Osteoporosis

A fracture of the hip bone in an elderly person can be the proverbial last straw. We saw a friend’s mother go through it all. She used to be petite and frail and a hump (bent spine). One day she fell in the bathroom, broke her hip and became bedridden. Orthopedicians and her children, two of whom were doctors, felt scared to subject the 75 year old to surgery. She therefore lay in bed for 3 long years, fed and bathed by domestic aids. She suffered the extra misery and humiliation of depending on them for the bed pan as she could not make it to the toilet. In spite of all possible care that the family could provide, she developed bed sores. Her recent death was perceived by many as liberation from her painful hopeless state.

Each year, there are an estimated 500,000 spinal fractures, 300,000 hip fractures, 200,000 broken wrists, and 300,000 fractures of other bones.  About 80% of these fractures occur from relatively minor falls or accidents, and are caused by osteoporosis. The stats in India are scary: one of three women above 45 has bones that are fragile and weak ,with 30 million people estimated to be suffering from this condition.

Osteoporosis usually causes no symptom and hence goes unrecognized, till a bone, usually the hip or the spine, cracks or breaks often with very minor trauma or fall. "With every major osteoporosis fracture, the risk of death doubles. Yet it is not taken seriously the world over," says Professor John Allan Eisman, Director, Bone and Mineral Research Programme, Garvan Institute of Medical Research, and Professor of Medicine, University of New South Wales, Sydney.

There are 3 factors that keep bones strong and healthy: adeqaute quantities of calcium, Vitamin D and regular exercise.

Calcium, as we all know, is present in in fish, milk and dairy products. For calcium to be absorbed form the gut and deposited in bones, comes the role of Vitamin D. While adequate exposure to sunshine is considered to ensure abundant supplies, it is paradoxical that 70% Indians are found to be deficeinet in this vitamin despite the hot sun blazing overhead most months of the year. Recent studies have pointed out that affluent Indians, who can and usually do avoid the sun, are more Vit D deficient; manual workers exposed to sunlight rarely are.

The third factor, and perhaps the most crucial, is excercise. The bones of those who excercise regularly seem to remain thick and strong. In such short spans as a month, bones, if not put to adequate use, lose their calcium. This finding explains why  hips and legs become weak and fracture-prone in those who do not walk regularly, why women from affluent homes who travel more in cars and walk little suffer more from osteoporosis, and why the focus on treatment  in the west has moved to regular sessions of dancing or sports for the elderly. Let us then walk the miles before we sleep.

As published in HT City( Hindustan Times) dated 27 March, 2011.

Nuclear Energy: Are We Prepared?

After the accident in the nuclear energy plant in Fukushima, and the radiation leak that a nation as developed as Japan is finding helpless to contain, the uncomfortable question posing itself in our minds is “What if it had happened in India?”

While nuclear energy is “clean” and has helped meet burgeoning energy demands of many countries, its accidental leak from reactors has been a major health concern. The world had learnt  the hard way from Japan after the atom bombs were dropped in Hiroshima and Nagasaki in 1945. Nausea, vomiting, weakness, fatigue, bleeding gums and diarrhea occured soon after exposure to raditaion. Later effects included development of catarct and cancers of the thyroid gland, lungs, breast and blood. Young children exposed around birth developed leukemias and died often in their teens.

Several accidents have occured in nuclear power plants across the world, the worst being in Chernobyl (near Ukraine) in 1986. The radiation that leaked was not just huge but went undetected for quite some time exposing thousands of unsuspecting people to toxic doses. Many fell ill, developed cancers and leukemias and died painfully. What was worse is that it affected the next generation as well: maimed babies, with deformed limbs, mental retardation and heart diseases were born to mothers who had been accidentally exposed during their pregnacies. Till date 16,000 people are thought to have died due to the Chernobyl disaster.

What gives us the feelg that we are invincible and better prepared than Japan or Russia? The machine in Fukushima that broke down is the GE’s mark 1 reactor, 2 of which are already in India in Tarapur. The locations of our new and upcoming nuclear plants are on the coasts where they are vulnerable to natural disaters like tsunamis and earthquakes. Further, our high population density causes much higher loss of human lives when disasters strike. And most important: we are not, and cannot in the forseeable future, be as disaster-prepared as Japan or other developed countries.

I recall when I was in Japan 20 years ago on a fellowship, almost all buildings in the country were already “earthquake proof” and an earthquake drill was undertaken with utmost seriousness in our trainees’ centre once a week. The resuscitaion and emergency gears were checked and kept ready all the time. And no one took these drills as a joke as we tend to here in India.

Residents who have dwelled in and tilled the lands around proposed sites like Jaitapur or Kalpakum for generations may indeed have cause for concern with the proposed intrusion of nuclear plants in their territory. They have seen the occasional fury of the seas or felt the trembling of the land but accepted them as being beyond human control. The recent decision of our government to play with nuclear fire in their backyard may understandably be a cause of grave concern and anxiety to them.

As published in HT City ( Hindustan Times) dated 20 March, 2011.

The Comfort Factor

Why a patient feels comfortable with one doctor and not with another depends on whether the attitudes and expectations of the two match well.

In the conventional “Paternalistic attitude that doctors have sported over the centuries, it is he who decided what was best for the patient and ordered only one line of treatment that the patient  followed  unquestioningly and faithfully. Assuming a father-like role, he assessed his patient’s need, tolerance and affordabilility and “told” him what to do. Many patients still prefer this simple apprach and ask “Doctor, please tell me what I should do”.

This “paternalistic” attitude prevailed when treatments were few or none, and the doctor-patient relationship was hinged on blind faith. In present times, when treatment options are exploding and patient’s expectations escalating to dizzy heights, this appraoch is heading towards obsolescence.

In the current age of “Cafeteria Appraoch” doctors are required to place all the treatment options on the table, each with its risks and benefits, and facilitate the patient to choose from the “menu”. A typical example is to discuss with a patient of heart disease the risks and benefits of 3 treatment strategies; continuing medications alone, undergoing coronary angioplast, or a “bypass” heart surgery. Each has its unique advantages and risks, the perspective often varying from severity of disease, age, and the patient’s ability to endure the invasive procedure. A frank discussion on cost of therapy and expertice of the doctor helps the patient make a well informed choice.

Although a mathematical answer is what many doctors and patients grope for, it is often not easy to come by. How, for instance, does one weigh the small risk of death of 2% for a 60 year old man contemplating heart surgery against a 5-year survival of 85% if it goes well, when his daughter’s wedding is scheduled 6 months later?  

The onus of a decision whose outcome has gone awry is therefore now shifting from the doctor to the patient himself. As the society gets more litigant , requiring doctors to become defensive, many are finding it more comfortable, albeit time-consuming, to quote appropriate facts and figures, and leave patients to decide their own fates. However, as surgeries and procedures fetch in the moolah, doctors do inject their biases. Watch the laparoscopic surgeon deftly mention the “slight” but tangible risk of cancer developing in your gall bladder should the silent stones not be removed, or the cardiolist tell the anecdote of one of his patients who refused angioplasty last month and collpased on the golf course a week later.

Highlighting the features of a new product is easy but customer feed back, that could critically tilt the scale, is not often easily forthcoming. Appealing to the “fatherly” sentiment of the modern doctor with the question “What would you do if you were in my shoes, doctor?” often makes it easier for Indian patients to decide.

As published in HT City ( Hindustan Times) dated 13 March, 2011.

FATTY LIVER and the Heart

“Fatty Liver” that commonly finds mention in an ultrasound examination report and is often passed off as an incidental finding, may not be innocuous after all, suggest recent studies in reputed medical journals.  Japanese and European scientists have noted a four-fold increase in risk of heart disease in these patients compared to those of the same age and sex who had normal livers.

Using sophisticated techniques, doctors have found the wall of arteries to be thicker and the lumen narrower, causing reduced flow of blood to their heart muscles and brains, in these patients. Their findings support the clinical observation that those with excess fat in their livers are more vulnerable and die earlier from heart problems.

The appearance of a “bright” and swollen liver suggesting excess fat deposition is a common finding on ultrasound examination. While it is commonly seen in drinkers, it is often seen in tee-totallers too, and is referred to as non-alcoholic fatty liver disease or NAFLD in them. Although the risk of liver damage due to this fat is modest and occurs in only 20% when present for over 20 years, proneness to heart attacks is grossly increased.

NAFLD is usually associated with obesity, diabetes, hypertension or high amounts of circulating fats in the blood, and is often called a “Life Style Disorder”. Lack of adequate exercise and consumption of excess calories have been shown to lead to obesity and excess fat deposits in the liver.

The mechanism underlying this disorder called Insulin Reistance, is similar to that which occurs in diabetics of the Type 2 variety or the common adult type, in which patients have high circulating levels of Insulin that prove ineffective in driving sugar into cells. Insulin Resistance also causes excess accumulation of fat in liver cells, as well as thickening of arteries that cause heart or brain disease.

Regular excercise and reduction of weight form the fulcrum of treatment of this disorder. Apart from helping reduce weight, aerobic excercise up-regulates a protein (glut-4) that restores the sensitivity of cells to circulating insulin. Hence insulin and sugar levels both come down, fat gets mobilized from the liver, buttocks and abdomen, and the increased risk of heart disease is restored to normal levels.

India is in the eye of an emerging global epidemic of diabetes and heart disease. While our genes may be partly accountable for our misfortune, the greater share of blame lies in our reluctance to exercise regularly. While vagaries of weather and unsafe roads may come as handy excuses, we Indians, more than any other race, need to shake off our laziness and indulge ourselves in far more and regular exercise than what we are doing at present.  And we need to start quite urgently if we need to live longer and healthier lives.

As published in HT City ( Hindustan Times) dated 6 March, 2011.