Dr Swati Goyal

CORONA VIRUS: Hype or Hope?

The recent flare-up of an infectious, novel type of COrona VIrus Disease — notoriously known as COVID19— has triggered global panic and concern owing to its “fast and furious” outspread without any cure or vaccine to curb the menace. Apprehension and restlessness constitute a basic human instinct with a knee-jerk reaction to any danger, especially when it is unheard-of.

The upsurge of social media and the infodemic of baffling statistics is adding fuel to the fire.
All we need to do is to get down to brass tacks, take few precautions, and lessen our anxiety.

To begin with, the viruses are microscopic organisms that exist almost everywhere on earth. Usually, viral infections cause mild symptoms. But sometimes a virus can cause pestilential disease, which may prove fatal to some. These emerging and reemerging pathogens are universal challenges for public health.
Coronavirus — named so because it has crown-like projections on its surface and corona in Latin means crown — is attempting to gain a foothold all over the world. Due to mutations, some forms of Coronavirus are terrifically communicable and possibly lethal and have hence been declared a global health emergency by the World Health Organisation (WHO).

Brief history

Six coronavirus species are known to cause human disease. Four viruses — 229E, OC43, NL63, and HKU1 — are prevalent and typically cause common cold symptoms even in immunocompetent (individuals with a sound immune system) individuals. The two other strains — Severe Acute Respiratory Syndrome coronavirus (SARS-CoV) and the Middle East Respiratory Syndrome coronavirus (MERS-CoV) — have been associated with deadly illness sometimes. SARS-CoV was the pathogen culpable of the severe outbreaks in 2002 and 2003 in China. MERS-CoV was the causative agent for grave respiratory disease outbreaks in 2012 in the Middle East. Being zoonotic in origin, these viruses spread via animals to humans. In the case of this new coronavirus (SARS-CoV2), some of the common carriers are bats; however, it is complicated to discern the animal from which a coronavirus infection started disseminating initially. The preliminary reports from China associated the outbreak to a seafood market in central Wuhan.

Symptomatology and mode of transmission

The mode of transmission — like other viruses — is via respiratory droplets of an infected person while coughing or sneezing. It may enter our body mainly through the mucosa present at mouth, nose or eyes after touching the surfaces contaminated with viruses. The symptoms may range from mild, flu-like symptoms with fever, cough, sore throat, and chest discomfort to progressive, severe disease with pneumonia, respiratory failure, and may prove fatal. WHO officials also pointed out that a runny nose is not usually a symptom of COVID-19. As per studies, the good news is that the virus is being kind to children, but that’s still the million-dollar question, and we can’t take chances with children.
The high-risk category experiencing severe illness due to a SARS-CoV-2 infection are older adults and individuals who have other debilitating health conditions with compromised immune systems.

Diagnosis

Real-time Reverse Transcriptase Polymerase Chain Reaction (RT-PCR) tests for COVID-19 nucleic acid using nasopharyngeal swabs.
Identification of the virus in the bronchoalveolar-lavage fluid.
Chest X-ray and HRCT (High-resolution CT scan) of the chest.

Management

Antibiotics won’t work against the virus. Antiviral drugs mainly slow down the progression of the disease. The vaccine will take time and is at least a year away.

Standard recommendations to avert the infection spread

Regular handwashing with soap and water.
Use alcohol-based sanitizers and avoid touching your face.
Cover the mouth and nose while coughing and sneezing. Cover it with your elbow bent instead of hands or better with a tissue and discard the tissue in a closed bin.
Namaste (folding hands)/elbow bumps/foot shakes instead of handshakes.
Thorough cooking of meat and eggs.
Avoid close contact with anyone showing flu symptoms.
Wash your hands before putting on a new mask, dispose of the mask appropriately and clean your hands once again after removing it. Mask should be tightly secured over the mouth and nose.
Avoid visiting crowded places
Keep your house well-ventilated and clean.
Avoid unnecessary travel.
Boost your immunity by eating healthy, exercising regularly, and meditation.
Rest and avoid overexertion, if you get infected with any flu.
Keep yourself well hydrated
Symptomatic treatment for fever and aches.

Panicking and hoarding of surgical/ N95 masks, gloves, sanitizers, respirators, etc. leave doctors, nurses, and other frontline workers alarmingly ill-equipped to care for patients apart from exposing the healthcare workers to this lethal virus. Governments must act expeditiously to increase the supply and facilitate export without restrictions.

Maybe what we are experiencing is just the tip of an iceberg with only a few exposed cases and a more substantial chunk of asymptomatic carriers who are spreading the infection. If Lady Luck is at our side, ushering of warm weather, proper ventilation, less assemblage of the crowd may reduce the risk of transmission of this calamitous virus. However, as per research, its infectivity and reproducibility rate is very high in comparison to other viruses. Fingers crossed!

Is Your Liver Fatty?
Non-Alcoholic Fatty Liver Disease (NAFLD): An Emerging Public Health Crisis!!


ABC underwent abdominal sonography as a routine yearly checkup and was diagnosed to have grade one fatty liver.

XYZ had a fatty liver in old scans, but he thought nothing of it since he was in good health. It wasn't until a few months ago that he reached a critical phase and his health started to go downhill. The 70-year-old got ascites (fluid in the abdomen), varices (swelling of veins, a type of blood vessel) in his esophagus (food pipe) and severe muscle cramps. Two to four months later, he was diagnosed with liver cancer in a tertiary care center. He was flabbergasted and horrified as he has never had even a drop of alcohol or any sort of addiction in his lifetime.

So, it's the real kick in the teeth of the teetotalers when it comes to liver disease. They don't seem to be safeguarded from this ailment. Incidence of NAFLD (Non-Alcoholic Fatty Liver Disease) is exceeding bounds with an ominous number of young people getting afflicted by it. Though alcohol precipitates the morbidity and mortality due to liver damage, NAFLD is emanating as a reason for disquietude.

The ballpark estimates of an imaging-based prevalence of NAFLD seems to be around 25%, that is approximately 2 billion individuals globally have this disorder! Besides, it is emerging as one of the most notorious causes of chronic liver disease and hence the liver transplantation worldwide. However, its progressive up surging nature is a matter of great concern warranting the contemplation of general and specialist medical practitioners, researchers, and policymakers.

First of all, we need to familiarize about the liver and its functions. Liver, the body's largest gland and the largest solid organ, weighing around 1.5 kilograms, sits on the right side of the belly usually and is the only organ that possesses the capacity to regenerate after any chemical/ surgical injury. It has multiple functions, including removing toxins from the bloodstream, processing nutrients, balancing proteins, fats, and sugars in the blood, destroying old red blood cells and disease-causing agents, producing chemicals, regulating cholesterol and digestion and so on.

Now we need to wrap our heads about NAFLD

Non-alcoholic fatty liver disease (NAFLD) is an umbrella term for a spectrum of liver ailments ranging from milder fatty liver to steatohepatitis to cirrhosis, affecting people who drink occasionally or are stone-cold sobers.

• Level 1: Simple fatty liver (simple steatosis, NAFLD) - When the liver has excessive fat of more than 20-30% without any significant inflammation, tissue damage, or scarring. The majority of people are in this stage, and usually, do not develop any severe liver damage.
• Level 2: Non-Alcoholic Steatohepatitis (NASH) – Few patients develop a tad more grave condition in which the liver gets inflamed and swollen along with fat deposition. It can progress to liver fibrosis/cirrhosis.
• Level 3: Fibrosis/ Cirrhosis - Some people with NASH can develop scarring of the liver called fibrosis. It gradually replaces healthy liver tissue and can lead to further liver damage. The most severe stage is when the entire liver gets shrunken, turns hard and is replaced with bands of scar tissue. Over time, this ensues the loss of liver function, fluid buildup in the abdomen (ascites), swelling of veins in your esophagus (esophageal varices) which can rupture and bleed, confusion, drowsiness and slurred speech (hepatic encephalopathy), liver failure, and even liver cancer (hepatocellular carcinoma)

The disease initiates with an aberrant accumulation of triglycerides (the type of fat/cholesterol) in the liver advancing to NASH, a progressive condition which can damage the liver by causing cirrhosis and liver cancer and emerges as the most common indication for liver transplantation. Further aggravating, signs of the disease are asymptomatic, so a person often is not diagnosed with NASH until it advances to a late stage, when cirrhosis begins to wreak havoc in the body.

Risk factors
Apart from genetic susceptibility, certain modifiable risk factors like sedentary lifestyle, central obesity, hypertension (high blood pressure), diabetes (high blood sugar), intake of certain drugs, hyperlipidemia or dyslipidemia (abnormal blood lipids) are the predisposing variables.

Symptomatology
Fatty liver disease usually has few symptoms, and many people who have it are not aware of the ailment. Symptoms include fatigue, abdominal discomfort in the right upper quadrant, poor appetite, physical weakness, severe tiredness, weight loss, yellowing of the skin or eyes, spider-like blood vessels on the skin, itching as per disease progression.

Diagnosis

• Mildly raised LFTs (Liver function tests)
• Altered lipid profile with increased triglycerides and LDL (bad cholesterol) with low HDL (good cholesterol)
• High Uric acid
• Increased ferritin and transferrin saturation
• Serological markers
• USG - Hepatomegaly (enlarged liver size). Fatty liver with raised echogenicity of varying grades
• Fibroscan, a non-invasive method to assess the stiffness of the liver via the technique of transient elastography
• But the only way to be conclusive that fatty liver disease is the sole cause of liver damage is with a liver biopsy which involves getting a tissue sample of your liver with a needle to further study under a microscope.

High prevalence of NAFLD in kids especially the ones who are overweight, is tedious and an arduous task for a doctor to manage as it entails certain dietary restrictions and lifestyle adjustments — and that has to kick off at home.
As for any ailment, awareness is pivotal and fundamentally, the starting point in prevention. Surprisingly, a more significant number of the general population remains incognizant of this silent yet perplexing and vexatious disease. Besides, there is a dearth of patient awareness and enlightenment curriculums. Recent study data revealed that more than three-quarters of the general population had never encountered the term NAFLD.

While simple fatty liver itself is not perilous and is reversible if diagnosed early. Currently, there is no validated therapy for fatty liver, only the promising lifestyle strategy with few modifications can help assuage this overwhelming disastrous ailment. The primary prevention of NAFLD mandates the weeding out of the incumbent risk factors like central obesity, metabolic syndrome, and insulin resistance. It involves:
• Regular moderate-to-vigorous exercise
• A balanced low-calorie diet with

Compilation of my fb articles with few additional topics in the form of book.

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Food Colours: Terrific but Terrifying!
A Rainbow of toxic concoctions!


With the terms ‘healthy food', ‘diet' and ‘exercise' constituting a substantial part of our very existence, we are with or without our cognizance engrossed in the vogue of leading a healthy life. Nonetheless, there are few ways deleterious toxins intrude in our body furtively—through additives.

Additives are defined as non-nutritious substances which are added un-intentionally to food, usually in small quantities, to enhance its flavour, texture, appearance and storage. First category additives are generally considered relatively safe and include natural colouring agents (saffron, turmeric), natural flavouring agents (vanilla), preservatives (sorbic acid, sodium benzoate) and acidity imparting agents (citric acid, acetic acid). Second category additives constitute contaminants through packaging, processing, farming (pesticides) or environmental conditions and other chemicals like anticaking agents, antifoaming agents, artificial sweeteners, enzymes, emulsifiers, emulsifying agents, flavour enhancers, modified starches, phosphates, thickening and jellying agents, stabilizers etc. Unrestrained/ indiscriminate use of such food additives may pose health hazards among consumers.

Saccharins and cyclamates are weak urinary bladder carcinogens though the risk is low. Potassium bromate – the food additive in bread that increases dough strength – and potassium iodate – a flour treatment agent – are also considered carcinogenic.

Ajinomoto "essence of taste", the trade name for MSG (Mono Sodium Glutamate), a chemical flavour enhancer, causes headaches, depression, dizziness, mood swings and is a neurotoxin. Benzoic acid – used as an emulsifier, stabilizer and thickener in cream, butter, mayonnaise and ice cream – is known to cause neurological disorders and skin allergies.


Adulteration
Some examples of the addition of unwanted and unsafe substances in food items are as follows:

Whole spices: Dirt, dust, other seeds
Chilli powder: Brick powder, salt powder or talc powder, lead pigments
Ghee/butter: Vegetable ghee, animal fat, mashed potato, sweet potato, etc.
Ice cream and beverages: Saccharin
Honey: Jaggery, sugar syrup
Cereals and pulses: Chalk powder, stone chips

Food processing
Recent technology has revolutionized food processing chemicals to extend the shelf life of, upgrade the taste of, and to alter the texture or colour of food. But all this progress is at the expense of our health as it involves inimical processes like exposure to high temperature, production of nitrosamines (responsible for certain types of stomach cancers) and Polycyclic Aromatic Hydrocarbons (PAHs), oxidation, polymerization etc.

Food colourants
Dynamic ways of life throughout the entire world have metamorphosed food consumption patterns. It may be the whirlwind urban sprawl, societal changes and their repercussions, the general inclination towards eating out, the boom of foreign travel, the burgeoning demand for pre-packaged food or other modern technological advancements which have led to the use of a variety of colours, even in our day-to-day foodstuff.
Adding colours to food can make them look a lot more fascinating and irresistible – a tactical gambit the food industry has been exploiting on for decades!

Would your children rather eat dull brown cereal or the flamboyant many-hued variety? Are you more allured to pay for a bright red confectionery or an off-coloured one?

These rainbow-colored appetizers at your city cafeterias and shops may stimulate and entice your visual and gustatory senses, but be cautious of what you eat as risk abounds in most of them in the form of a camouflaged toxic concoction. All this is done to mimic a colour that is discerned by the public as natural – such as adding artificial blue, green, red, yellow colour to sweetened water in the name of fruit juices without any actual fruit in them, orange colour to candies, Kurkure and orange cheese puffs, reddish pink colour to strawberry flavoured items which would otherwise be in the dull shades.

Conventionally, natural colours like chlorophyll, caramel, carotene etc. and spices like turmeric, pure red chilli powder and saffron were used both for the colour and flavour, but nowadays non-permitted colours are being capitalized on to jazz up most of these savouries.

The deficit in availability and the high price of natural colouring materials, and hitches in including these in the current technology of food processing and packaging that appears appealing to kids and convenient to busy parents have resulted in the sea change use of synthetic food dyes. The dismaying revelation is that the extensive rampancy of unscrupulous practices – like chemical colouring agents that are used by sewage industries to detect the leaks, colours used to dye our clothes or some colours that are used during the Holi festival are being mixed with the ingredients to advantageously do the trick and vibrantly brighten up the much-publicized trade names. Further perturbation is regarding the addition of colour to foods that may not contain a label such as in gravy preparations, starters, desserts and other restaurant take-home preparations. Majority of candy-floss, sugar toys, beverages, sugar syrups, fluorescent blue/green juices, mouth fresheners, bakery samples, drugs and cosmetics exceeded the prescribed limit of permitted colours and contain non-permitted ones too.

Synthetic colours like erythrosine, carmoisine, ponceau 4R, indigo carmine, brilliant blue, blue FCF, fast green FCF, tartrazine, sunset yellow are permitted though with maximum permissible levels of 100 ppm.
Some examples of artificial colorants that are being preferred due to their high coloring capacity and inexpensive nature are as follows:

Rhodamine, a chemical giving bright red or brown color is used to make sev and laddoos. A study revealed that Rhodamine B, used in Chili powder (relished by us in various gravies, pav bhaaji etc) is carcinogenic and could cause cancer of the intestines.

Malachite green is used to brighten up the green vegetables, shelled peas or chips before frying them. When the artificially coloured peas are soaked, the water turns green.

Metanil yellow, a non-permitted coal tar colour, often mixed with gram flour for making pleasing crimson bhajjis, bondas or crunchy savouries – damages our nervous system.

Auramine, yellowish orange in colour used in various sweets, damages liver and kidney.

Lead chromate with its vivid yellow colour is added to turmeric powder.

Red lead is added to colour cheese and confectionary

Copper arsenite to colour the used tea leaves for resale.

Sudan III &IV (reddish orange), Orange II used in chilli tomato sauces are also noxious, affecting our nervous system including our eyes.
Meat industry keeps the raw meat packaged in carbon monoxide which gives it a bright red colour and artificially fresh for almost a year. Nitrates and nitrites are used to kill bacteria and give the meat a pink or red colour.

Astaxanthin is used to keep the flesh of farmed fish pink, no matter how diseased their bodies are.
Erythrosine inhibits iodine uptake, resulting in goitre.

Few examples I could jot down are just a drop in the ocean compared to the list of toxic chemicals we feast on almost daily.

The number of dyes with known or suspected genotoxic or carcinogenic properties has been shown to be added illegally to foods, residues of which take almost a month to leave the body. Children are the most susceptible ones. From the mild irritation or stomach upset to intestinal cancer, all of us are vulnerable to an alarming range of health hazards. Food producers use the cheapest of ingredients and additives with loads of side effects and toxicity, at both medium and long terms, like allergic reactions varying from urticaria to dermatitis, angioedema and exacerbation of asthmatic patients after consumption of non-permitted food colours along with behavioural and neurocognitive effects. They have always been under suspicion as possible carcinogens in their long term effects. The safety of commodities containing synthetic colours has been a contentious issue for decades – antagonists proclaiming of their toxic, cancer-causing nature and accusing the food colourants as contributors to ADHD (Attention Deficit Hyperactivity Disease).

The dearth of data worldwide, especially in developing countries, on the consumption of processed food to which additives including colours are added is a serious matter with far-reaching implications. Failure to enforce the laws stringently in spite of regulatory provisions precipitates the use of unpermitted industrial dyes and the excess of the permitted statutory limit. The need of an hour is to implement robust monitoring programs based on reliable detection methods to assure safe food free from harmful colours.

* The nature and quantity of additives should be clearly printed on the label.
* One should buy only the packed permitted colours, certified by BIS (Bureau of Indian Standards) in
India.
* WHO & FAO (Food and Agricultural Organization) created an international commission Codex
Alimentarius to work out the application of food additives. However, this is not legally bounding to date.
* Try to stick to whole processed foods.
* Avoid artificial colours and include the diet rich in natural colors like red, green and yellow bell peppers, purple eggplant, blueberries, rainbow chard, spinach juice, parsley juice, carrot juice, beetroot , pomegranate, cranberry juice, grapes, saffron, orange juice, cocoa, cinnamon, activated charcoal powder; just to name a few.

Immensely controversial topic with discrepant opinions, consideration of some food dyes safe in one country, but banned from human consumption in another, make it complicated to make up one's mind about their safety. Having knowledge of these perilous facts doesn't make it less parlous, one will have to be mindful and more vigilant to ensure their avoidance absolutely.
So next time, keep an eye out for synthetic colours as well along with the calories and nutrients in your meal.

DIABETES MELLITUS

One of the most diabolical and monstrous lifestyle diseases!



Diabetes, a diversified assemblage of diseases, identified by hyperglycemia, basically is a long term disease with variable clinical manifestations and progression.

Pathophysiology

Glucose is the main energy source for our body cells. Faulty production or action of insulin, a hormone produced by pancreas that controls glucose metabolism is considered as the intrinsic abnormality resulting in diabetes.
After eating food when the blood glucose surges, insulin is released from the pancreas to normalize the glucose levels. In patients with diabetes due to absent or insufficient production of insulin, glucose levels are not being normalized leading to hyperglycemia.
In ancient history, diabetes was known as madhumeha or honey urine as the urine attracted ants.

TYPES

Type 1 diabetes mellitus (IDDM) - Insulin Dependent Diabetes Mellitus.

It is usually hereditary and severe form with the usual onset in < 30 years of age group. Normally circulating insulin is almost absent entailing the need of exogenous insulin in an injectable form.

Type 2 (NIDDM) - Non Insulin Dependent Diabetes Mellitus

In type 2 diabetes, our body can make insulin but is not utilized by cells properly. Frequent, though is often discovered by chance due to gradual onset mainly in middle aged and elderly, is usually caused by unruly lifestyle.

Impaired Glucose Tolerance (IGT)
It is an intermediate pre-diabetic state between diabetes mellitus and normalcy which is usually diagnosed by oral glucose tolerance test (OGTT).


Secondary diabetes – due to
Malnutrition
Any illness/ infection lowering the immunity
Medications
Stress- emotional/ due to surgery



Gestational diabetes mellitus (GDM)
It is a condition in which women exhibits high blood glucose levels during pregnancy, though she was normal before, evincing high likelihood in overweight females with family history of diabetes.

Off springs of diabetic mothers are heavy at birth (>4 kg) with the propensity to develop obesity and type 2 diabetes mellitus at early age.

High risk group includes

• Mothers > 40 years of age (late pregnancy)
• Family history
• Obese women
• Women with baby weight > 4 kilograms
• Excessive weight gain during pregnancy
• Patients with premature atherosclerosis (deposition of fat and hardening of blood vessels)



Insulin resistance syndrome
In centrally obese patients with type 2 diabetes mellitus due to genetic defect producing insulin resistance -- high glucose and insulin levels in blood, altered lipid levels, hypertension result in coronary artery disease and stroke.
In some instances obesity reduces the number of insulin receptors on target cells. Voluntary weight loss improves insulin sensitivity and has shown to reduce the risk of progression from IGT (Impaired Glucose Tolerance) to type 2 diabetes mellitus.

Diabesity (Diabetes + Obesity) has become a global health infirmity troubling zillions of people worldwide.


Etiology

Apart from genetic propensity, there are modifiable risk factors blameworthy for diabetes

• Central obesity/ high waist circumference
• High Blood pressure
• Altered Blood lipids levels (Dyslipidemia)
• Smoking and alcohol consumption
• Sedentary life style due to lack of exercise
• Irregular sleeping patterns
• Increased intake of unhealthy food, saturated fat intake
• Stress- surgery, trauma or any other stress may "bring out" the disease
• Malnutrition in childhood
• Air pollution
• Low vitamin D levels
• Patients with PCOD and Thyroid problems also have an inclination for diabetes though sometimes they are not resilient.



Heap of deleterious risk factors presents pestering vignettes of the way how opulence and deep pockets are trading off with our health!



Symptomatology

• Frequent urination (Polyuria)
• Excessive thirst (Polydipsia)
• Excessive hunger/appetite (Polyphagia)
• Weight loss
• Frequent infections of the skin, va**na, urinary bladder etc.
• Fruity/ sweet breath
• Tiredness and drowsiness
• Loss of sensation of skin especially feet due to defective circulation (foot ulcers)
• Slow healing wounds and reduced resistance to infection



Complications

Diabetes, often contemplated as a silent killer, wreaks havoc in our bodies without us knowing it.
It takes a severe toll on almost all the crucial body parts ensuing following complications-

• Coronary artery disease (heart disease)
• Stroke (damage to brain due to interruption in blood supply)
• Diabetic retinopathy due to damage to blood vessels of the retina (inner membrane of eye) eventuating visual disturbances and ultimately the blindness. To delay the complications leaked blood vessels can be sealed using laser.
• Diabetic renal (kidney) disease – presenting with micro albuminuria, macro albuminuria, impaired GFR (Glomerular Filtration Rate)
• Limb amputation (severe diabetes ensues gangrene eventuating the need to remove toes, fingers or any other body part)
• Diabetic neuropathy (afflicts all the nerves in the body)
• Cognitive decline
• Peripheral artery disease
• Acanthosis nigricans – few insulin sensitive areas like armpit, groin, behind the neck become dark when the body develop resistance to insulin
• Erectile dysfunction


Sad to relate, there's still skimpy cognizance regarding the substantial magnitude of the sugar problem, forbye the existing interventions for managing diabetes and its complications, among the commoners.

Flaws in primary health care systems which are not formulated to surmount the additional challenges posed by this awful chronic non -communicable disease eventuating disappointing detection of cases, suboptimal treatment, piteous follow up and hence the redundant disabilities, dreadful complications and early death.




Glycemic index (GI)

Glycemic index ranking of carbohydrates on the scale from 0-100 according to the extent to which they raise blood sugar (glucose) levels two hours after eating.

Foods with a high GI (> 70) are those which are rapidly digested, absorbed and metabolized resulting in marked fluctuations in blood sugar levels.
GI increases with ripening of fruits, over cooking and processing of food

Low GI foods (