|HEALTH TRIBUNE||Wednesday, May 22, 2002, Chandigarh, India|
Diabetic nephropathy : the ever-rising burden
AYURVEDA IN PUNJAB—II
Air travel : problems
to be anticipated
IF you wish to earn a lot of money, you will not be able to avoid frequent air travel due to the globalisation of trade and commerce. More and more people are now undertaking journeys by air for business and pleasure. It is therefore, important to examine its implications for health.
The jet lag: We have a biological clock, one of the many, in our bodies which regulates our sleep. That is why we feel sleepy around the same time every day. Sometimes this clock is disturbed and disrupts this 24-hour cycle. Environmental factors are usually responsible, and an important version of this disruption occurs in international travellers going long distances due to rapid changes of time zones from country to country. Our biological clock is normally synchronised with the day-night cycle of the home country.
While a gradual change in the environment does produce a gradual change in the timings of the internal clock, a sudden change can bring about a disturbance. Such a change occurs on long-distance high-speed flights. While flights crossing more than three time zones can confuse this clock, real problems arise after air journey with 8 to 12 hours time difference such as would occur when you fly from New Delhi to New York.
You feel fatigued, both physically and mentally. You may be confused and depressed. You may want to sleep when everyone else is starting the day. This is called "jet lag". Initial adjustment is, therefore, necessary before you can attend to your business satisfactorily. Any method for reducing jet lag symptoms involves resetting your biological clock with the watch on your wrist. A simple method is described below.
* If you are going to travel eastwards, i.e. Hong Kong and Tokyo, try sleeping earlier than usual for a few days before your departure. Conversely, if you would be travelling westwards, i.e. London or New York, stay up late.
* Immediately on entering the plane, set your watch to the time of the new location and adopt the sleep-wake cycle of that place in the plane itself.
* Remove your contact lenses if you are wearing any.
* Do not eat heavy meals on the day of departure or in the plane.
* Take plenty of water (not tea, coffee or cola) to counteract dehydration which tends to occur in the plane environment.
* Do not consume alcoholic drinks in the plane or on landing. This increases the chances of a hangover; the cabin pressure reduces the ability of the liver to metabolise alcohol.
* Avoid caffeinated drinks (tea, coffee, cola) for the first your biological clock.
* Avoid sleeping pills; they delay the adjustment process as they do not provide natural sleep.
* Avoid sleep during the day. If you must sleep, avoid a nap of more than one hour.
* Sunlight plays a major role in the synchronisation of your internal clock with the external; hence spend time outdoors sight-seeing on the first few days.
* Your biological clock will not change instantly, but if you follow the above suggestions and help yourself to synchronise with the day-night cycle of the host country, you will most likely feel less tried and depressed on the second day and adjust by the third. All serious business can then be safely transacted. Till then have a nice time sight-seeing.
Other problems: The loss of atmospheric pressure at high altitudes at which the aeroplanes fly usually poses no problem because the modern aircraft is pressurised. However, the pressure is usually lower than the one obtaining at sealevel. This can create difficulties if you have a heart problem. You may need extra oxygen, for which arrangements will have to be made with the airline and you may be required to undergo a medical test.
The main problems which you have to deal with are the cumbersome, sometimes distressing formalities of immigration and customs at the airports of entry and exit. The security checks have become very cumbersome and are likely to be further tightened in view of the increasing terrorism. Other problems which may arise are due to conditions prevailing at the airports which cannot always be visualised before embarking on the trip, such as the necessity of carrying heavy luggage because trolleys or porters are not available, and problems of food and rest.
When you should avoid air travel: All the problems mentioned above make it necessary to ensure that you are in good health before embarking on the air journey, particularly international. If you have had a health problem such as a heart attack, a domestic flight may be undertaken a couple of months after full recovery, but it may have to be much longer, almost a year, before you can be considered fit for international travel. You must consider the fact that tolerance to undergo privation and inconvenience as a result of long-distance travel is lowered after any serious illness. If after a test flight you do not feel too well, you should avoid such journeys in future till you have fully recovered. Tolerance also decreases with advancing years. If you are an elderly person, you will do well to travel in the company of healthy younger person (s).
Diabetic nephropathy : the ever-rising burden
DIABETES mellitus is a group of metabolic disorders characterised by raised blood sugar levels (hyperglycaemia) resulting from defects in insulin secretion, insulin action or both. Diabetes mellitus is generally classified into two main groups. Type 1 (also) called insulin-dependent diabetes mellitus or IDDM is due to absolute deficiency of insulin in the body and therefore insulin treatment is essential to maintain life in this group. Type 2 (also called non-insulin-dependent diabetes mellitus or NIDDM) is late onset, responds to diet/exercise or oral anti diabetic drugs, and insulin though not necessary to maintain life, may be required to control hyperglycaemia.
There is a rapidly spreading epidemic of Type 2 diabetes in India. It is projected that by the year 2005, there will be 30-35 million diabetics in India, the highest number of diabetic population anywhere in the world. Diabetic patients now have a better chance of being diagnosed and referred to specialised clinics for treatment. Clinics are, therefore, now flooded with diabetic patients. Diabetes is an expensive disease because of its many complications affecting almost every system in the body.
Diabetic nephropathy or renal involvement due to diabetes mellitus has become the leading cause of end-stage renal disease (ESRD) accounting for as many as 35-40% of the cases. During the course of their illness, 35-40% of the diabetics develop this complication. In type 1 diabetes, most of the patients are detected to have clinical nephropathy 10 to 15 years after the onset of diabetes whereas 8 to 10% of type 2 diabetics are found to have nephropathy at the time of diagnosis.
Once diabetic nephropathy sets in, there is relentless progression to end-stage renal disease (ESRD) when the patient’s survival is dependent upon regular dialysis or a successful kidney transplant. Both forms of treatment are very expensive and beyond the reach of a large majority of the population. Therefore, every effort must be made to prevent the occurrence of renal involvement in a newly diagnosed case. Male patients, with a positive family history of renal involvement, onset of diabetes in the second decade of life and smokers are at particularly high risk of developing this complication and need careful monitoring.
The earliest clinical evidence of nephropathy is the appearance of low but abnormal levels of albumin in the urine referred to as microalbuminuria. Microalbuminuria is increased urinary albumin exertion when routine tests for protein in the urine are negative. Radio-immuno assay is the most sensitive method for microalbumin estimation but is expensive and not readily available. Immunological reagent strip (MICRAL-TEST II) gives an immediate and reliable estimate of microalbuminuria. Numerous studies have shown that without specific intervention 50-80% of the diabetic patients who test positive for microalbuminuria progress to overt renal involvement.
It has been convincingly proved by animal experimental models and the results of diabetes control and complications trial in humans that strict diabetic control with intensive insulin treatment can postpone if not prevent the development of microalbuminuria and if microalbuminuria has already developed further progression of renal disease can be slowed down. However, intensive insulin treatment is possible only if the patient monitors his blood glucose at home and learns to take appropriate action with diet, exercise and the insulin dose. Those who can afford should buy a glucometer; those who cannot, can still get good results by visual comparison of the blood glucose strips.
All diabetic patients who are found to have microalbuminuria should be treated with drugs belonging to the group of Angiotensin converting enzyme — inhibitors (ACE-I) even if they have normal blood pressure. ACE-I have been shown to abolish/reduce microalbuminuria and postpone the development of nephropathy if they are started early. They should be given in the maximum tolerated dose and their effect on the reduction of microalbuminuria should be evaluated periodically.
Whether ACE-I will be beneficial if started before the onset of microalbuminuria in diabetics who have other risk factors for the development of nephropathy is still not known. Other risk factors such as obesity, hyperlipidemia and smoking should also be controlled to check the development of nephropathy.
The incidence of diabetes and its complication, diabetic nephropathy in particular, is rapidly rising. Early detection to the patients at higher risk of developing this complication, strict blood glucose control with insulin and use of ACE-I can go a long way in checking the rising burden of this complication.
THERE are many factors which are responsible for the downhill journey of Ayurveda in Punjab. Most important of these is the education system which is rotten to the core. To impart standard ayurvedic education, the Central Council of Indian System of Medicine and Homoeopathy has laid stringent norms. However, the guidelines are hardly followed, reducing ayurvedic education to a farce.
The most glaring example of this travesty is the sole state-run ayurvedic college at Patiala. What previously was a flagship is today going through the worst phase of its history. More than half of the posts of the teaching staff are lying vacant. The majority of the teachers don’t possess an MD degree in the subject concerned and a large number of them are handpicked doctors from dispensaries having no experience of teaching. Postgraduate studies in this institution have come to a halt and no admission has taken place for the past few sessions.
Punjab has 10 privately run ayurvedic colleges; the state has double the number of the medical colleges. And the number is still increasing. The poor infrastructure, the absence of basic standards of teaching in most of them and the atmosphere are anything but academic. It is not difficult to judge the frustration of the students who, after passing the strenuous entrance tests, opt to study Ayurveda. It is amazing to see how these "colleges" hold their recognition by the Central Council of the Indian System of Medicine. Had a similar situation emerged at any medical college, it is not difficult to guess the manner in which the Medical Council of India would have reacted.
Punjab is said to have about 500 ayurvedic dispensaries. Though the salaries of the doctors and the staff in each dispensary amount to five lakh rupees annually, one is amazed to know that the average cost of medicines supplied to each dispensary per day is three rupees only. (Rs 3 per day per dispensary).
The state has a couple of government-run indoor ayurvedic hospitals where admitting the patient is a far cry. At many places the locks of the indoor departments have not been opened for years.
Call it unconcern if not callousness of the Government where not a single technical person has ever been appointed as Director of Ayurveda for the past 20 years. The lack of direction is so pronounced that despite huge overhead expenses the production of the Government Ayurvedic Pharmacy at Patiala is far less than what a village-level small and impoverished pharmaceutical unit could have done. With proper planning and professionalism the pharmacy could have earned crores of rupees for the exchequer by manufacturing, selling and exporting ayurvedic medicines.
The medicinal plant board of the state is a non-starter. Punjab could have at least learnt a lesson from the neighbouring Himachal Pradesh where a separate minister looks after Ayurveda and the state has 1,000 better maintained ayurvedic dispensaries. It has plans to venture into advanced projects like panchakarma and health tourism.
Governments have come and gone but nobody knows whether the neglect of Ayurveda in Punjab has come about by design or by chance. Poet Iqbal’s lines, "Kuchh baat hai ki hasti mitati nahin hamari" may be true for somebody somewhere but not for an exponent of Ayurveda in Punjab. History spares nobody. Somebody, for the plight of Ayurveda, its present-day exponents will also be held responsible. It is time when all of them should do some soul searching. It is not the government alone that has betrayed Ayurveda.
Dr R. Vatsyayan is an ayurvedic consultant based at Sanjivani Ayurvedic Centre, Ludhiana.