short, pretty much any given armpit is the site of a microbiological turf war between these two tribes. But our established, interventionist approach to managing the microbiome—namely, a regime of washing and deodorising that blitzes everything in its wake—is not working as might be expected, as Callewaert’s inquiries into his samples’personal hygiene habits revealed.</p> <p>&nbsp;</p> <p>“When more deodorant was used in the armpit, the diversity of different bacteria actually increased,”he says on, the website he established to bring his findings to a broader public.</p> <p>&nbsp;</p> <p>“How do I understand this? If you don’t use deodorant and you don’t wash yourself too often, very few different bacteria will occur there. If you do not have smelly armpits, keep it like that and don’t overuse deodorants. Because, if you are using a lot of deodorant, more different kinds of bacteria will occur, and if one of those bacteria is an odour-causing bacterium, it can suddenly take over and smelly armpits will be the result.”</p> <p>&nbsp;</p> <p>What’s more, Callewaert’s hypothesis that he had “caught”body odour from a specific life event seemed to chime with the lifestyle data gleaned from participants. “Other triggers that cause the corynebacteria to flourish include beginning a course of new medication or going into hospital, changes in eating habits, moving into a new place and wearing certain clothes that have their own microbiome and their own bacterial community,”he says. “There are a lot of triggers.”</p> <p>&nbsp;</p> <p>This is borne out by the comments that flood the message board of on a daily basis. “I hear their stories and I get ideas,”says Callewaert of the forum. “It is very international. I get Brazilian people asking questions in Portuguese and Colombians posting questions in Spanish.”A self-described “adaptable millennial”, Callewaert runs his advice through Google Translate and posts cheery nuggets of advice.</p> <p>&nbsp;</p> <p>“My bf told me that I smell bad even after showering,”writes one forlorn correspondent. Another wants to know why their left armpit stinks, whereas their right armpit does not. Some sufferers are considering drastic interventions, from armpit Botox to liposuction to remove sweat glands. Others have tried them, to no avail. Almost everyone feels that their body odour isn’t taken seriously by the medical community.</p> <p>&nbsp;</p> <p>“It is not considered a real disease,”says Callewaert. “Science aims to cure diseases and it is more important to cure cancer than to cure body odour, and that is a fact. If there are two patients at the doctor’s surgery and one has cancer and one has body odour, you know whom they are going to treat.”</p> <p>&nbsp;</p> <p>Besides, he notes, among doctors, the armpit isn’t exactly regarded as a “sexy”specialism, and this may have hampered the rate of research.</p> <p>&nbsp;</p> <p>In his next round of research, Callewaert performed the world’s first armpit biome transplant. Fortunately for his first pair of patients, this isn’t half as gruesome as it sounds. Via mutual friends on campus, Callewaert got wind of a pair of male identical twins with a crucial difference: one of them smelt terrible; the other didn’t.</p> <p>&nbsp;</p> <p>You might expect identical twins to have similar microbiomes, in the flesh Callewaert discovered a “huge difference”, with corynebacteria dominating the armpits of the smelly twin and staph dominating those of the non-smelly twin.</p> <p>&nbsp;</p> <p>Callewaert asked the twin with nice-smelling armpits not to bathe at all for four days, while the stinky twin was instructed to wash thoroughly with antibacterial products. Then Callewaert took sweat from the nice-smelling twin, applied it to the stinky twin’s armpits using cotton swabs and secured it there. After a second application, his microbiome improved and the twins became indistinguishable by nose.</p> <p>&nbsp;</p> <p>With this successful result in the bag, Callewaert repeated his experiment with further pairs of people. Most of the transplanted armpits were rendered tolerable within one month. But when Callewaert revisited those participants after three months, many had smelly armpits again. Their original armpit microbiome had reasserted itself in the course of everyday life. “I thought, there must be a better, more consistent way to do this,”he says. What if the benign staphylococcus bacteria could be applied directly to the armpit in a way that didn’t require swabbing? His dream of a probiotic deodorant was born.</p> <p>&nbsp;</p> <p>Late last year, after returning from a sunny, surfy sabbatical at the University of San Diego, where he proved to be a popular dinner party guest (“People there were curious about the arrival of Dr Armpit,”he says), Callewaert started a clinical trial in Belgium to test his idea, using 60 malodorous candidates recruited via a national newspaper.</p> <p>&nbsp;</p> <p>For two months, participants doused their pits daily with a spray supplied by Callewaert. For the first month, it contained little more than water, a placebo. For the second month, it contained specially harvested staph bacteria. Weekly swabs were served to the odour panel.</p> <p>&nbsp;</p> <p>Although the full results won’t be published for months, Callewaert has agreed to give me a preliminary heads-up. In short, there is a sweet smell in his office and it ain’t failure.</p> <p>&nbsp;</p> <p>His speech takes on a Trumpian tinge as he elaborates. “We have seen wonderful changes—beautiful changes—on people who have always smelt bad,”he says. “For example, there is a student who is at boarding school. His teachers say his room smells, his clothes smell and he smells constantly. But during the trial, it was completely absent. His teachers say it is a wonder. The room doesn’t smell bad any more. His clothes smell nice and so does his body. It is wonderful because in the beginning he was very, very smelly. It resolved in a magnificent way.”</p> <p>&nbsp;</p> <p>The spray didn’t work for everyone in the trial, Callewaert admits, and there are some procedural wrinkles to be ironed out, but ultimately he aims to start a company that will bring his idea to market. And what a market. Global spend on deodorants and antiperspirants is predicted to be worth an astounding £18.3 billion by 2023.</p> <p>&nbsp;</p> <p>There have been meetings with big cosmetics companies already, he says. I wonder how he is going to stop them from making off with his idea. Turns out he has been able to patent the stabilisation process that makes his bacteria safe to administer.</p> <p>&nbsp;</p> <p>“It is a bacterium that we bought from a so-called culture collection, a microbial library that is available only to scientists,”he says. “But we grew it and stabilised it, making it safe to use, even in a context where there might be blood contact. When users are shaving, for example. That was, of course, a very important prerequisite. No one who used it experienced any problems.”</p> <p>&nbsp;</p> <p>Quite apart from the money, Callewaert says he is motivated by the idea of solving a problem that is responsible for untold misery. “I do see that females tend to have bigger psychological problems with body odour,”he says. “I have heard these stories from them, that they have dropped out of school, lost a job or chosen a self-employed career path because they want to be on their own. They have terrible stories about the gossip they have experienced. And if they are out in public and they hear a sniff they think, ‘Oh no! They can smell me.’”</p> <p>&nbsp;</p> <p>Evaluation of his subjects using the standard Quality of Life questionnaire from the World Health Organization has been illuminating. While the average score is 75 for someone living in the western world, Callewaert’s malodorous subjects were typically scoring below 70. They report being afraid to talk to strangers, or having strained interactions with colleagues on account of their body odour: “Major, life-changing stuff.”</p> <p>&nbsp;</p> <p>Dogged by playground memories of being called smelly, one forty-something man who volunteered for Callewaert’s early transplant study was so self-conscious he had kept himself in a state of isolation for decades. Then the odour panel revealed he had nothing to worry about. “No odour at all,”says Callewaert wistfully.</p> <p>&nbsp;</p> <p>That is an extreme example, of course, but Callewaert says that across the board people are prone to thinking their body odour is worse than it really is. “Your own nose tends to be closer to your armpits than anyone else’s,”he says.</p> <p>&nbsp;</p> <p>In any case, amid all the censorious language we use in relation to odour (kicking up a stink, smelling a rat), it is instructive to know that the way we smell isn’t always a matter of choice. It is down to the erstwhile mysteries of the microbiome.</p> <p>&nbsp;</p> <p>If Callewaert’s plan comes to fruition, we may soon be able to manage that microbiome with renewed confidence. To mangle Voltaire, the French language and science generally, il faut cultiver notre armpit (we must cultivate our armpit).</p> <p>&nbsp;</p> <p>But what of my own axillary biota, now that my goblet has been put to the odour panel? Two days after our meeting, Callewaert emails me. “This is the result of the odour panel (both male and female),”he writes, before hitting me with my own personal stink stats.</p> <p>&nbsp;</p> <p>For intensity, on a scale of 0 to 10, where 0 means no odour and 10 is an intolerable odour, I score 1.5. In terms of hedonic value (i.e, appeal), on a scale of -8 to +8, where -8 is deeply unpleasant, 0 is neutral and +8 is irresistible, I score -0.75. So not a total disaster.</p> <p>&nbsp;</p> <p>Here’s my favourite bit, though—the descriptive summary of my body odour's bouquet, which reads like the kind of label you might see in the supermarket under a bottle of cheap cabernet sauvignon. “Odour characteristics: musty, but also little floral notes (leaves of lavender, spices).”</p> <p>&nbsp;</p> <p>So there you have it. My armpits smell faintly like a poorly ventilated balti house in Provence. But given the range of breathtaking possibilities, I will gladly settle for that. For now, at least.</p> Sat Jul 20 16:08:17 IST 2019 requiem-to-a-surgeon <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>I was at a concert at the park when I first saw Chris. I was talking to a colleague when a car with music on came by at a pretty fast pace and parked. He was tall and lean, with peppered hair, and he walked with a swagger. He looked like someone out of GQ magazine. “Who’s that guy?” I asked my colleague. “Oh him, he is the new neurosurgeon the hospital hired.” He shouted out to Chris, and we made our introductions. Firm handshake, looked me in the eye. I welcomed him to the community, we talked shop and settled down to watch our kids who were performing in the concert.</p> <p>&nbsp;</p> <p>Chris backed up his swagger with his work ethic and talent, both of which he had in abundance. Doctors as a group are pretty smart, but we get trapped in our silos. We focus on what we are trained at—patient care—and lose ourselves in the management and delivery of health care. Not Chris, he excelled at patient care, but was also very good at management skills, had an impeccable bedside manner, and was able to focus on higher concepts about health care economics and population health delivery. He was a leader and was fast-tracked into the leadership hierarchy. We participated in care of patients together, served on committee’s together and soon became good friends. I heard nothing but praise from all my patients who came into contact with Chris. His surgical statistics were excellent. He was honest to a fault and he never bent the rule book.</p> <p>&nbsp;</p> <p>We became neighbours. Our families met and we grew closer. I had Chris over a few times, and we always schemed about future wine tasting at his place. He was happy around his family and the barbecue. He became the chief of surgery this year. “You are our fearless leader,” he told me as we took to our administrative roles, which was not entirely true. Chris had a better mind than me with regard to health care management. He was the squeaky wheel with the administration, and he made sure they ran a tight ship. I would sometimes text him in the middle of a meeting to back off, so we could finish and head home. He would smile and stop talking.</p> <p>&nbsp;</p> <p>I got a call one evening from the CEO telling me Chris had resigned effective immediately. He said he couldn’t say anymore. I called Chris and he filled me in on the details. I really wouldn’t be doing justice discussing a case that I know nothing about, but Chris’s version was he didn’t do anything wrong. I met Chris a week later and was shocked to see him. He looked beaten, he walked slowly, and was distraught. The swagger was gone. I cheered him up. I assured him that the medical faculty held him in the highest esteem. I called around and there were quite a few hospitals interested in him. Unfortunately, the hospital enforced the noncompete portion of his contract, and most of these offers fell through.</p> <p>&nbsp;</p> <p>A month went by, and I saw Chris falling apart in front of my eyes. “Do you know what it’s like for a guy like me to sit at home?” he asked. I couldn’t believe that we as a community had nothing to offer this brilliant and compassionate neurosurgeon. I shared my darkest times with him, and how I was able to claw out of it. He listened and we always came out with how we would fight it out. We decided that he would open his own practice. There was never a doubt in my mind that he would excel.</p> <p>&nbsp;</p> <p>I was in India at a school reunion, when I got the call. Chris was no more. I lost a part of myself that day. Just like that we had lost our very best. We need to do some soul searching as a society. What have we become as a people? Why is there always a need to punish, rather than educate and rehabilitate? We are all going to be making mistakes as humans. How we react to these mistakes defines us as people. Our heroes are men and women just like the rest of us, who have extraordinary talents but are as flawed as the rest of us. Assuming there was an error of judgement, can’t there be a better system, where all parties are compensated, there is action taken, and subsequent education and supervision? We talk endlessly about health and compassion to our patients. But who looks after the healer? I know what Chris would say—he would want to make sure this never happened again.</p> <p>&nbsp;</p> <p>Chris was a better man than most. Our community lost a brilliant neurosurgeon. Patients have lost a healer. His family has lost a loving husband and a father. The medical community lost a leader and I lost a colleague and a friend. Nobody won. Everyone lost.</p> <p>&nbsp;</p> <p><b>Arab is chairman, department of medicine, and director, division of cardiology, Florida Hospital Memorial Medical Center, Daytona Beach, US.</b></p> Tue Jun 25 18:12:50 IST 2019 hope-in-the-time-of-adversity <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p><b>IN A LONG QUEUE</b> within an outpatient department, one can witness different kinds of patients. There is the occasional humble septuagenarian who touches the doctors' feet, showing respect for their services. There is also an increasing tribe of aggressive patients and relatives, which tends to blame the doctor and the health care system.</p> <p>&nbsp;</p> <p>Violence against doctors is unacceptable and needs to be condemned. During my tenure as the national president of the Indian Medical Association, we conducted a survey which indicated that over 75 per cent of doctors had faced violence during their practice. More than 50 per cent of them were also practicing with a fear of violence and wanted to hire security. More recently, some doctors mentioned that they would like to have a licensed gun with them.</p> <p>&nbsp;</p> <p>If doctors and other health care staff are always under threat, it would become difficult for them to do justice to their profession. It is therefore in the interest of the public that violence against doctors is condemned and controlled. One answer is a stringent Central act. This can be prominently displayed in the practice area. While such solutions have to be implemented at a larger level, it is also time for doctors and health care institutions to introspect. Here are some points to mull over:</p> <p>&nbsp;</p> <p><b>BE ALERT</b></p> <p>The first step towards a better doctor-patient relationship is to understand that the doctor needs to spend time with the patient. A concept that every doctor must remember is ALERT (Acknowledge; Listen; Explain; Review; Thank). Acknowledge patients when they enter your office. Greet them by name and introduce yourself and your staff who would be involved in patient care. Listen to your patients. Explain the disease to them. Review the information given to them to ensure that it has been understood correctly and thank the patients for giving you an opportunity to serve.</p> <p>&nbsp;</p> <p><b>UNDERSTAND YOUR PROFESSION</b></p> <p>There is a need for doctors to acknowledge the fact that there is no law in India that allows doctors to prefix 'Dr' before their names. It is a precedence which has been accepted and honoured by society. We must respect this. And there are certain principles involved in acting towards the welfare of the society, such as giving 10 per cent of our time to charity and not charging a fee from those who cannot afford it.</p> <p>&nbsp;</p> <p><b>ENSURE BETTER COMMUNICATION</b></p> <p>It is important to remember that communication is the key to a strong doctor-patient relationship. It is also a must to acknowledge the altered dynamics of doctor-patient relationship, and the paradigm shift from the doctor’s right to take a decision. There are many ways in which communication can be improved. This includes organising seminars about the penal provisions for violence against doctors, displaying patients' rights in every hospital and clinic and educating doctors about etiquette, conduct and ethics.</p> <p>&nbsp;</p> <p>Patients should also be educated about the significance of informed consent and about triage in emergency, and that error of judgment does not mean negligence. A grievance redressal mechanism should be set up in every health care establishment for both patients and doctors. Hospital charges should be transparent and treatment and prescription should be rational. It would be advisable to provide transparent daily billing at hospitals to avoid future disputes and brief legal heirs of patients on the various aspects.</p> <p>&nbsp;</p> <p><b>BRING BACK THE FAMILY DOCTOR</b></p> <p>This is also the time to think about bringing back the age-old concept of ‘family physicians’. Unlike general practitioners, the former looked after all the health needs of a family, for many generations, regardless of their specialisation. They not only treated, but also provided preventive health care to the family as they were aware of the medical history. Considered a part of the family, the physicians were an integral part of all the important functions and events as well. All in all, they were friends, philosophers and guides to the family.</p> <p>&nbsp;</p> <p>In conclusion, we must remember that doctors are not there to harm patients. But, they are also not gods who can never go wrong. Outcomes can be optimised only when other things are conducive, and this includes not just cooperation from patients but also better health care facilities and an assurance of safety. As doctors, the time has come to work towards better communication with those we treat, and take them into confidence.</p> <p>&nbsp;</p> <p><b>Dr Aggarwal is Padma Shri awardee, and president, Heart Care Foundation of India.</b></p> Fri Jun 28 17:06:03 IST 2019 open-to-injury <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>Soon after her delivery, Anjuly Jerrin, 25, developed postpartum psychosis, and was admitted to a psychiatric nursing home in Nanded, Maharashtra. Dr Mohit Sholapurkar, who runs the nursing home, explained the treatment to the patient and her family. The caregiver signed the consent form and read the rules and regulations of the nursing home. “We gave five sessions of electroconvulsive therapy to her, and she got back to normal,” said Sholapurkar. “She started taking care of her child and lactating it.”</p> <p>&nbsp;</p> <p>When the caregiver was given the bill on discharge, he pleaded with the doctor to reduce the charges. Considering his socioeconomic status, Sholapurkar waived off the consultation fee. “Then the caregiver got angry without any reason and gathered a mob of 40 people,” said Sholapurkar. The mob refused to pay the bills and threatened to destroy the furniture in his consultation room. “We told them it would be difficult to waive off the entire cost even in a government setup, where they charge Rs35 per day,” said Sholapurkar.</p> <p>&nbsp;</p> <p>The patient's family assembled more people, some of whom were drunk. The mob brought a bottle of kerosene and poured it around Sholapurkar's cabin. “I was all alone,” he said. “I sensed danger and alerted the medical association.” The mob, however, told him that he could call the police superintendent and that they were ready to go to jail. Sholapurkar somehow managed to escape. But the incident still sends shudders down his spine.</p> <p>&nbsp;</p> <p>The Indian Medical Association reports that 75 per cent of doctors in India have faced violence at some point in their lives. The situation has escalated to such an extent that surgeons sometimes refuse to do emergency surgeries fearing for their lives.</p> <p>&nbsp;</p> <p>Patients themselves are not violent, but their relatives are, said Dr Vivek Kadambi, chairman, IMA's National Committee for Functional Medicine. “In government hospitals, poor infrastructure and perceived lack of sympathy by doctors are responsible for patient anxiety,” he said. “Long waiting hours and doctor's behaviour towards patients and relatives contribute to aggression. In corporate hospitals, the financial anxiety and billing opacity create frustration and emotional volatility.”</p> <p>&nbsp;</p> <p>Dr Ankit Fusakele, secretary of Jabalpur Surgeons Association, has had nightmarish experiences in hospitals. While doing his masters in general surgery at the Jabalpur government medical college, Fusakele attended to a patient with gastrointestinal perforation. He needed a blood transfusion. “It was the resident doctor's responsibility to arrange for blood and make all the arrangements for the operation,” he said. While Fusakele was getting things done, the patient's attendant walked in, grabbed him by his throat and said, “Arranging blood for the patient is your responsibility, not ours.” Fusakele told him that he had been trying to find a blood donor. “He said I was purposely delaying it as I didn't want to do the surgery,” said Fusakele.</p> <p>&nbsp;</p> <p>By then, Fusakele's colleagues came to his rescue. Together, they found a donor, got blood from a bank, and the patient was operated upon. The surgery went well. “Even after the surgery, I lived in fear. I was told that the patient's relatives were likely to come back to attack me. I was sent on leave. I rejoined only after the patient had stabilised,” said Fusakele.</p> <p>&nbsp;</p> <p>As legal procedures in India take a long time, patients and their relatives prefer to take the law in their hands to punish the doctor. “They have cleverly learnt to use goons to attack doctors as a mob, knowing well that the hand of the law is weak and mob confusion helps them get away with the assault,” said Kadambi.</p> <p>&nbsp;</p> <p>The apathy of hospital authorities makes matters worse. Having a grievance redressal system in place could help hospitals prevent attacks on doctors to a great extent. Fusakele said Jabalpur Medical College did not try to beef up security even after the incident. “In government hospitals, you have to take care of yourself,” he said. “If you file an FIR, you will get entangled in a legal muddle. Nobody would want to go through that.”</p> <p>&nbsp;</p> <p>Added Dr Rohit Shetty, chairman, Narayana Nethralaya, Bengaluru, “Violence against doctors is escalating because there is an increasing belief that the delay in giving treatment or negligence is solely because of the doctors, completely disregarding the system and background infrastructure, which the doctors do not have any control over.”</p> <p>&nbsp;</p> <p>Even female doctors are not spared. Shraddha Khandelwal, 37, a general and laparoscopic surgeon based in Madhya Pradesh, no longer does emergency surgeries after having done a surgery “at gunpoint”. She once got a call from the casualty around 8pm while she was putting her children—aged 6 years and 10 months—to sleep. She rushed to the hospital. “There were two patients with stab injuries. One of them had died while being brought to the hospital. The other one was 65 years old. His blood pressure was falling, and he was unable to breathe. He was stabbed in the abdomen,” she recalled.</p> <p>&nbsp;</p> <p>The patient needed emergency surgery. Khandelwal got all the investigations done. By then a mob of 400 people had gathered in the hospital. “Can you give us a 100 per cent guarantee that the patient will be saved?” they asked. Khandelwal said that she would try her best to save him. While she was taking the patient to the operation theatre around midnight, 200 people surrounded the OT and told her, Bach jana chahiye, madam. Nahi toh, dekh lenge (He should be saved, or else).” Khandelwal was the only woman in the OT, which had five people inside, including the anaesthetist and two technicians. The surgery got over by 5am.</p> <p>&nbsp;</p> <p>“The moment I came out, the mob started questioning me,” said Khandelwal. She told them that the patient would survive, and would be shifted to the ICU in a while. They told her, “We won't let you go home until we see our patient is doing fine.”</p> <p>&nbsp;</p> <p>The surgery made headlines the next day. “There were interviews with the patient and the hospital management,” recalled Khandelwal. “But nobody bothered to understand what I went through that night. I could have been attacked by the mob anytime.” That was the last time she did an emergency surgery.</p> Tue Jun 25 18:08:05 IST 2019 violence-stems-from-misconceptions <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p><b>INCIDENTS SUCH AS THE</b> recent violence against doctors highlight the widening gap between them and the patients. With people venting their frustrations, at times driven by vengeance, doctors’ reputations are at stake. The intrinsic trust in the doctor-patient relationship is now in doubt. There is an urgent need for a collaborative effort to reestablish this faith.</p> <p>&nbsp;</p> <p>Medical science has seen revolutionary changes over the years, with technology bringing about some life-changing innovations. It has also raised the awareness among people. A decade or so ago, the family physician was almost God. Today, people are questioning the diagnosis and treatment, based on information they gather from the internet. According to a survey, patients rated a doctor’s diagnosis as more trustworthy if it was in line with what they read on the internet.</p> <p>&nbsp;</p> <p>With the internet offering everything from medicines to medical consultation, people have greater expectations from their doctors. Adding to this is the rising cost of treatment and other things, which affect the doctor-patient relationship. A doctor’s plight is understood by few. It is a sorry tale of overflowing wards, pathetic working conditions, gruelling shifts and uncooperative hospital staff. Add to this poor infrastructure and strained budgets, and the mental well-being of doctors is affected. This, in turn, affects their outlook towards patients and takes away the critical human touch in treatment.</p> <p>&nbsp;</p> <p>While India has done well in improving its doctor-patient ratio (1:921, currently), the burden of diseases is growing. Most doctors complain of lack of sleep, and long hours that leave them with no time even for food. Government hospitals and clinics get an overwhelming number of patients. While doctors in government hospitals work for more than 120 hours a week, they get less than two minutes with a patient any given day. Sometimes they see more than two patients at a time. This allows them very little one-to-one time with a single patient. While hospitals can advertise, doctors cannot engage in self-promotion. Besides, the grip of insurance companies on the medical industry has further burdened doctors.</p> <p>&nbsp;</p> <p>Perhaps, better communication holds the key. Technology can help bridge the gap between patients and doctors. Innovative apps that are coming up not only relieve doctors of paperwork and recording patient data, but also allow patients to get better medical assessment, more personalised consultation time and specialised advice.</p> <p>&nbsp;</p> <p>Both doctors and patients need to understand their role in curing ailments. Violence arises from frustration and anger, which in turn stems from misconceptions or ignorance. Therefore, it is the responsibility of a patient to ask questions with the intention of gaining more insight and not to create discord. Doctors are only human. While a doctor may have the healing touch, the true magic of healing comes from the mutual human bond that a doctor and patient share.</p> <p>&nbsp;</p> <p><b>Tushar Kumar is CEO and founder, Medlife.</b></p> Fri Jun 28 17:07:30 IST 2019 why-doctors-are-upset <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>For Dr Neha Verma, 28, strikes have been part of her training as a medical professional. As a first-year student of medicine, Verma, now a resident at Delhi’s Kasturba Hospital, has seen her fraternity at loggerheads with the administration of government hospitals, typically over the issue of violence by patients and their attendants. “Verbal abuse and physical aggression against doctors is not new; neither is the agitation against it. We have learnt to live in fear. I carry a pepper spray and a small knife in my bag, especially when I am working on an emergency case,” says Verma, who requested that her real name not be used in the story.</p> <p>&nbsp;</p> <p>On June 17, doctors in West Bengal and across the country called off their agitation to demand a safe workplace and strict punishment against those who assault doctors after they received assurances from both the Central and the state governments. The Indian Medical Association, an influential body of doctors that boasts a membership of 3.5 lakh doctors, said that though the strike had been called off, the struggle would continue “for a comprehensive, Central law” that serves as a deterrent against such violence, provides for adequate security for doctors and addresses the root cause of such incidents of violence. Such a law would not only prohibit violence, but also allow for compensation to the hospital and penalty for “improper investigations”. To that end, the IMA would conduct “workshops, work with political parties, doctor MPs, professional associations and NGOs” to create awareness and ensure that such a law was passed by Parliament.</p> <p>&nbsp;</p> <p>Also, Union Health Minister Dr Harsh Vardhan wrote to the chief ministers to consider enacting a specific legislation for protecting doctors and medical professionals, and sent them a copy of the draft law—The Protection of Medical Service Persons and Medical Service Institutions (Prevention of Violence and Damage or Loss of Property) Act, 2017. He also asked them to enforce the provisions of the Indian Penal Code, the Criminal Procedure Code with vigour in states where such a law was not present and take strict action in case of assault against a doctor.</p> <p>&nbsp;</p> <p>“The current draft [of the law] deals only with the punishment part of it, where the person who assaults a doctor can be punished with seven years of imprisonment, and the offence is a non-bailable one,” says Kerala-based Dr R.V. Asokan, honorary secretary of the IMA. “We are pushing for a Central law that deals not just with that, but also ensures that hospitals have a three-layer security system with CCTVs and restricted entry of visitors.”</p> <p>&nbsp;</p> <p>Also, the IMA wants the law to address the shortage of doctors, which is the root cause of the problem. “Each year, of the 68,000 [MBBS graduates], only 28,000 go for postgraduation. The [rest] 40,000 need jobs, but the government is not filling up vacancies for permanent jobs. The young MBBS doctor is jobless, frustrated and angry,” says Asokan.</p> <p>&nbsp;</p> <p>However, Verma, one of the several resident doctors across the country who, as frontline health care workers, are more vulnerable to such violence, is unsure whether such a law would change things on the ground. She concedes that the need for adequate security in hospitals is high, but says that the issue of doctor-patient mistrust and the ensuing violence is systemic. For instance, at her hospital—one of Asia's largest maternity hospitals—on an average, the maternity ward has 60-70 patients, that too on a “lean” day, and only two residents to attend to all of them. “I have been on duty since 9am yesterday, and though my shift ended at 9am today, I won’t leave until 1pm. In my 24-hour shifts, I don't know when I will eat or rest because of the heavy patient load,” she says. “Besides, if I am doing this every third day, how does the government expect me to be able to attend to all the patients properly and be compassionate towards everyone? I am bound to make mistakes and invite the wrath of the patients' families.”</p> <p>&nbsp;</p> <p>Verma, who is in her third year of postgraduation in gynaecology, says while doctors are ready to brave it all, they are handicapped when there is a lack of supplies and basic infrastructure. “At my hospital, we don’t even have basic medicines such as oxytocin and misoprostol, which are mandatory in a delivery ward,” she says. “If we ask patients to bring these things from outside, they get upset and ask us, ‘Why don’t you get it yourself?’ Yesterday, I didn’t even have sutures to do the stitches, and the blood bank was out of all negative blood groups. Patients don’t, and won't, understand our situation. They blame us for the pitiful conditions.”</p> <p>&nbsp;</p> <p>In Kolkata, which was the epicentre of the recent doctors' protests after two junior doctors were attacked by a patient's kin at the NRS Medical College and Hospital, Dr Vijay Mukherjee (name changed on request), 40, an emergency physician at a private multi-speciality hospital, says that though doctors across government and private hospitals were at the receiving end of violence from patient attendants, those manning the emergency wards at government hospitals were especially vulnerable. “These wards are often manned by interns or junior medical officers who are overworked and not trained properly to handle such situations. Besides, the infrastructure at government hospitals is crumbling, even basic supplies such as ventilators are not available at several government hospitals in the state,” says Mukherjee, who is part of the West Bengal Doctors' Forum that has 1,500 paid members and a membership of 18,000 on social media.</p> <p>&nbsp;</p> <p>In West Bengal, the face-off between the government and doctors escalated largely due to Chief Minister Mamata Banerjee's “high-handed” attitude, new laws such as the Clinical Establishment Act that doctors in the state say has branded them as “thieves out to fleece patients” and the rising incidents of violence, says Mukherjee. The situation, however, is the same across the country, he adds.</p> <p>&nbsp;</p> <p>“In the last two years, doctors' bodies in the state have registered 240 cases of violence. However, in none of these cases, the police has taken any action,” says Mukherjee. “The fact that we have The West Bengal Medicare Service Persons and Medicare Service Institutions (Prevention of Violence and Damage to Property) Act, 2009, has not changed our situation because of lack of awareness on the subject, especially where police officers are concerned,” he says. At least 19 other states, like Delhi, Assam, Andhra Pradesh, Goa and Chhattisgarh, have enacted similar laws, but doctors, many of whom are unaware of such legislation, insist their plight has not changed.</p> <p>&nbsp;</p> <p>The need for a Central law, says Asokan, has risen because despite the existing laws, there has not been a single conviction in cases of violence. “If the government can have a law such as POCSO [Protection of Children from Sexual Offences], with stringent provisions to deal with the crime of child abuse, why not have one to address violence against us?” asks Asokan, adding that the specifics of such a law were still being worked out.</p> <p>&nbsp;</p> <p>Both Mukherjee and Verma say that more laws would not improve the situation of their lot. “Unless the government puts money in its hospitals, creates better infrastructure, improves the supply of medicines, and gets more doctors on its rolls, we will not be safe, and will continue to be at the receiving end of the public anger,” says Verma. “Young doctors such as me will not want to work in this country, certainly not in its government hospitals, and will move out of the country.” The point, says Mukherjee, is not having a new law, but its implementation. “With a new scheme such as Ayushman Bharat, the demand will rise, but where are the facilities?” he asks. “We also need to have uniform treatment protocols across the country so that doctors are not blamed in case of a casualty.”</p> <p>&nbsp;</p> <p>A young resident doctor at a government medical college in Haldwani, Uttarakhand, draws an apt analogy: “The government only wants people to put on helmets. But it won't consider improving the state of the country's roads or enforce traffic rules. In such a situation, accidents are bound to happen.”</p> Sat Jun 29 14:46:50 IST 2019 indian-masculine-features-are-easier-to-feminise <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>Belgium-based maxillofacial surgeon Dr Bart van de Ven specialises in facial feminisation surgeries. He has done close to 2,000 such surgeries, and has had a couple of Indian patients, too. Excerpts from an interview:</p> <p>&nbsp;</p> <p><b>From a surgical perspective, what are the prominent differences between Indian faces and that of people from other races?</b></p> <p>&nbsp;</p> <p>My approach to facial feminising surgery is based on the skin type. In people with coloured skin, very few incisions in visible areas have to be made. This is because the skin heals in a different way and the risk of leaving behind bigger and uglier scars is higher. Hence, procedures such as lip lift or hairline lowering have to be avoided, if possible. If these are unavoidable and hypertrophic scars appear, we treat them by injecting corticosteroids into the scars, which greatly help to make them heal beautifully.</p> <p>&nbsp;</p> <p><b>What is the facial feature that is most desirable among Indian trans patients?</b></p> <p>&nbsp;</p> <p>Racial differences between white and Indian people are not that big. In fact, masculine facial features of people from India tend to be a bit softer than in most white people. This makes it easier for me to feminise these faces. There is a big difference, however, not only in the colour, but also in the healing tendency of the skin. There are a few major procedures that are deemed important for most patients, no matter where they are from. These include the reduction of the brow bone, together with forehead recontouring and a brow lift, the reduction/recontouring of the jaw and chin, and rhinoplasty.</p> <p>&nbsp;</p> <p><b>Given the geographical limitations, how do you work with your trans patients before the surgery?</b></p> <p>&nbsp;</p> <p>The geographical limitations don't form an obstacle. I give advice on procedures based on high-quality pictures we receive from the patient and [send] computer simulations of the result such procedures would have [to the patient]. Subsequently, we have a Skype consultation to discuss everything.</p> <p>&nbsp;</p> <p><b>What has been your most challenging surgical experience till date?</b></p> <p>&nbsp;</p> <p>The most challenging obviously are patients with very masculine faces. I have treated many of them. In all, I have performed over 2,000 facial feminisation surgeries.</p> Sat Jun 15 18:59:37 IST 2019 a-woman-face <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>It is because everyone looks at your face, not what’s inside,” says Dr Niya, 42, when asked about the multiple facial surgeries that she has undergone in the past four years. “It is what you see every day in the mirror. And, you have to be at peace with what you see.”</p> <p>&nbsp;</p> <p>Born male, Niya, who prefers I use her first name only, lived as a man for more than 35 years. For the world, she was a man. She wore “unisex T-shirts, jackets and pants”, spoke like a man, and behaved like one, too. Inside of her though, Niya, since she was seven years old, knew she was a woman.</p> <p>&nbsp;</p> <p>About five years ago, things began to change. In 2014, Niya, who works as an anaesthetist at a government hospital in Maharashtra’s Thane district, finally began to realise her dream. That year, she went for a gender reassignment surgery (GRS), and started to live as a woman.</p> <p>&nbsp;</p> <p>Much before she opted for GRS, the more common surgery associated with transsexuals, Niya had wanted to get a different procedure done. She had been poring over medical literature on the subject, and even began contacting some of India’s top plastic surgeons to ask whether they could perform those procedures that, she believed, would allow her to be the woman she had always wanted to be.</p> <p>&nbsp;</p> <p>These procedures, together known as facial feminisation surgeries (FFS), include surgical techniques that alter masculine facial features to bring them closer to that of a woman. The ‘feminising’ techniques involve ‘shaving’ facial bones and soft tissues to smoothen, soften, structure and shape prominent facial features such as the forehead, jaw and chin. Some of these procedures include forehead reconstruction or contouring, brow lift, rhinoplasty, cheek implants, lip lift, lip augmentation, chin and jaw recontouring and face lift.</p> <p>&nbsp;</p> <p>Globally, FFS procedures are fairly popular among transwomen, particularly in countries such as the US, the UK and Europe. In India though, given the prohibitive costs of these surgeries (upwards of Rs5 lakh, depending on the number of procedures desired) and the limited expertise available, the number of trans patients who are getting them currently is not huge. But the demand is steadily rising, say surgeons. Even non-trans patients ask for these procedures to enhance their femininity, says Dr Debraj Shome, a Mumbai-based facial plastic surgeon.</p> <p>&nbsp;</p> <p>The reconstruction of facial features to feminise them is surgically complex. It involves the nuances of facial gender differentiation, and calls for distinct professional expertise. “It is not just about changing the nose to make it more beautiful, which is a common procedure that any plastic surgeon can do. Here, the idea is to make a certain part, such as the nose, look more feminine. Besides, each face is different, and we work with individual patients to understand what changes will work for them,” says Dr Narendra Kaushik of Olmec transgender clinic in Delhi. Chennai-based oral and maxillofacial surgeon Dr S.M. Balaji says he prefers “long interviews” with his trans patients to design the “new look”. “These surgeries require more than clinical and surgical acumen,” he says. “Understanding their mental makeup is also essential, as is managing their expectations, which can be really high at times. Besides achieving symmetry on the face, the management of expectations can be challenging.”</p> <p>&nbsp;</p> <p>Depending on the face—and the costs involved—decisions on the “look” are made. Is a nose job really required? Or, will just an alteration of the forehead, jaw and chin be enough to pass off as a woman?</p> <p>&nbsp;</p> <p>For transwomen such as Niya, the transformative power of the surgery— sometimes even more than the genital surgery—lies in their ability to pass off as women post it, and hence gain a higher degree of social acceptance. “You go out in the crowd and people look at you. They don’t know you, but they look at your face for maybe just a couple of seconds. In that time, they assess your gender—man or woman. In that moment, you want to fit in, and not confuse them. Because if they are confused, they will give you a second look. Now, they have marked you as different... abnormal... maybe even a freak,” she says, adjusting a delicate pair of rimless spectacles that sit on her slim nose.</p> <p>&nbsp;</p> <p>In her own case, Niya has resolved the “confusion”. Behind the rimless spectacles, you notice her doe-shaped eyes framed by high-arch eyebrows that sit on a smooth forehead. Her cheeks plump up when she smiles, and her jawline tapers towards a somewhat rounded chin. Her wheatish complexion is smooth and flawless, and for a stranger, it is hard to tell that this face has been “worked on” extensively. Her face is sans makeup or jewellery, except a pair of diamond studs on the upper portion of her ear.</p> <p>&nbsp;</p> <p>The “naturally feminine look” has not come easy. When Niya, who says she is possibly the first transwoman in India to get facial feminisation surgery, started researching the subject, she couldn’t find a surgeon who was willing to do it. “At that time, most surgeons in India were scared because it is a new procedure. No one wanted to experiment, and that, too, on a face. Even now, only a handful of surgeons offer these procedures,” she says.</p> <p>&nbsp;</p> <p>The basis of FFS procedures lies in the surgical sub-speciality of craniofacial and maxillofacial surgery. Experts in this sub-speciality—and India has many—work on the face, jaw, palate and skull, to address a range of problems by reconstructing the missing or damaged skeleton, correcting deformities of the skull, closing the palate and rebuilding facial features.</p> <p>&nbsp;</p> <p>Niya, a medical professional herself, understood this well, and began contacting surgeons within this sub-speciality. She even managed to convince a surgeon at a reputed private hospital in Mumbai to perform the facial surgery. But on the day of the surgery, as Niya lay on the OT bed, the surgeon freaked out and said, “You will get me into trouble!”. He refused to do the surgery, she recalls.</p> <p>&nbsp;</p> <p>“FFS is an art. And, when it comes to the face, our fight is in the range of millimetres,” says Kaushik. A difference of a few millimetres, he says, can change a facial feature from male to female, and alter a patient’s facial expression. “The position of each feature is relative. For example, the distance between the base of the nose and the upper lip, the distance between the hairline and the eyebrows, all of these could make a face feminine or masculine,” says Kaushik.</p> <p>&nbsp;</p> <p>The alterations that surgeons make are based on the science and mathematics of facial gender differentiation, developed in the early 1980s by Dr Douglas Ousterhout, a San Francisco-based cranio-maxillofacial surgeon. Drawing from the discipline of physical anthropology, Ousterhout, also referred to as the father of FFS, developed the theory of the 'female face' as one defined by a smaller, smoother (or convex) and vertical forehead; the comparatively smaller distance between the eyebrows and the hairline; a smaller gap between the base of the nose and the lips; V-shaped jawline and a slim nose.</p> <p>&nbsp;</p> <p>The core of FFS surgeries is the forehead feminising surgery. For many transwomen, this procedure is enough to achieve a desirable femininity, says Niya. In this procedure, the surgeon reduces the brow bossing [masculine foreheads tend to have a ridge of bone running right across them at about eyebrow level,], removes the irregularities and the protrusions of the male forehead and makes it smoother and vertical, like that of a woman, explains Kaushik.</p> <p>&nbsp;</p> <p>“The ideal feminine forehead requires an aggressive approach by the surgeon,” says Niya. She describes how surgeons use different ways to smoothen the male brow bossing: Type 1, where the bone is merely shaved; Type 2, where the bone is shaved and filled with bone cement to achieve a smoother look; Type 3, a more aggressive technique of cutting through the anterior wall of the sinus cavity, restructuring the wall and pushing it back to get a flatter effect.</p> <p>&nbsp;</p> <p>“Think of our sinus cavity like a house with four walls. You want to bring the front wall back, so, the best way is to break it down and set it back,” she says. “In Type 3, the surgeon has to cut through the sinus wall, the bone plate that lies behind the space between the eyes, that space where an Indian woman applies a bindi.”</p> <p>&nbsp;</p> <p>Here, the surgeon’s skill is important. “If the bone was merely shaved and some bone cement added to create a smoother appearance, the result would be a 'dolphin forehead', a rounder but outward projecting forehead, as opposed to a flatter [feminine] look,” explains Kaushik.</p> <p>&nbsp;</p> <p>After the forehead and the eyebrow lift, most transwomen tend to opt for the jaw and chin contouring, to complete the softening of the features. The efficacy of the facial procedures takes a few months to show, and sometimes several revisions are required, too. For Niya, it meant another surgery for the forehead, a hair transplant that she got done in April, and two revision surgeries on the jaw and the chin that she is planning to get done. For Niya’s Kolkata-based friend Ankita (name changed), it has taken four forehead surgeries, three nose surgeries, and another three to correct the jaw and the chin. “Now she has a beautiful face,” says Niya.</p> <p>&nbsp;</p> <p>Not all transwomen want the procedure, Niya clarifies. “Few will have a naturally tapering jawline, and perhaps even a rounder chin, and won’t need surgery. Conversely, even cis-women have certain masculine features, but overall, the impression is that this is the face of a woman,” she says.</p> <p>&nbsp;</p> <p>Post surgery, how the new face gets read, is a layered process too. Niya recalls that initially it was difficult for her to even step out. “I wasn’t sure how people would respond. It would take me about 15-20 minutes to muster the courage to go out, and face the world,” she says.</p> <p>&nbsp;</p> <p>In her situation, Niya faced an interesting contradiction. During the transition phase, when she was on hormone therapy and had had her GRS, her face was hairless, she had long hair, but still wore unisex clothing. “Some people would get confused about how to address me—Sir or Ma’am. Because of my male name, they were compelled to address me as Sir, even though they felt that I looked like a woman,” she says. “Now, post my complete transition, they are having trouble switching to Ma’am, which is what they had believed in the first place!”</p> <p>&nbsp;</p> <p>Beyond social recognition though, Niya, also known as Niyatee among friends, says that the face is important not just in the social context, but also for the self. “It is about aligning your outer self with your inner self. I feel complete now,” says Niya.</p> <p>&nbsp;</p> <p>All the changes, and the entire journey of Niya’s transition and recognition apart, there is one thing that has remained the same—her family members have accepted her trans status, but still address her by her male name. “It is okay with me. They are used to that name,” she says. “Besides, I think I am beyond gender now. I am at peace with my identity. In the end, that is all that matters.”</p> Sat Jun 15 18:56:35 IST 2019 guess-who-went-to-the-movies <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>Mihir Jain, 15, can now go to the toilet on his own. A few months ago, he watched his first film in a cinema hall, and has seen several since. He has a wardrobe full of T-shirts and can breathe without machines. “But the best part is that I can walk,” he says with a smile.</p> <p>&nbsp;</p> <p>A year ago, Mihir could not walk, needed help in the toilet, could not fit into a cinema hall seat, could not breathe easy and could not find clothes that fit him. At five feet, Mihir weighed more than 237kg.</p> <p>&nbsp;</p> <p>Mihir's doctors say this boy from Uttam Nagar, west Delhi, was the ‘world’s heaviest teen’ before his surgery. They also claim that Mihir is the only teen in this range of weight to have had a gastric bypass.</p> <p>&nbsp;</p> <p>Even weighing him was a task—he could not stand on the weighing machine. “He weighed 237 to 247kg when he came to the hospital,” says a doctor at Delhi's Max Super Speciality Hospital, where Mihir went under the knife last year.</p> <p>&nbsp;</p> <p>He was brought to the hospital on a wheelchair. “Inside his body, there was a metabolic storm,” says Dr Pradeep Chowbey, chairman, Max Institute of Minimal Access, Metabolic and Bariatric Surgery, Max Hospital, Saket, who performed the gastric bypass in April, 2018. “With a body mass index of 92, there was not much hope [normal BMI would be in the range of 19-23.5]. To complicate matters, Mihir had diabetes, too. For us, Mihir was a high-risk patient, with or without surgery. It was not a matter of years, months or even weeks. We could have lost him any day.”</p> <p>&nbsp;</p> <p>Four months before the bypass, doctors put him on a very low-calorie diet (VLCD) to make him lose about 40kg. “The VLCD powder is a such a tasty thing, even better than a chocolate shake. And it would keep me full for several hours,” says Mihir.</p> <p>&nbsp;</p> <p>Despite the kilos he lost, Mihir remained a high-risk patient. “The decision for administering anaesthesia before a surgery is made on the basis of units per kilogram of body weight. For my weight, there was no category,” says Mihir.</p> <p>&nbsp;</p> <p>The fault lay in Mihir’s genes, wrong food habits and lack of physical activity, says Chowbey. By seven, Mihir had stopped going to school because he could barely walk. Confined to his three-storeyed house—where he lives with his parents, sister, uncle Rakesh and his family—Mihir needed constant help. He needed support via a BiPAP (Bilevel Positive Airway Pressure) machine that helps to deliver the prescribed pressure of oxygen into the lungs, thus keeping the airways open. Finding clothes of Mihir's size, too, was an issue; the teenager had to make do with tailored loose kurtas and trousers.</p> <p>&nbsp;</p> <p>Over the years, Mihir lost friends, but did not lose touch with the world. A personal computer and an internet connection helped him follow his passion of online gaming. “He would find these high-end toys on the net, and I would go looking for them everywhere,” says Rakesh.</p> <p>&nbsp;</p> <p>Now 13 months after the surgery, Mihir has shrunk to 135kg. He says he never liked school: “Too much theory, and no practical knowledge.” Now, Mihir wants to do a course on coding. “That will fuel my ambitions to settle down in Manhattan,” he says.</p> <p>&nbsp;</p> <p>His doctor agrees. “Probably that is the best option. In the US, there is more acceptance and opportunity for someone like him. Here, there is still a lot of stigma around issues concerning weight and body shape,” says Chowbey.</p> Wed May 22 12:34:58 IST 2019 size-point <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>Mornings at Dr Sudhir Kalhan's are always busy. New and old patients walk in and out of his chambers. Inside, the walls are plastered with several before-and-after photos of young men and women, reminiscent of newspaper ads for weight-loss clinics. Some faces have been blurred, but the bodies reveal a telling story of their transformation.</p> <p>&nbsp;</p> <p>But there is no photo of Shaheen (name changed on request); she is “special”, says Kalhan, co-chairman, Minimal Access and Obesity Surgery Clinic at Delhi’s Sir Ganga Ram Hospital. It has been five years since her weight-loss surgery, but Shaheen, who divides her time between Srinagar and Delhi, drops in “every once in a while” for a review. “She is just like my daughter, so don’t put her name, please. I don’t want her surgery status to have a bearing on her future. She is doing so well now. Isn’t she pretty?” asks Kalhan, even as Shaheen, 22, insists that she is fine with revealing her identity.</p> <p>&nbsp;</p> <p>Five years ago though, things weren’t looking that “pretty” for the management graduate. Shaheen weighed 135kg, and had a BMI of 48kg/m2. Typical to those in her stage of obesity, Shaheen had stopped going to school, wouldn’t talk much, and had her parents worried about her future.</p> <p>&nbsp;</p> <p>“Most parents turn up for help when they start thinking about the kids’ marital prospects,” says Kalhan, without naming Shaheen’s case. They come when the kids are suffering from mental health issues, co-morbid conditions such as diabetes, sleep disorders, difficulty in breathing, walking, and in extreme cases, when the teenager is on a ventilator, he says.</p> <p>&nbsp;</p> <p>Take the case of Delhi-based Mihir Jain, who had a surgery last year at the age of 14. When Mihir, who weighed more than 200kg before his surgery, had to step out of his house to travel to hospital, it struck him that he could not make the ride without a machine to support his breathing.</p> <p>&nbsp;</p> <p>Shaheen’s case was not that bad. Though her BMI was above the safe limit, she barely had any co-morbid conditions, except her pre-diabetic status, recalls Kalhan.</p> <p>&nbsp;</p> <p>Shaheen and Mihir are not alone in their condition. India has 75 million obese people, of which 50 million are morbidly obese, with a BMI higher than the 37.5 limit. When it comes to adolescents, estimates suggest that 10 per cent of adolescents are overweight and around 5 per cent obese. Adolescent obesity in India has increased from 16.3 per cent in 2001 to 19.3 per cent in 2010.</p> <p>&nbsp;</p> <p>“When it comes to adult obesity, India comes third after the US and China. But when it comes to adolescents, we are ahead of China, too,” says Dr Arun Prasad, chief of Bariatric and Metabolic Surgery Centre, Manipal Hospitals, Dwarka. The obese child is highly likely to develop into a morbidly obese adult, say doctors.</p> <p>&nbsp;</p> <p>School-based studies from Chandigarh to Chennai suggest that 10 to 25 per cent of kids are overweight, and need to alter their lifestyle to avoid diabetes and other diseases in adulthood. For instance, a study done by Postgraduate Institute of Medical Education &amp; Research (PGIMER), Chandigarh, on 9,000 school-going children in 2014 found that 15 per cent of them were overweight and obese, and 50 per cent had low HDL (good cholesterol) levels, an early marker of metabolic syndrome (increased blood pressure, high blood sugar, excess body fat around the waist and abnormal cholesterol or triglyceride levels), says Dr Anil Bhansali, head of department, endocrinology, PGIMER Chandigarh.</p> <p>&nbsp;</p> <p>According to a 2018 study in The Lancet, in the next decade, the number of diabetics in India would have touched 98 million. Around 10 per cent of all new diabetics, says Kalhan, are obese children. Another study published in The Lancet (February 2019) also suggests that in the US, the obesity epidemic might be blamed for the rising number of certain kinds of cancers in adults aged 25 to 49 years. These cancers include colorectal, corpus uteri, gallbladder, kidney, pancreatic and multiple myeloma.</p> <p>&nbsp;</p> <p>In India though, awareness around adolescent obesity, its risk factors and the option of surgery is still low. “Of every 1,000 surgeries, only 2 or 3 would involve adolescents. The numbers may seem small, but it only points out that a large number of children need help but are unable to reach out because of social stigma,” says Prasad, also president of the Obesity and Metabolic Surgery Society of India.</p> <p>&nbsp;</p> <p>To be considered for surgery, doctors say the cut-off for kids would be a BMI of 32.5 with co-morbid conditions and above 37.5 without co-morbidities. Even within these parameters, not everyone would be taken in for surgery. “First, we counsel them. A majority can be treated through medical management, that is change in diet, lifestyle and hormonal therapies,” says Kalhan. “We also assess their goals—they have to be realistic; this is not for aesthetic purposes—and their motivation levels before deciding on surgery. For every 100 patients, I would take only ten for surgery.”</p> <p>&nbsp;</p> <p>Most bariatric surgeons concur that surgery is advised when all else fails and a life is at stake. As in adults, for morbidly obese kids, too, two surgical options are considered—a Roux-en-Y Gastric Bypass or a sleeve gastrectomy. In the first, the surgeon separates the upper portion of the stomach from the lower, and then connects the upper portion to a limb of the small intestine. The new stomach pouch is smaller, and restricts the amount of food one eats. The digestive system is rerouted to bypass the larger part of the stomach and part of the small intestine, leading to less absorption of nutrients. “Until five years ago, this used to be the gold standard in weight-loss surgery. But because of the issue of malabsorption of nutrients, it is no longer the preferred one,” says Dr Atul Peters, Apollo hospital.</p> <p>&nbsp;</p> <p>In sleeve gastrectomy, the more preferred option that obviates the issue of nutritional deficiencies, the surgeon cuts much of the stomach to create a small pouch, which is then stapled together with a “gun-like machine”. “It is like we make the stomach from XL to XS. You eat less, and feel full quickly,” says Kalhan.</p> <p>&nbsp;</p> <p>In a first-of-its-kind study to evaluate the effects of sleeve gastrectomy on morbidly obese adolescents in the Indian subcontinent, doctors at the All India Institute of Medical Sciences found promising results, says Dr Sandeep Aggarwal, professor, bariatric surgery, AIIMS. The children lost 54.5 per cent of their weight in the first year (over 50 per cent means the surgery is successful). Though they regained the weight in the next one year, two participants that were followed up reported sustained weight loss after that. Four of the ten kids had diabetes, and three of them were cured of it after surgery, according to the study published in the January-March issue of the Journal of Minimal Access Surgery. However, further studies are needed to evaluate the efficacy and safety of the surgery on adolescents, it says.</p> <p>&nbsp;</p> <p>For Shaheen though, the surgery has proved effective until now. She lost 10kg in the first month, and in the next six months, she was 30kg lighter. This January, she weighed 75kg, and her BMI stood at 32 kg/m2, not too far from the ideal of 24 in her case. “You feel confident and better about yourself. Other than that, the only change is that earlier I used to eat one large meal in the day, and then have a heavy dinner. Now, I eat smaller meals through the day,” she says.</p> <p>&nbsp;</p> <p>Those who undergo surgery also need to take supplements. Kalhan advises one multivitamin tablet and protein supplements for about six months to compensate for any nutritional deficiencies.</p> <p>&nbsp;</p> <p>The procedure has risks, too—bleeding, leak and deep vein thrombosis. Peters though says that the risk is limited to less than 1 per cent of patients.</p> <p>&nbsp;</p> <p>Kalhan says that the surgery carries as much risk as an appendectomy or a gallbladder surgery.</p> <p>&nbsp;</p> <p>Of course, the best thing would be to avoid ending up on the surgeon’s table in the first place. Doctors say they cannot emphasise enough the value of healthy eating practices and physical activity. “Look at the average day of a school kid. From school to home to tuitions, where is the time and space to play? Besides, private schools would rather invest in money-generating activities (such as extra classrooms) when it comes to space, instead of having a ground for the kids to play,” says Dr V. Mohan of Dr Mohan's Diabetes Specialities Centre, Chennai.</p> <p>&nbsp;</p> <p>Family support is also important. “Thirty per cent of obese kids will have obese parents. There are genetic reasons, but unhealthy eating practices also need to be curbed because kids follow the parents,” says Peters.</p> <p>&nbsp;</p> <p>Besides, surgery is not a permanent option. Says Kalhan: “If they go back to their old ways—start eating like they did, become inactive—then nothing can save them.”</p> Sat May 25 17:45:52 IST 2019 pack-in-the-nutrients <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>As parents, we are always concerned about our children’s calorie intake and often feel guilty for not being able to provide them the best diet. Here are some nutrition tips that will ensure greater health for your little ones and improved confidence for parents:</p> <p>&nbsp;</p> <p><b>Give first priority to the first meal of the day</b></p> <p>&nbsp;</p> <p>Make sure your child has a good start to her day by eating a healthy breakfast before going to school. Studies reveal that children who have breakfast are healthier than the rest as it improves their mood, classroom focus, memory power and learning. An ideal breakfast would be a combination of carbohydrates and protein. Some of the options can be: a glass of milk with a banana, breakfast cereal in milk with fruits or nuts, or egg with toast. Nuts like almonds are a natural source of many essential nutrients, including protein and healthy fats.</p> <p>&nbsp;</p> <p><b>Think before you pack each meal</b></p> <p>&nbsp;</p> <p>It is said that about one third of the child’s daily nutritional needs are met while at school. It is always a good idea to pack a fruit along with the tiffin. The benefits of balanced, fresh, and traditional food cannot be replaced. The next step is to identify food that is high in fat, salt and sugar (HFSS food) as they are unhealthy for children. HFSS food include junk food like chips, fried food, sweetened carbonated beverages, sugar-sweetened non-carbonated beverages, ready-to-eat noodles, pizza, burgers, potato fries and confectionery items.</p> <p>&nbsp;</p> <p><b>Prioritise healthy snacking and timely meals</b></p> <p>&nbsp;</p> <p>Snacking is yet another key aspect in your child’s health. Children should be encouraged to eat small and frequent meals with the distribution of three main meals and two to three snacking slots. In India, snacks are the main culprits when it comes to unhealthy eating. Plan healthy snacks like fruit salad, sprouts and a handful of nuts like almonds. Not only are nuts easy to carry, they can be flavoured with spices. Furthermore, a handful of almonds may have satiating properties that promote a feeling of fullness, which may keep hunger at bay between meals. They also lower the blood sugar impact of carbohydrates.</p> <p>&nbsp;</p> <p><b>Don’t hesitate to hydrate</b></p> <p>&nbsp;</p> <p>Hydration is key to good health. Children don’t usually drink water or fluids unless they are very thirsty. Hence, it is necessary to inculcate in them the habit of drinking fluids regularly. Water is the best option, but there are other refreshing and healthy liquids like fresh lime water, fresh juice, lassi and milkshakes. Say a strict no to aerated drinks, high sugar juices and calorie-dense drinks. Keep an eye out for symptoms of dehydration: headache or light headedness, fatigue or sleepiness, less frequent urination or decreased urine output, dark yellow or amber-coloured urine and constipation.</p> <p>&nbsp;</p> <p><b>Ingredients to healthy nutrition in children</b></p> <p>&nbsp;</p> <p>The important nutrients for children include calcium, protein, vitamin C and iron. Iron, along with key nutrients like protein and vitamin C, are crucial to your child being alert and active. Lean meats and fish are rich sources of iron and protein. A combination of 15 nutrients including protein and dietary fibre can be found in almonds. Pulses, green vegetables and fortified cereals are also good sources of iron. Vitamin C helps the absorption of iron, so having fruit juice with an iron-rich meal will increase iron absorption. Citrus fruits, tomatoes and guavas are all good sources of vitamin C.</p> <p>&nbsp;</p> <p>Deficiency of iron leads to growth impairment, compromised immunity, learning problems and behavioural issues in children. Calcium is needed for healthy bones and is found in dairy products, green leafy vegetables and nuts. Vitamin D assists in the absorption of calcium for stronger bone health. Vitamin D is best synthesised in the skin when exposed to sunlight, but can be found in dietary sources such as egg yolk, fortified milk, oily fish and mushrooms. Carbonated drinks contain high levels of phosphorus that leach out calcium from the bones, leading to poor bone health.</p> <p>&nbsp;</p> <p><b>Clean up the diet</b></p> <p>&nbsp;</p> <p>Remove unnecessary and harmful food such as refined food, sugar, salt, caffeine and junk food.</p> <p>&nbsp;</p> <p><b>Refined food:</b> Reduce your child’s consumption of overly processed, refined products such as white bread, buns, pastries and biscuits. These are empty calories with zero nutrients.</p> <p>&nbsp;</p> <p><b>Sugar:</b> Refined sugar is a major contributor to children’s health and behavioural problems. Research shows that sugar can cause a rapid rise in crankiness and hyperactivity in children. It also plays a big role in lowering immunity, promoting weight gain and causing anxiety in children.</p> <p>&nbsp;</p> <p>Salt: Excess salt causes hypertension and puts a load on the kidneys to eliminate it. Junk food is a major source of salt.</p> <p>&nbsp;</p> <p><b>Boost your child’s immunity</b></p> <p>&nbsp;</p> <p>Incorporate food that can help build your child’s immunity. Proteins are first in the list. Good quality proteins come from pulses, nuts and seeds, egg, lean meats and dairy. Antioxidants found naturally in fruits, vegetables and nuts and seeds clean the system of all toxins. Probiotics are friendly bacteria found in our intestines that help to fight infections and disease. They help your child’s immunity to develop. Top up probiotic levels with fermented food such as yogurt or probiotic supplements. Lastly, water is important for immunity, as it flushes out toxins from the body.</p> <p>&nbsp;</p> <p><b>Be on the move, constantly</b></p> <p>&nbsp;</p> <p>For children and teens to grow up healthy, it is important that they are physically active every day. Daily physical activity for 30 to 60 minutes coupled with adequate calcium intake increases bone mass by an average of 2 to 3 per cent. The current guidelines recommend that kids above two years should engage in at least 60 minutes of moderate to vigorous physical activity on all days of the week. Physical activity helps kids keep their heart and lungs strong and healthy develop strong bones, maintain a healthy body weight, improve their mood and self-esteem, and make them more alert.</p> <p>&nbsp;</p> <p>Lastly, the most efficient way to keeping kids of all ages healthy is by taking a family approach. The key principle is to practise what you preach.</p> Wed May 22 12:13:55 IST 2019 opt-for-food-that-is-local-seasonal-and-traditional <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p><b>You say a child wants food, not nutrients.</b></p> <p>&nbsp;</p> <p>As parents when we offer food to children, it shouldn't be based on its composition of proteins or fats or carbs or sugar. Instead, it should be based on what is local, in season and traditional. What we are fast losing is a sense of connectedness with our food and environment. Until ten years ago, people only had dal chawal for dinner and now they are avoiding carbs. It is an obsession with all these fancy labels, which doesn't really mean that we are getting fitter as a society. In fact, we are only getting much fatter and sicker. Also, choosing food based on nutrients is only profitable for the food industry. It doesn't work for the health of people. Yet, it is so ingrained in our education system that we think it is the most scientific method of choosing food. It is rather a confusing and biased method of choosing food that makes people feel the need to connect with a dietician, professional or a doctor. So, you need to go back to basics when it comes to giving a child her daily food.</p> <p>&nbsp;</p> <p><b>You talk about grandma's wisdom in your book, Notes for Healthy Kids.</b></p> <p>&nbsp;</p> <p>Our grandmothers haven't got their due. When I attend international conferences where they talk about sustainable development and what human life will look like in 2050 and what AI and climate change will do to us, I realise that we need to take a multidisciplinary approach [to food]. For good health, we need to look at land, politics, gender equations in society, crop cycle, policies, schools, households, societies and cities from a more holistic point of view and see whether people are turning healthier or unhealthier.</p> <p>&nbsp;</p> <p>Today, India has the second most obese children in the world. That's not because we don't care for our children, in fact we care too much. It is actually the government policies that are making [junk food] the easy choice. The United Nations has slogans such as make healthy choice the easy choice. But how do you do that? Instead of having fruits or peanuts, which is a healthy choice, outside schools, a child is exposed to chips and tetra pack juices. That's a sociopolitical problem, not just a lifestyle problem. It will take investment and commitment from the government.... There are ecological connections, too. Everything is related to health.</p> <p>&nbsp;</p> <p>Our grandmas had pickled stuff, ate food that was in season, chose food that was climate resilient, and ate in a way where they were conscious of their consumption. So, we need to go back to traditional wisdom in the way we eat. All this wisdom is available in indigenous languages. Because we think English is the language of science, we lose on more and more of this traditional wisdom.</p> <p>&nbsp;</p> <p><b>How can one handle fussy children?</b></p> <p>&nbsp;</p> <p>It is a multifold problem. What works well is getting the child connected to the soil. If you grow, for example, coriander in the window, the child knows how the process works. Take them to the farm at least once every month. Let them observe plants, trees, fruits, berries in their natural settings so as to make them conscious about food. Because when they know where it is coming from, they buy into it. Connecting with food requires connecting with the environment. Also, parents must cook more at home. When children see their parents in the kitchen, they, too, will follow and will fall in love with the process of cooking and eating. Also, the entire family must eat at a fixed time everyday with no phone activity or TV at all.</p> <p>&nbsp;</p> <p>There was a five-year study that was done in the European Union on children's health (the I.Family Study), and they found that a child doesn't get unhealthy in isolation. It is a part of the entire environment that contributes to it. They noticed that saying no to the child helps them.... The point is that as a parent you have to overcome your child's pester power. You must persist. But we also want the government to respond to this problem, which was also what the I.Family Study noted. The government must ensure that there is no junk food advertisement on TV. As parents, we must lobby for it and vote for the government on the lines of health.</p> <p>&nbsp;</p> <p><b>What led you to write the book?</b></p> <p>&nbsp;</p> <p>It was to educate and inform parents. We can't shame a child into eating right. We can educate them to eat right and then the change invariably comes.</p> <p>&nbsp;</p> <p><b>What should be the food pattern of a low birth weight child?</b></p> <p>&nbsp;</p> <p>Low birth weight of a child is also a part of nutrition transition, which I have written about in the book. Nutrition transition is not good. It means ending diversity for uniformity in food. Earlier, we had a Malayali eating differently than a Punjabi, who, in turn, ate differently than a Bengali. But now, we are all eating westernised food or packaged and processed food. And, we move much lesser than our parents used to. Children are not low birth weight in isolation—it is mostly the result of a mother who has become very fat during pregnancy. A mother's obesity is also not a personal problem, but a policy issue. For instance, when mothers are asked to not travel by local transport during pregnancy, it leaves them with no choice but to remain at home, which, in turn, adds to their weight.</p> <p>&nbsp;</p> <p>But what we can do to tackle low birth weight kids is to give them desi cow's milk and ghee in proportion to the meals. But don't do anything extra to fatten them. Please do not subscribe to any protein powders or supplements. Because in the process of fattening them up, we are also feeding them fears that something is wrong with them. And, these fattening tonics that we give toddlers change them so much that they get PCOD and other problems on growing up. Instead, feed them ragi kheer and sooji halwa, which is very homely and healthy.</p> <p>&nbsp;</p> <p>Having said that, I want to reiterate that a child's weight is no one's business. And, mothers must stop feeling guilty or pressured about it. If the child is energetic, active and happy, it is just fine. Raising a child is a collective commitment. It takes a village to raise a child, not the mother alone. So, she shouldn't be facing the judgment alone. If something is wrong with my child, it is also your fault.</p> <p>&nbsp;</p> <p><b>Given the nuclear family setup we live in, how can parents bring up their children in the best way?</b></p> <p>&nbsp;</p> <p>Cooking isn't the chore that it is made out to be. It is actually time-saving than time-consuming. It also keeps everyone in the family healthy, [and helps] save on the money you spend on tonics and medicines. It is a critical investment. The game changer for a nuclear family is getting the Indian male to start working at home. We don't need reservations in Parliament, rather we need men's reservation in the kitchen. Earlier, men would work in the kitchen, but this new breed doesn't seem to think the same way, which is shameful. We are geared in a way where the woman is just killing herself to service everyone at home.</p> <p>&nbsp;</p> <p><b>To what extent can parents allow the child to consume junk food?</b></p> <p>&nbsp;</p> <p>There are many decent vendors who sell on the roadside. Eat there once every two weeks and eat one or two dishes at one time. Don't think you can have chaat for dinner. Also, the point is to not make junk food aspirational for children. Parents must not bribe them as return gifts or treats.</p> <p>&nbsp;</p> <p><b>What should a child eat daily without fail? Also, how can one limit chocolates?</b></p> <p>&nbsp;</p> <p>Rice, peanuts, ghee, a seasonal fruit, a homemade laddu—these must be given every day, and other food that is locally available. Chocolates must be limited and children should be made aware that it is the chocolate industry that still involves child labour in a big way. Don't give them chocolates as a treat. It should be limited to once a week.</p> <p>&nbsp;</p> <p><b>Five snacks for children</b></p> <p>❍ Handful of peanuts</p> <p>❍ Fresh fruit</p> <p>❍ Poha</p> <p>❍ Roti, jaggery and ghee</p> <p>❍ Homemade snacks like chiwda and matthi</p> Wed May 22 12:06:19 IST 2019 what-on-your-kid-menu <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>Till two years ago, Munazzah Kazi from Mumbai would fret and sweat in the kitchen, trying to figure out a way to make her daughters—Zinirah, 11, and Zahara, 9—eat healthy and without making a fuss. Kazi, a nutritionist, realised it was easy to dole out nutrition advice to her clients but difficult to put it into action. “I remember how my daughters would compare their tiffin boxes with that of their friends' in school and then demand that I, too, give them exactly that, which was just junk food,” she says.</p> <p>&nbsp;</p> <p>Likewise, Shreya Manhout (name changed) from Delhi would face problems with her five-year-old son, who was obsessed with eating tomato ketchup, be it with rice, chapatis or chips. “So there was no consumption of dal, vegetables and fruits. He would rarely have milk. That way he was almost on the point of malnutrition,” says clinical nutritionist Ankita Ghag, who handled the case six months ago. In order to get the boy off ketchup and help build a positive attitude towards food, Ghag advised the parents to “play around with his plate a little”. So, instead of buying ketchup, Manhout started making tomato puree at home with a few veggies added to it and storing it in the ketchup bottle. “Over a period of time, the child came to accept that it was indeed ketchup and began consuming it generously,” says Ghag. “Slowly, in small increments, we changed his wheat-based chapatis to multigrain ones and began adding grated veggies such as carrots, beetroot, crumpled paneer to the dough so that he would have them. That way, he eats everything now.”</p> <p>&nbsp;</p> <p>Kazi, too, experimented with pizza—her daughters' favourite. She would make the pizza at home, instead of buying it, using “multigrain khakhra as the base, topped with a variety of vegetables and low fat cheese”. Parents must focus on the basic food groups, and then learn how to to camouflage it, says Shonali Sabherwal, a celebrity macrobiotic nutritionist and chef. “For instance, if you give them white rice at home, they want that taste. But it is very easy to add a spoon of cooked brown rice to the white, making it healthier and taking them one step closer to eating a more nutritious grain,” she says. Also, parents must focus on a child's daily nutrition intake from 'whole food', mainly plant-based whole grain, vegetables, fruits, healthy fats like nuts and seeds, she adds, and beware of “the sugars coming from processed and preserved foods”.</p> <p>&nbsp;</p> <p>Parents should have the knowledge about the basics of good nutrition to understand what the children should eat and avoid, explains Ryan Fernando, an award-winning celebrity nutritionist and coach from Bengaluru. “Children require good nutritious food for two reasons: for growth and for boosting immunity to prevent diseases,” says Fernando, who is a hands-on father to Ivank, 5. “Parents must take real interest to understand the science of food, only then will they be able to do justice to their child's diet. The nutritional requirement of a child far outweighs that of an adult. For instance, a child's daily requirement of protein is 1.5 times that of an adult's and as per age groups—from ages 1-4 (breastfeeding infants to toddlers), 5-9 (adolescence) and 10-18 (early and late teens)—the nutritional requirement or the recommended dietary allowance keeps shifting.”</p> <p>&nbsp;</p> <p>Fernando advises young, educated, new-age parents who have access to technology to “count the calories they provide to their child and also be aware of the child's important indicators such as the body mass index, basal metabolic rate, carbs and calcium levels and weight”. The National Institute of Nutrition, Hyderabad, recently came out with its Nutrition Atlas, which mentions the nutritive value of Indian food, dietary sources of energy along with corresponding values of the number of kilocalories provided.</p> <p>&nbsp;</p> <p>Fernando also talks about our culture of feeding by love, especially by grandparents. Parents must take into account the amount of energy a child spends in a day, and the amount of calories she will get to balance it from the food given to her, in terms of proteins, carbs and fats. Every day must follow a given pattern. “One day more proteins and the next day no proteins at all will not work,” says Fernando. “Also, what many parents don't follow is that genes, too, have a role to play in shaping a child's body structure and so there is no point in overfeeding her.” When a child is overfed between the ages of one and six, he says, her body is pre-programmed to understand what it needs to store as adult fat. “Which is why I say don't overfeed the child because if she is obese later, it is most likely that parents have overfed her between the ages of one and six.”</p> <p>&nbsp;</p> <p>Ryan believes in detailing Ivank's diet based upon his height (119cm) and weight (20kg) requirements for his age category. Ivank had a gene test done, which revealed that he was lactose intolerant and that his body absorbs less vitamin C and D. “So, he has at least one egg and one fruit a day. We feed him 1,400 calories per day, split up into six meals. And since he doesn't have breakfast and has only milk before going to school, we pack in a heavy breakfast like a French toast with dried fruits or pancakes with honey or egg dosa, which he has later in the school.”</p> <p>&nbsp;</p> <p>All experts agree that most ready-to-eat food are designed to have high sugars to make it appealing to children. Once children are hooked on to the sugars when they are in their teens and early adult stages, it is almost impossible for them to give it up later. Dr Paras Kothari, a paediatric surgeon at Sion hospital, Mumbai, says, “It is best to prepare food at home, so that you know what you are using and how much. For instance, at home you can replace refined sugar with palm sugar or jaggery, which is higher in iron content. It is just that parents have become lazier and busier now.” Eating out, he says, is one of the primary reasons for the declining state of health. The oil, rice and masalas used in restaurants are of the lowest quality. He is also critical of new-age parents who mollycoddle their children, and mothers who obsess about their kid being underweight. “Both my sons (aged 20 and 18) are black belts in karate, they rarely have junk food, drink two big glasses of milk a day and weigh 60kg at 6.2ft. They are tall and thin, but very strong,” says Kothari. “The point is that we have never indulged them in packaged food and neither took them to fancy restaurants every week.”</p> <p>&nbsp;</p> <p>The best way to get an obstinate child down to the dinner table is to let her remain hungry for as long as she can, suggests Kothari. “They should know what hunger is,” he says. The strategy works wonders, says Kazi. When her daughters refused to eat green vegetables, she told them they had no option—either eat the vegetables or no food. “Eventually, they would come back and finish their quota of palak and methi,” she says. “So, the point is to not give an option to kids.”</p> <p>&nbsp;</p> <p>Yaman Banerji, however, prefers to lead her daughter by example. Ruhaani, 5, has always been a lean child, but Banerji never gave much importance to her weight. As long as she is active and happy, kilos do not matter much. But Banerji does ensure that Ruhaani, whom she lovingly refers to as Little Miss Ru, finishes everything on her plate, including bitter gourd. And, she does it with relish. “The main reason why Ruhaani enjoys food so much and eats everything is that I involve her in the process,” she says. “I take her along to the market, make her sit on the kitchen countertop as I prepare food, talk to her about different items and give her bright coloured fruits and veggies on toothpicks for her to munch on.” If parents involve children in the preparation of food, children will be more accepting of home-cooked food.</p> <p>&nbsp;</p> <p>Setting a routine, following a disciplined schedule and inculcating good lifestyle habits also go a long way in moulding a child's outlook towards food, says Rasika Iyer from Bengaluru. Cofounder of Soulfull, a millet-based health brand in India, she has two daughters—Anaika, 6, and Antara, 2. “Kids never get bored of monotony. They love to be put into a routine and don't mind eating the same thing every day. So, during breastfeeding, I was keeping the routine in mind—breakfast, lunch and dinner—so that the child could move into the zone as she was being weaned off,” says Iyer. The Iyer family has ragi porridge every morning and the girls never question it. Lunch is at 12.30pm followed by a snack at 4.30pm and then family dinner at 6.45pm. “The concept is to have a healthy timetable in place. A little before you know a child is going to be hungry, like 15 minutes before designated meal times, you feed them an appropriate quantity. A well-fed child is always a happy child,” says Iyer. “Also, ragi helps because it breaks down slowly, so there is a constant flow of energy and the person remains full for longer and as a result eats no junk.” The family uses a lot of millets at home. “We usually avoid gluten and instead make rotis from amaranth, bajra, jowar and nachni grains. Evening snacks for the kids are usually a variety of dosas along with a banana, which acts as a laxative and helps the kids remain constipation free. Dinners for the girls are lighter, like tomato rice and dosas and appams,” she says. The challenge Iyer faced with Anaika was that she needed to be fed until she was three while Antara started eating solid food all by herself since the age of one. “I learnt it the hard way that as parents whatever we do, it reflects in the child's habits. So, I would mash food and feed Anaika so she got used to that, while I let Antara help herself, and she got used to that.”</p> <p>&nbsp;</p> <p>According to a study in Science Daily, the visual presentation of the food plate affects how much children eat. The research was to find out whether children prefer their food served in a particular way and whether their gender and age make a difference with regard to their preferences. The study concluded that children, depending on gender and age, have different preferences for how food should be arranged on the plate to make them want to eat it.</p> <p>&nbsp;</p> <p>Discouraging other habits such as watching television and playing on the mobile when eating also go a long way in shaping the eating patterns of a child, says Minal Paresh Sawant, a nutritionist with the Tata Institute of Social Sciences. Additionally, convenience food that do not require cooking at home but are high in fats, sugars and calories are known to cause not just physical problems like obesity and hormonal imbalance, but also mental health problems. “Also, if a child's breakfast is skipped, her brain does not get any calories to work with, thereby leading to eventual sleep disorders,” says Sawant. “Sending the child to school with just a glass of milk is absolutely wrong. Milk is high in proteins and must be used for muscle development, but if no food is taken with it, then the milk will be used for making calories. Also, 99 per cent of children consume one to two servings of maida per day, which is also a major concern.” So, it is important to pack a tiffin for your child so that she does not opt for a samosa or chips in school. Also, parents must refine their own dietary habits to make sure children refine theirs, says Sawant. She cites the example of her seven-year-old son who never eats noodles or burgers because she has never taken him to the mall and he never developed that taste.</p> <p>&nbsp;</p> <p>Greig Cloney, father of a 15 year-old boy, has the last word: teach your children to be responsible and independent when it comes to food so that they do not need someone watching over them and know for themselves when to refrain from having certain kinds of food.</p> Sat May 25 17:44:57 IST 2019 the-viral-factor <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>Though the definition of chronic fatigue syndrome (CFS) has changed multiple times over the last decade, in a majority of cases, the symptoms should be present for at least six months and its intensity should vary from moderate to severe for half the time. Apart from fatigue, other signs include post-exertional malaise, lack of refreshing sleep, cognitive impairment and orthostatic symptoms.</p> <p>&nbsp;</p> <p>CFS is not caused or maintained by a single agent. According to several findings, psychological and physiological factors work together to make an individual prone to this condition. The assessment and treatment for CFS must be multidimensional and be customised as per the needs of the patient. Inputs sought from multiple medical specialities can help improve the quality of life of those suffering from CFS.</p> <p>&nbsp;</p> <p>While CFS mostly affects young to middle-aged adults, some cases in children have also been recognised. Older adults may also suffer from this condition. However, the already existing medical conditions among them preclude the consideration of CFS in the seniors. CFS is twice as common in women than men.</p> <p>&nbsp;</p> <p>A lot of effort has been made to investigate the possible causes of CFS. Viruses, immune dysfunction, endocrine-metabolic dysfunction and neuropsychiatric factors can cause CFS. Considerable interest has been shown to find out if certain viruses, including Epstein-Barr virus (EBV) and retroviruses, could be responsible for causing CFS. However, no infection agent has been proven to cause CFS, although many patients attribute their symptoms to a viral infection.</p> <p>&nbsp;</p> <p>In the mid-1980s, EBV was considered to be a possible cause for CFS. This was because of three observations. EBV persists for life and reactivates frequently, thereby providing the virus the biologic potential for chronic illness. Also, patients suffering from CFS were found to have higher concentration of antibodies to EBV capsid and early antigens or to lack antibodies to EBV nuclear antigens (EBNA), and each of these indicates a recent or active infection. Moreover, some patients have clearly attributed the onset of their illness to a mononucleosis-like infection. Other viruses include human herpesvirus type 6 (HHV-6), enteroviruses, Ross river virus, and Borna disease virus.</p> <p>&nbsp;</p> <p>A syndrome similar to CFS can be seen in patients with Lyme disease and following Q fever. Besides infection, other proposed theories include immunodeficiency, depression, sleep deprivation, endocrine abnormalities and genetic factors.</p> <p>&nbsp;</p> <p>Signs and symptoms may include fatigue, loss of memory or concentration, sore throat, enlarged lymph nodes in the neck and armpits, unexplained muscle or joint pain, headaches and extreme exhaustion lasting more than 24 hours after physical or mental exercise. Possible complications of CFS include depression, social isolation and lifestyle restrictions.</p> <p>&nbsp;</p> <p><b>Rajagopal is consultant, infectious diseases, Aster CMI Hospital, Bengaluru.</b></p> Fri May 03 16:14:35 IST 2019 combined-approach <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>There is that old story about the blind men who encounter an elephant for the very first time. Each describes the animal by touching one part of it. To one blind man, touching the leg, the elephant is like a mighty tree trunk. To the man touching the tusks, it is like the finest marble, and to a man at the tail, it is like a rope.</p> <p>&nbsp;</p> <p>To really understand what the elephant looks like, all perspectives need to be synthesised. Understanding a disease is often similar. It needs a synthesis of different perspectives and specialities. Many conditions do not fit into our neat categories—a disease can and often does affect both mind and body.</p> <p>&nbsp;</p> <p>Chronic Fatigue Syndrome (CFS) is one such condition that medical science doesn't yet understand. CFS, which affects about 80 to 100 per lakh people, is defined as the presence of debilitating fatigue that lasts at least six months, and the fatigue has no other diagnosable medical cause. Other symptoms can include headaches, lack of refreshing sleep, muscle pain and problems with memory.</p> <p>&nbsp;</p> <p>Most of these symptoms are what doctors would call “non-specific”, meaning that they are common in many illnesses. So the doctor would first look for other medical conditions such as infections, thyroid disorders, heart disease and metabolic issues. However, when all of these are negative, and no other medical causes for the symptoms are found, then the person would be diagnosed with CFS.</p> <p>&nbsp;</p> <p>Now, most people suffering from CFS have a coexisting psychiatric issue such as stress, anxiety or depression. However, the treatment of the depression alone does not result in remission of CFS.</p> <p>&nbsp;</p> <p>Although researchers speculate that CFS occurs possibly because of immune system dysfunction, and others speculate that it is a neurobiological problem, it is probably a blind-men-and-the-elephant situation. As a psychiatrist and physician, I see the symptoms of fatigue and the emotional symptoms as aspects of the same condition—some symptoms are expressed through the body and others through the mind.</p> <p>&nbsp;</p> <p>An integrated treatment approach works best for CFS. Firstly, the person is evaluated for other medical conditions that cause similar symptoms. If there are no other conditions, the doctor (or a lifestyle coach) would then help the patient improve their nutrition—research shows that processed food and sugars worsen CFS. The next step is to help the person begin a graded exercise programme and to help them stay motivated to follow it despite fatigue and pain. If there are any problems with mood, the person should consult a psychiatrist, and any anxiety, depression or other issues should be treated.</p> <p>&nbsp;</p> <p>The psychiatrist or psychologist will then also use what is called CBT (cognitive behaviour therapy), a form of psychotherapy that helps a person change their negative thought patterns into more balanced thinking. This would help the CFS sufferer address fears and misgivings about the condition and about their own limitations. Therapeutic massage, yoga and meditation add a lot of benefit as well. A combination of these approaches in the right manner is the best approach to treating CFS.</p> <p>&nbsp;</p> <p><b>Bhat is head of, a part of health and lifestyle startup</b></p> Fri May 03 16:11:07 IST 2019 chronic-fatigue-syndrome-on-the-exhaust-trail <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>Dr Priyadarshini Deo, 52, would hit the wall like a marathoner by the time she would get back home from work.</p> <p>&nbsp;</p> <p>The exhaustion wouldn't go away with rest or sleep. “Many people think if you take rest, you recover from fatigue. It was not like that. I felt tired all the time and would have cervicogenic headaches (that develop in the neck) and a lot of muscular pain,” says Deo, a counsellor at the Centre for Cancer and Palliative Medicine, Kokilaben Dhirubhai Ambani Hospital, Mumbai. At times, she would feel foggy in the head and have difficulty concentrating. “It affected my quality of life so much that it led to a kind of social isolation,” she says.</p> <p>&nbsp;</p> <p>Deo was later diagnosed with Chronic Fatigue Syndrome (CFS), a condition wherein extreme fatigue occurs without an obvious reason. “If someone has persistent fatigue, we look for the causes. CFS is diagnosed when the causes of fatigue like hormonal imbalances are ruled out,” says Dr Ambrish Mithal, chairman, endocrinology and diabetology, Medanta-The Medicity, Gurugram.</p> <p>&nbsp;</p> <p>CFS is a complex illness characterised by persistent mental and physical fatigue. “Mostly people with this condition are very sensitive to normal day-to-day activity or exercise,” says Dr Pankaj Singhai, senior consultant, internal medicine, Manipal Hospitals, Bengaluru. A little bit of physical exertion or any mental activity can worsen the fatigue. Even with medicine, exercise, rest and eating the right kind of food, the patient does not get better and constantly complains of tiredness. “CFS manifests as intense exhaustion, interference in day-to-day activities, lack of concentration, restless legs, sleeplessness, memory problems, fall in blood pressure, palpitations, ringing in the ears and weight changes,” explains Singhai. “Sore throat, headache and enlarged lymph nodes in the neck and armpits are also some of the common symptoms of CFS. It can vary from mild fatigue, where one may work with short periods of rest, to severe fatigue, when everyday tasks become increasingly difficult. These can be cyclic in nature.”</p> <p>&nbsp;</p> <p>Sometimes, there is an overlap between CFS and depression. There is a school of thought that states that CFS is nothing but a manifestation of mild depression. But Dr S.K. Chaturvedi, senior professor of psychiatry, National Institute of Mental Health and Neurosciences, Bengaluru, says, “It works both ways. Fatigue causes depression and depression causes fatigue.”</p> <p>&nbsp;</p> <p>Persistent fatigue can be a sign of an underlying health problem as well. “When a patient presents with tiredness and weakness, we look for the causes. If we find a cause and the patient gets better with treatment, then it is not CFS. It is just chronic fatigue,” explains Mithal.</p> <p>&nbsp;</p> <p>Chronic fatigue can be triggered by a multitude of factors, ranging from routine viral and bacterial infections, impaired immune system and hormonal imbalances to mental health problems such as depression. Dengue, chikungunya, malaria and pneumonia can cause chronic fatigue after the patient has recovered from the infection. “It is more common in middle-aged women than men,” says Dr Shaunak Ajinkya, a psychiatrist at Kokilaben Dhirubhai Ambani Hospital, who was part of the team that treated Deo.</p> <p>&nbsp;</p> <p>People with chronic fatigue are a misunderstood lot, often labelled as lazy and socially disconnected. But wellness consultant Ranjana Ramakrishnan from Chennai argues that society shouldn't be blamed for not understanding the challenges faced by people with chronic fatigue, as there is a general lack of awareness about the condition. “On many occasions, I have missed weddings because of being hit by a sudden overwhelming tiredness. By the time I get down to draping a sari and getting ready for the wedding, I am just so exhausted,” says Ramakrishnan, 55, who has been suffering from fatigue since her forties. Even her close friends cannot fathom the difficulties she faces, she says. They think she just makes up excuses to skip weddings.</p> <p>&nbsp;</p> <p>She describes her condition as “real and vast”. “There are days when I come out of the shower and feel like I have had a strenuous workout. After the bath, I feel totally depleted of energy,” says Ramakrishnan. “I am forced to lie down for 20 minutes or even take a post shower nap, depending on the intensity of tiredness.” She struggles to get out of bed in the morning, despite a good ten-hour sleep. “Most days, if I don't take a power nap in the afternoon, then I am thoroughly exhausted by 7pm and the body behaves as if I had worked in the fields,” she rues. So, her late night plans with friends depend on how she feels post 7.30pm.</p> <p>&nbsp;</p> <p>Ramakrishnan thinks her fatigue is caused by hypothyroidism. “The onset of menopause has aggravated it,” she says. “I know for a fact that my metabolism has slowed down because of hypothyroidism. My other parameters are normal.”</p> <p>&nbsp;</p> <p>Another common cause of chronic fatigue is diabetes. It is always worth ruling out diabetes in anyone who complains of unexplained exhaustion, says Dr V. Mohan, chairman and chief diabetologist at Dr Mohan’s Diabetes Specialities Centre, Chennai. “Indeed, it is often the presenting symptom of diabetes. When one has very high blood sugar levels, this leads to excretion of glucose in the urine—a condition called glycosuria. When glucose is excreted in the urine, large quantities of water are also lost along with it. Hence, the patient may lose weight due to the loss of water and this produces symptoms of increased thirst as well as fatigue and tiredness,” he explains. Once the diabetes is well controlled, the fatigue may go away. “Long period of uncontrolled diabetes can also lead to breakdown of fat as well as protein in the body, all of which get converted into glucose. When one loses fat and muscle, this can lead to tiredness and, in turn, to chronic fatigue,” says Mohan.</p> <p>&nbsp;</p> <p>Fatigue can be present very early on in HIV infection. “One of the commonest symptoms of HIV infection is persistent fatigue,” says Dr Diwakar Tejaswi, a general physician based in Patna. “It is seen that fatigue occurs when the immune system is suppressed owing to the HIV. But how HIV leads to chronic fatigue continues to baffle scientists.”</p> <p>&nbsp;</p> <p>Relentless fatigue, a potential symptom of many underlying conditions, is often under-diagnosed. Take, for instance, Dipika Chaturvedi, 26, from Agra. She was flummoxed when she started losing weight and felt fatigued and weak. She lost about 10kg in a year. Her blood pressure was always on the lower side. She lost her appetite, too. As her condition worsened, it affected her daily life. For someone who used to help around the house, Chaturvedi started getting overwhelmed with the simplest of chores. She consulted a physician, who prescribed her some multivitamins. She tried them for about a month, but to no avail.</p> <p>&nbsp;</p> <p>Her cousin suggested that she see an endocrinologist. Finally, she was diagnosed with Addison’s disease, which is characterised by cortisol deficiency. Apart from the fatigue and loss of appetite, her darkened lips and knuckles helped the endocrinologist diagnose the disease. Blood tests confirmed she was producing little cortisol.</p> <p>&nbsp;</p> <p>“Addison's disease is an endocrine disorder in which the adrenal glands fail to produce cortisol hormone, which, in turn, leads to chronic fatigue,” says Dr M. Shafi Kuchay, a consultant at Medanta-The Medicity, Gurugram. “Cortisol is a crucial hormone for life. If this hormone is not replaced soon enough, the sufferer might lose his or her life.” Cortisol is required for maintaining normal carbohydrate, fat and protein metabolism, he says, and it regulates blood pressure and keeps inflammation in check. “Cortisol boosts energy so that you can handle stress well. In Addison’s disease, these adrenal glands get destroyed by autoimmunity or chronic infections such as tuberculosis, and the patient feels too tired to do even simple daily tasks,” explains Kuchay.</p> <p>&nbsp;</p> <p>Chaturvedi is now on medication. She takes cortisol pills twice a day. “After I was put on cortisol medicine, the effect was immediate,” she says. “I regained my appetite, put on a few kilos in a month and I have almost no fatigue now.”</p> <p>&nbsp;</p> <p>Ramakrishnan, who has consulted many doctors, says that not all doctors take the signs of fatigue seriously. “They see hundreds of patients every day and maybe they become numb to conditions like chronic fatigue,” she says. “In fact, there is really nobody out there to advise you.” She has, therefore, taken to surfing the internet to know more about her condition.</p> <p>&nbsp;</p> <p>Chronic fatigue is becoming increasingly prevalent among urban Indians. Experts attribute it to vitamin B12 and D deficiencies. Changes in hormone levels can result in extreme tiredness, says Mithal. “Thyroid disorders are common causes of fatigue in urban India. People with hypothyroidism often complain of fatigue as the only or the main symptom,” says Mithal.</p> <p>&nbsp;</p> <p>Men experience fatigue as they age. One possible reason for debilitating fatigue in men is the male hormone imbalance. As men get older, their testosterone levels drop. “Most men above 40 tend to have a minor decline in their testosterone levels and they may experience fatigue and muscle pain as the only symptoms. In those above 60, it is very common,” says Mithal. “Another possible symptom of low testosterone is low libido. However, patients may not necessarily be very forthcoming about it.”</p> <p>&nbsp;</p> <p>Many experts say that a decline in dehydroepiandrosterone (DHEA), a steroid hormone naturally produced in the body, can cause fatigue. “DHEA supplements are available over the counter. They don't have side effects. One can use them, if required,” says Mithal.</p> <p>&nbsp;</p> <p>Another important cause of fatigue that is often missed is growth hormone deficiency. “Earlier on, it was thought it is required only in children. But adults, too, could develop growth hormone deficiency because of a tumour or some underlying medical problems,” says Mithal.</p> <p>&nbsp;</p> <p>For CFS, there is no single confirmatory diagnostic test. “There is no cure for it, either,” says Singhai. “The most effective treatment of CFS is a combination of cognitive training by a counsellor and graded exercises. Low dose of antidepressants can help in depressed patients.”</p> <p>&nbsp;</p> <p>To combat fatigue, Ramakrishnan has tried everything, from changing her diet by cutting out carbohydrates and adding more protein, leafy vegetables and nuts to incorporating strength training programmes that include more weights to retain bone density and muscle mass. She believes lifestyle changes can go a long way in fighting fatigue. Also, since people with CFS may not be able to explain their distress to their spouses or bosses, Ramakrishnan says, “It is time we start our own support groups, spaces where people can come together and share their experience without the fear of being judged.”</p> <p>&nbsp;</p> <p>Deo believes her CFS is idiopathic. It is often said that doctors make the worst patients. But Deo is different. She sought medical help as her life became unmanageable and followed the doctors' advice to a T. “I figured out that in my case the fatigue was caused by varied factors,” she says. “I took the opinion of pain specialists to deal with muscular pain. The sleep issues got resolved by meditation. I have also had a lot of counselling sessions. It feels good to talk to somebody who is not your family. There is nothing to feel shy about it.”</p> <p>&nbsp;</p> <p>Deo now enjoys cooking and often cooks for her close ones at work. She spends a lot of time with her plants in the evening. Tuffy, her pet dog, keeps her occupied, too. “Sometimes, he acts like a bed-bound parent,” she says, smiling. “I feel uncomfortable in extreme social situations like marriages or parties. However, I have my close friends with whom I hang out occasionally.” Acceptance of the illness and family support, says Deo, are key to get back to normalcy.</p> Sat May 04 12:36:13 IST 2019 fitness-mantras-of-our-politicians <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>Five days and about seven text messages. That’s what it took to finally get an appointment with Nationalist Congress Party leader Supriya Sule in Mumbai. All this while she had been posting regular updates and selfies on her WhatsApp status and Instagram feed, capturing moments spent with villagers during her campaign across Baramati, her constituency. The most striking photo was the one with a bunch of women from Bavdhan, listening to her in rapt attention at 10.30pm. That night, after the rally, she left for Mumbai and reached home at 2.30am only to wake up at 7am. “Politicians live by exhausting and punishing schedules. During elections, I campaign anywhere between 14 to 16 hours, covering as many as 18 villages in a day,” says Sule. “Of course, I would have liked to sleep for seven to eight hours every day, but that is quite far-fetched at least at the present.”</p> <p>&nbsp;</p> <p>Ahead of the Lok Sabha elections, politicians are going out of their way to woo the voter, covering as much area as possible before calling it a day. But erratic schedules that demand long hours out on the field amid a scorching Indian summer involve a certain toughness of the mind and the body. While some steel themselves for it well in advance, others learn it the hard way. For Dr Shweta Shetty, founder of the National Women's Party, aggressive campaigning in south India took a toll on her body and she had food poisoning. “I had been travelling extensively for launching the party, but the heat got to me,” she says. “This is what campaigning does to you. I don't fall ill otherwise. This is the first time this happened. I have already lost three kilos in the past month or so of campaigning.”</p> <p>&nbsp;</p> <p>The most common complaint among political leaders across party lines pertains to the lack of access to home-cooked food while campaigning. Some like Shiv Sena’s Dr Shrikant Shinde make it a point to carry food from home at times, while others like Congress leader Sachin Pilot have to make do with whatever is offered by well-wishers and party workers. “Politicians need to work on themselves extra hard, given that their bodies are more prone to problems of dehydration, glucose imbalance, fatigue and stress, especially during campaign days,” says Karishma Chawla, a Mumbai-based nutritionist. And, the leaders know this only too well. Most of them are conscious of their fitness goals and try and make time for workout. While both Shinde and Congress’s Milind Deora swear by their home gyms for the daily dose of exercise, others such as Pilot and Sule prefer cycling, running and yoga. The MPs Club is where all of them get together and sweat it out over generous doses of music and gossip. While Union minister of state for home Kiren Rijiju was Sule's “ex-gym partner”, Shinde has played cricket with the “Parliament team at the cricket ground in Dharamshala, along with Hisar MP Dushyant Chautala of the Indian National Lok Dal, Srikakulam MP K. Ram Mohan Naidu of the Telugu Desam Party, BJP’s Anurag Thakur and others”.</p> <p>&nbsp;</p> <p>But, when they are on the road campaigning, they improvise. Here’s how politicians are taking care of their health in the time of polls:</p> <p>&nbsp;</p> <p><b>Walking the talk</b></p> <p>&nbsp;</p> <p>Baramati MP Supriya Sule is blessed with a body that never gets tired. On a bright Tuesday afternoon, Sule, dressed in a pastel green cotton sari with neon red sneakers, meets us at Mumbai's Marine Drive promenade. She has barely slept for four hours the previous night after returning from a rigorous campaign in her constituency. Yet, she doesn't seem jaded at all. “I seriously never feel worn out. My body plays along quite well,” she states. Sule passionately follows the fitness-on-the-go mantra for good health. “I compulsorily carry my sneakers and crocs at all times and depending on when I get the time I work out.” She tries following a pattern—alternating between cycling, yoga and brisk walking every two days—but mostly ends up exercising impromptu, it could be any time of the day. When in Pune or Baramati, Sule simply dons her helmet and goes cycling in a sari and when in Mumbai, she makes it a point to walk back from Marine Drive to her home on Peddar Road after work. The 50-year-old used to be a hardcore gym person about five years ago, but now swears by the outdoors. Sule's current fitness goal is to lose six kilos but she is not anywhere close it, especially not with the erratic schedules that are a constant feature in the run-up to the elections. “Right now, it is all a mess. There is no discipline as there is no regular set pattern for my days,” she says. “Unlike many others who lose weight in the heat and dust of elections, I gain by the kilos because I am a stress eater. I also have a weakness for Diet Coke. It is my energiser and I must have one can a day without fail.” And yet, she doesn't remember the last time she fell ill or had to cancel a campaign because of a bad stomach. She never takes food from home and mostly ends up eating in “karyakartas’ (party workers) homes” or at local dhabas. Normally, the food is veggies, mutton or chicken and rice or jowar bhakris. The hygiene at the roadside eateries does not bother her much, but she makes sure that she carries bolied water in the two flasks with her. “That is my only precaution,” she says. Breakfast is a fruit and six almonds, and evening snacks mostly consist of any two varieties of biscuits. “I have outgrown the taste of fried food and I am not addicted to tea or coffee,” she says. But, she is a foodie, and food is always on her mind even while campaigning. “I know the most amazing places to eat, district wise, in Maharashtra, and I plan accordingly and inform them beforehand to keep some food for me,” she says.</p> <p>&nbsp;</p> <p>But if there is one thing that the mother of two teens misses the most, it is sleep. “It actually feels like it has been ages since I enjoyed a good, long sleep,” she says. “I need to work on that.”</p> <p>&nbsp;</p> <p><b>Committed to fitness</b></p> <p>&nbsp;</p> <p>In politics, time is a crucial resource. And keeping to a fitness regime can be a real challenge. “Daily workout? Oh, where's the time really,” says Kiren Rijiju, Union minister of state for home affairs, who is fighting on a BJP ticket from Arunachal (West). Given the constraints of time, and managing meetings that last, at times, until the wee hours, the lawyer-politician says he had to find some way to keep fit.</p> <p>&nbsp;</p> <p>So he had a small, but well-equipped gym, built at his official residence in Lutyens Delhi, and resolved to set aside half an hour for exercise, whenever possible. “It could either be early in the morning, or late evening, whenever my schedule allows,” he says. Rijiju says he manages to squeeze in time for a quick workout every now and then. “I start with some warm-up, then move on to functional exercises such as burpees, some light weights, and then end with some stretching,” he says.</p> <p>&nbsp;</p> <p>For the 48-year-old fitness enthusiast—Rijiju posted a video of him doing pull-ups that went viral during the #FitnessChallenge last year—being physically active is extremely important. Fitness, says Rijiju, is a way of life, and in his case, the routine began early. A national-level athlete in school, Rijiju played tennis and volleyball, and was a javelin thrower. The lull in physical activity came in 2004, when he moved to Delhi in his first stint as an MP. “From 2004 to 2009, I gained a lot of weight,” he says. “After that, I realised I had to do something.”</p> <p>&nbsp;</p> <p>Rijiju believes that fitness is important in any profession. “If you are fit, you will be good at your work,” he says. “A successful professional is one who is committed, and that is also an essential part of any fitness regimen. If I don't do any exercise, I get lethargic, and it shows in my work. I have to keep moving, doing something.” At 5'9'', Rijiju says he weighs 82kg. “This is okay, but ideally, I should be about 75kg,” he says.</p> <p>&nbsp;</p> <p>It is not tough if one realises the importance of fitness, he says. “These days, people are aware that they need to keep fit,” says Rijiju. “And that kind of awareness has to be created among our politicians, too. The idea is not to bulk up, but to remain fit and active so that we are able to deliver on our promises and serve our people.”</p> <p>&nbsp;</p> <p>Exercise routines apart, the minister, also the BJP’s star campaigner in the northeast, says he keeps a check on his diet, too. “I am not into any diet fad. I just like to keep it simple. I try to avoid carbohydrates, especially rice at night. During my travels, I carry home-cooked food such as vegetables, chapati and rice,” he says.</p> <p>&nbsp;</p> <p>But all his resolve weakens when it comes to a certain sinful treat. “Jalebis! I love jalebis. Rajnath Singhji and I are really very fond of them. It's tough to stay away from them,” he says with a smile.</p> <p>&nbsp;</p> <p><b>- NAMITA KOHLI</b></p> <p>&nbsp;</p> <p><b>Gym junkie</b></p> <p>&nbsp;</p> <p>Dr Shrikant Eknath Shinde is a fitness freak. The state-of-the-art gym set up at his home stands testimony to the fact. “I don't have a fixed time to exercise, but I make sure I work out for 60 minutes every day, be it early in the morning or late at night,” says the Kalyan MP from Maharashtra. He, too, agrees that the life of a politician is “extremely challenging, given the rigorous amount of travel involved”. From morning to night, he is on his toes, looking over his constituency affairs, he says.</p> <p>&nbsp;</p> <p>Shinde's personal trainer and fitness consultant Ravish Dobani makes sure he adheres to his workout plan on a daily basis. “We start with a few minutes on the treadmill, followed by body weight training,” says Dobani. He is not into hardcore weights but he does total resistance exercises for training his core. I also help him focus on lower back strengthening exercises, since his work demands that he be seated for much of the day.” Dobani also trains Shinde in aerial yoga and pilates. “If he is in the city, he is very punctual. He never skips workout,” he says. Shinde's constituency is barely a hour and a half away from his home in Thane and so it is convenient for him to carry home-cooked food along with him to Kalyan every day. He plays cricket, too, once every two months and cycles every alternate morning in the neighbouring Yeoor hills on a bike he has purchased recently. Shinde considers himself to be “decently fit”. “During elections, I always end up losing a lot of flab, given the physical and mental stress that goes with it,” he says. In terms of diet, he says only one thing is of utmost importance during election campaigns—“to keep oneself well hydrated”. “I don't make a fuss about food, but I make it a point to drink plenty of fluids at all times,” he says. “I think I have successfully maintained the same body profile in the past five years, right from 2014 elections to the present one. In fact, I am the youngest and the fittest in the Shiv Sena.”</p> <p>&nbsp;</p> <p><b>Meditation and metabolism</b></p> <p>&nbsp;</p> <p>Tejasvi Surya, 28, says he is, by and large, a people person, and is ebullient and perky most of the time. What makes him lose his temper is “nonsensical conversation”. “Boring people who talk stupid things and with whom it becomes impossible to have an intelligent and meaningful conversation drive me up the wall,” says Surya, one of the youngest BJP candidates in the Lok Sabha elections. After a pause, he adds that his impatience with some may also be affecting his blood pressure. And so, to counter the negativity, he meditates twice every day for ten minutes—before sunrise and after sunset. “I do it religiously,” says the candidate from Bangalore South. “Because that is the only way to keep myself sane. It helps me calm down and clear my head.” It also helps him forgive and forget—an attribute he considers essential for survival in politics.</p> <p>&nbsp;</p> <p>He admits that his life was hectic even prior to his candidature, given his law practice and the charge of the party's national digital communication team. But, suddenly, there has been a complete shift. “I feel all grown up overnight,” he says. “The worst part is that there is no time to watch Netflix any more. I'm literally running against time and, at the end of the day, it's all a haze.”</p> <p>&nbsp;</p> <p>To keep up with the deafening politics and relentless campaigning, Surya runs 5km thrice a week, plays badminton on weekends and tries to do yoga every morning. Having been a state-level swimmer at school, he also makes sure to dive in at least four to five times a month at a popular pool in Bengaluru. “This latest fad of hardcore gym workouts with weights and machines does not work for me. I'm too lazy and lack the discipline to get up and go to the gym every day. I've wasted so much money on gym memberships,” he says, laughing. At 72 kilos, Surya feels he is quite fit, but the challenge is sustaining his fitness while campaigning. “I hardly get to sleep now,” he says. “My day begins at 6am with a glass of warm water with lime and honey, and I'm out by 7am to meet party workers and volunteers at the nearby park. I'm back only at midnight and actually sleep at about 2am. Until then, it's all work. Answering calls, mail, etc.”</p> <p>&nbsp;</p> <p>A vegetarian, Surya makes do with whatever he can lay his hands on while on the campaign trail. He stocks food—like an apple, a bottle of cold milk or dry fruits—in his car. “But meals largely happen on the ground, depending on where I am,” he says. “So, a few days back, we were campaigning at Jayanagar and I gorged on sandwiches at the famous Hari Super Sandwich there. I have my favourites and stop by to eat there whenever I can.”</p> <p>&nbsp;</p> <p>Being “genetically blessed with a robust constitution”, he binges on chocolates and ice cream. But, no energy drinks or liquor. “I think I must have had my last drink in the pre-historic era. It really has been that long!” he says. Tumblers full of nariyal paani save his day when “the aggression on social media gets too much to digest”.</p> <p>&nbsp;</p> <p><b>Coffee, dogs and fake laughs</b></p> <p>&nbsp;</p> <p>Pointing to the jalebis, potato vadas and other fried snacks jostling for space on the small paper plate he holds, Milind Deora quips, “This is how I keep myself fit. This is my breakfast today.” It is 7.30am, and Deora, Mumbai Congress president and Lok Sabha candidate from Mumbai South, is at the famous Priyadarshini Park for a morning walk. He is dressed in a crisp white linen shirt and grey trousers, and is accompanied by some residents of Malabar Hill, his home turf.</p> <p>&nbsp;</p> <p>He looks radiant and smiles while greeting other walkers, but is exhausted inside. “I slept for barely 45 minutes last night,” he says. “I am actually completely zoned out and have been sipping coffee since 4am. Had a lot of email and messages to answer and just couldn't sleep because of this weird acidic feeling in my gut.”</p> <p>&nbsp;</p> <p>Ever since his candidature was announced, Deora has had a “dreadfully unhealthy routine”. He has been skipping his usual breakfast of oats and almond milk, and the gym workouts at his plush Peddar Road residence. “All I need is seven and a half hours of sleep every day to feel super relaxed. But that is a dream for now,” he sighs. “It's not that I don't want to work out, but there is just no time. I would even like to swim every day, but I cannot. I'm not aspiring to look like a model, but I just want to feel healthy, boost my immunity, keep fit and prevent lifestyle diseases. Nobody is as fit as Rahul Gandhi. And I know I'm not doing anything to reach my goal of fitness.”</p> <p>&nbsp;</p> <p>Coffee is his energiser. “It can keep me going from place to place, hour after hour, without feeling drowsy or famished,” he says. And then there is some dog therapy to keep him enthused. “Sometimes these four-legged residents of my constituency perk me up like nothing else can,” he says, as he bends down to cuddle a dog, offering it some biscuits from his pocket.</p> <p>&nbsp;</p> <p>A vegetarian, Deora loves bingeing on junk food. “I cannot always be conscious of what I eat, right?” he asks. “When you speak a lot, you do tend to get hungry and cannot always hope for the healthiest and most nutritious food to come your way. You make do with whatever is available.”</p> <p>&nbsp;</p> <p>The members of a laughter club, who have gathered at the park, invite him to join them. While he does so sportingly, he seems to be trying hard to join the voluntary laugh, which goes on for about 30 seconds. “This is my fourth election and the hardest part has been keeping up with the laughter,” he says with a smile.</p> <p>&nbsp;</p> <p><b>Ready for the race</b></p> <p>&nbsp;</p> <p>Two years ago at at an award function, Rahul Gandhi made a revelation about his interest in sports and fitness. It was in response to a question by boxer Vijender Singh as to why politicians were not interested in sports. Rahul said he is very actively into sports and takes his fitness seriously. He said he ran, swam and was a black belt in Japanese martial art Aikido. Rahul added that though he does not talk about it publicly, sports had an important place in his life and that he devoted one hour to fitness every day.</p> <p>&nbsp;</p> <p>Rahul trained in Aikido under master Sensei Paritos Kar. A group picture of him with Paritos Kar and other Aikido students was shared by his fans and supporters on social media, alongside an image of him cycling and a photo of the certificate he received from the National Rifle Association in 1989 for his participation in the National Shooting Championship. The pictures were shared with #FittestRahulGandhi on Twitter. According to his close aides and party workers, Rahul maintains a rigorous and regular workout schedule, which includes a 12km run every alternate day. As per Congress spokesperson Randeep Singh Surjewala, Rahul runs irrespective of the time he finishes work.</p> <p>&nbsp;</p> <p>He is also seems to be a consistent practitioner of yoga and meditation, going by his frequent visits to meditation centres in South Asia, especially the vacation he took between February and April 2015, across four southeast Asian countries—Thailand, Cambodia, Myanmar and Vietnam. In 2013, too, he had attended vipassana meditation camps, including one at a Jain ashram in Mohankheda, 87km from Indore, where a satvic routine was followed.</p> <p>&nbsp;</p> <p><b>Stretch to fit</b></p> <p>&nbsp;</p> <p>Severe lower back pain and neck pain made Jignesh Mevani take his health seriously. “I had been extremely careless about my body. With extensive travelling and constant eating out during campaigning in these last assembly elections and now, my stomach has become a mess,” says the 38-year-old MLA from Vadgam constituency in Gujarat. To correct it, he now requests people whom he meets while on the road to offer him home-cooked food only and some fruits. “I need no choppers, no money, no valuables. All I need is food that goes easy on the body and helps it,” he says.</p> <p>&nbsp;</p> <p>But that is not the only thing that has him worried. “In our desperation to cover more area, we travel like a dog and sleep far less,” he says. “In the last one and a half years, I have taken antibiotics almost 13-14 times for my throat infection, which aggravates by drinking cold water while campaigning.” Moreover, his right shoulder hurts because of constantly being on the phone.</p> <p>&nbsp;</p> <p>Mevani, however, has been successful in implementing changes to his diet and fitness routine in the last couple of months. For one, he has taken to yoga and swimming. Two, he has stopped having refined flour-based food and taken to drinking plenty of water. “I stick to home-cooked food, however simple it may be, and try and do yoga or swimming every day.” He dreads the toll the Lok Sabha elections will have on his body. “I am super scared of travelling now,” he confesses. “As a politician, one has to keep moving to know the impact of the welfare policies among people and to campaign, but somehow it scares me. Nothing is more scary than those erratic schedules that we have.” For independent politicians, he explains, it is all the more difficult to survive as there is no organisational support and one must prove one's mettle at all times. “At times, it becomes so hectic that the meetings begin at 10pm and go on till 2am,” he rues. “With the constant talking and standing, you even end up getting a sore throat and jamming your hamstrings.”</p> <p>&nbsp;</p> <p><b>Holistic healthfulness</b></p> <p>&nbsp;</p> <p>He calls himself a foodie, but he also vows by small portions. Anil Antony, the eldest son of former Kerala chief minister, and former defence minister A.K. Antony, says he loves everything about Kerala cuisine. “I am a hardcore non-vegetarian. But everything in small portions,” he says. Anil is currently in charge of the Congress's digital media campaign in Kerala and is busy organising workshops for party workers.</p> <p>&nbsp;</p> <p>Apart from Kerala cuisine, his favourites are Mediterranean and Japanese. “I particularly love Sushi,” he says, and repeats, “But everything in small portions.” Anil played tennis and basketball in college. “Now I don't get time to play,” he says wistfully. However, he hits the gym every day. Of course, the campaigning has upset his routine. “Going to the gym has become impossible ever since the campaign started,” he says. “I am more into yoga these days. I do it regularly wherever I am.”</p> <p>&nbsp;</p> <p>Anil also makes it a point never to skip breakfast. “A proper breakfast is very important for me,” he says. “I have never skipped it in my life.” The rest of the day can be managed with fruits or dry fruits or whatever is at hand, Anil says. Is he a morning person or an evening person? “I would love to say I am a morning person, but, actually, I am an evening person,” he says. “While in Kerala, I try to be a morning person as everything starts earlier here, but in Delhi I rarely sleep before 2am.”</p> <p>&nbsp;</p> <p>Anil says he gives equal importance to physical fitness and mental equilibrium. “Reading is a very important aspect in my life,” he says. A “non-fiction person”, he devours everything related to history and technology. Yuval Noah Harari is his favourite author at present. “I read even during the height of campaigning,” he says. “It calms you.”</p> <p>&nbsp;</p> <p>Does he give special care to his choice of clothes while campaigning? “I always prefer casuals. Khadi kurta and jeans are my favourites,” he says. Is he comfortable with mundu, the dhoti worn down south? “Yes,” he says proudly. &quot;It is most suitable for our climate, and for me, comfort comes before anything else.&quot;</p> <p>&nbsp;</p> <p><b>- CITHARA PAUL</b></p> <p>&nbsp;</p> <p><b>Pilot run</b></p> <p>&nbsp;</p> <p>Every morning, Sachin Pilot forces himself to eat sprouts—the one thing he admittedly hates. And that's pretty much the only thing he does consciously to keep himself fit in terms of diet. “For erratic schedules like mine, where I am literally out in the field for like 14 to 15 hours every day, it is impossible to manage healthy eating the way I would like to,” says the 41-year-old deputy chief minister of Rajasthan. There is always a huge gap between the food that he should eat and that which he has to eat, mostly served by well-wishers whom he meets while in the field. “They do it with such goodness of heart that I definitely cannot say no to those jalebis, pakoras, dahi bhallas and rasgullas. Also, sometimes I am so hungry that I just cannot stop myself from eating deep-fried stuff or sweets,” he explains. “So for a politician like me who is constantly on the move, life doesn't really allow that kind of set-up where I can choose to eat the most healthy food.” But he does exercise. “I run a couple of times a week at the Central Park in Jaipur and play football with my son.” But that, too, is subject to his hectic travel schedule, which is so erratic that he doesn't remember the last time he spent more than two nights at one place. “In the last few days alone, I travelled to nine parliamentary constituencies in Rajasthan,” says Pilot, who is also the state party president. Sometimes he does feel exhausted, he says, but he is no fan of instant energy bars, protein shakes or probiotics. “I am a big proponent of naturally available traditional food—dal, roti, sabzi,” he asserts. And, he is no fussy eater. “Porridge and eggs make for a delicious breakfast and doodh wali (milky) masala chai can keep me going for hours,” he says, excitedly. “I think it is running that has taken care of my body for years now more than anything else. It has kept me away from all sorts of lifestyle diseases.” But he doesn't consider himself to be fit yet. “I think because of my love for French fries and namkeen (savoury) I have gained weight in the last three to four years and have to reduce that. But I haven't actually got down to working on it.”</p> <p>&nbsp;</p> <p><b>Combined force</b></p> <p>&nbsp;</p> <p>A mix of aerobics, yoga and Zumba is what keeps Shweta Shetty going. Founder of the National Women's Party, a first-of-its-kind in the county, she has been busy campaigning, selecting candidates and filing nomination papers for the general elections. “I am very conscious of my health at all times and pay a lot of attention to what I eat. Every morning, after I wake up, I exercise or I would be irritable and lethargic all through the day.” Every three months, Shetty alternates between the three forms of workout and pairs each one with a few minutes of meditation. Until a few months ago, she would attend regular classes for Zumba and aerobics, but now she works out by watching sessions on YouTube and TV.</p> <p>&nbsp;</p> <p>As of now, she is practising Zumba and will continue with it until the end of next month. “But if I am extensively campaigning, I limit my daily exercise quota to yoga and meditation only. Because it is easier, faster and gets me relaxing in a short span of time.” Shetty, 37, prefers everything home-made. “I don't even buy the flour from the market,” she says. “We get the grains and powder them at home and then use it to make the dough. Same with condiments, too. I am obsessed about it.” So, how does she manage her food while campaigning? “There, my choices are extremely limited—egg whites, sprout salad, buttermilk, coconut water and juices,” she explains. “If I am really hungry and there is no option, I would opt for the local food. But surely not the processed junk,” says the mother of two.</p> <p>&nbsp;</p> <p>Her present fitness goal, she says, is to maintain her energy levels through the day.</p> Sat Apr 20 12:18:55 IST 2019 keep-an-eye-out-for-eschar <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>Across the world, rickettsial infections are re-emerging. In India, they are reported from Maharashtra, Tamil Nadu, Karnataka, Kerala and Jammu and Kashmir. Scrub typhus is an acute febrile illness, caused by Orientia tsutsugamushi (a bacteria), which is transmitted to humans by the bite of a chigger (the larval trombiculid mite). Agricultural labourers, especially rice farmers in endemic regions, are known to have a higher risk for developing scrub typhus.</p> <p>&nbsp;</p> <p>Scrub typhus is an important cause of acute undifferentiated fever in southeast Asia. The onset of the disease is characterised by fever, headache, myalgia (muscle pain), cough and gastrointestinal symptoms. Patients often present with fever of unknown origin. The presence of an eschar (scab at the site of the bite)—seen in about half the patients with proven scrub typhus infection and usually found in the armpit or groin region—is characteristic of scrub typhus.</p> <p>&nbsp;</p> <p>About a third of patients admitted with scrub typhus have evidence of complications such as respiratory failure, circulatory shock, acute renal failure or hepatic dysfunction or haematological abnormalities. Since the symptoms and signs are nonspecific and resemble those of other tropical infections like malaria, enteric fever, dengue or leptospirosis, appropriate laboratory tests are necessary to confirm the diagnosis.</p> <p>&nbsp;</p> <p>In view of a low index of suspicion, nonspecific signs and symptoms, and absence of widely available sensitive and specific diagnostic tests, these infections are notoriously difficult to diagnose.</p> <p>&nbsp;</p> <p>Treatment is easy, affordable and often successful with dramatic response to antimicrobials, with timely diagnosis.</p> <p>&nbsp;</p> <p><b>Kaneria is consultant, infectious diseases and tropical medicine, Jaslok Hospital and Research Centre.</b></p> Fri Mar 29 15:19:23 IST 2019