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How does underlying Cirrhosis influence Covid-19?

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Experts recommend treatment and follow-up care for people with chronic liver disease.

Chronic liver diseases are common worldwide, especially in developing countries. The rapid spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)/(COVID-19) leads to the infection of many patients with underlying chronic liver diseases. To discuss about the same, we interviewed Dr. Shiv Kumar Sarin, Director of Institute of Liver and Biliary Sciences (ILBS); Dr. Anil Arora, Chairman, Institute Of Liver Gastroenterology & Pancreatico Biliary Sciences Sir Ganga Ram Hospital and Dr. Kaushal Madaan, principal director and head of Hepatology from Max chain of hospitals.

Question: Since there is a lot fear among people as far as Covid is concerned, how should a liver patient, someone who perhaps has fatty liver, liver cirrhosis, how should they go about their regular checkups? Should they visit hospitals? Should they consult you all over? What are they supposed to do?

Dr. Sarin: First of all we should know that liver is located on the right side of the body and weighs a kilogram and a half. It is one of the largest organs in the human body. If you put a lot of stuff on the liver, then it is not a healthy liver. If there is extra fat for too long, the liver will shrink and it may become fibrous, discard and late stages of cirrhosis.

Question: Those who already perhaps have these diseases, they also have a lot of apprehensions as far as their regular checkups are concerned, because that’s also extremely important for them. Should they skip it as of now, should they visit hospitals, or should they stick to video consultation? What would be your advice to those who already have liver diseases, but perhaps don’t have Covid, have an anxiety or fear of Covid in the back of their mind.

Dr. Sarin: Those who have fatty liver certainly are not having the disease. Fatty liver itself is just extra fat. But if somebody has cirrhosis and he knows somebody who has got alcohol liver injury or has cancer, they all require treatment and monitoring. So don’t put it away. Treatment for all liver diseases must be given and should not be delayed. Treatment is essential whether you use a teleconsult or go to the hospital. What you can do at home is, of course, continue your own diet and the prescription that the doctor has given.

Question: We all know that because of the fear of Covid, there is a lot of concoction of medicines which many of us are consuming already. There are alternate medications that many people are taking. There were reports that Giloy could cause some liver damage, then later there were reports no it doesn’t do that.

What would be your stand on this alternative medication when it comes to avoiding Coronavirus or just taking these medications as a precaution?

Dr. Arora: Liver is an organ that does not require any servicing, does not require any maintenance till you intentionally or accidentally try to injure it. You do not need any medication. You do not need a specific diet. You do not need any type of maintenance, but do everything to prevent the damage.

Two major reasons why the liver gets damaged is, if you are having too much of the calories in the diet, so initially it gets deposited in the peripheral tissue that is subcutaneous tissue, and once those stores get exhausted, it tends to get into the vital organs. The liver is a central organ for the metabolism, production and synthesis of various proteins, and integrated metabolism of fat, carbohydrates as well as proteins. It also is known to produce a number of coagulation and anticoagulation factors.

In fact, there have been excellent guidelines from CDC, from our own ICMR and the Government of India and AIIMS, which tell us that we need minimum medication. Even allopathic medicines are needed in minimum doses for a minimum duration of time. They will do more harm than good. Especially all chemicals, all ingestions, all food has to be metabolized through the liver. So anything and everything that you are taking for any purpose you have to take under the guidance of a registered medical practitioner, take it for a minimum period of time, at a minimum dose, for a minimum duration. Never self-medicate yourself.

Question: But I specifically mentioned giloy because there is a lot of debate around it. And also it’s not just giloy, but a lot of as I said ayurvedic, alternative medication which people are taking. Dr. Kaushal, would you also perhaps tell your patients to stay off this concoction of alternative medicine, medicine that claim to be herbal and perhaps give you better immunity against Coronavirus?

Dr. Kaushal: These herbal and alternative medicines, even before this pandemic of Covid started, we have been advising our patients, whether or not they have underlying liver disease, to avoid taking herbal medicines of whose ingredients we are not sure of. When this pandemic came, we realised that there were many patients who were coming into us with unexplained liver failure and liver injury and some of them had even died. Only after a few months, we realised that they were taking a concoction and the most common ingredient of that concoction in these particular patients was Giloy. In fact, you would have recently seen a publication published in an indexed journal that presented about five or six cases similar to what I have been talking about and I think all of us would have seen such cases. See, how we make a diagnosis is by the exclusion of all other possibilities. We could not find any cause and only this thing stood apart, as patients were using kadhas… I don’t know what kind of mixtures they were having, what kind of concoctions… Two times a day, three times a day, for almost a year they were having it and they landed up with liver injuries. So I definitely think that these are the culprits in such cases.

Question: Could it also affect a healthy patient, someone who has a healthy liver and they start to take alternate medication? What would be your advice to them?

Dr. Sarin: Any medicine whether allopathic, homoeopathic or ayurvedic or preparation can be harmful or beneficial. I do not know much about the homeopathic or allopathic medicines. I can certainly say that there are certain herbs that can be harmful. No medicine should be consumed without a scientifically proven safety.

Secondly, a healthy liver is a necessity for better immunity. As far as covid is concerned, the infection initially transits to the lungs and then to the liver where it finally settles. This is called bystander hepatitis. Bystander implies that whatever Corona does, harm to the liver is possible.  has severe Covid, he will have something like 70% of them will have liver enzymes being normal. In mild Covid, 10-20% will be having liver enzymes normal. Food can injure the liver, drugs which are taken, preparations that are taken, all can cause injury to the liver.

Question: Talking of drugs, there were reports that azithromycin, remdesivir, those drugs could also affect the liver, but they were widely prescribed by physicians. What would you say to liver patients? Should they stay off these drugs? And those who get serious, perhaps their families are told to administer remdesivir. What are they supposed to do then?

Dr. Sarin: So, remdesiver cannot be given to patients with liver disease. Secondly, it is not proven beneficial. So I would be very hesitant to give. Azithromycin can also give liver injury. In fact, there is no reason to give these drugs if the patient has pre-existing liver diseases. If you have read some very interesting Lancet papers, Corona was more serious in those patients who had a BMI of about 25. In India, nearly 30%, one in three people have a high BMI, they all have fatty liver. So, the disease is more common, more susceptible, injury is more progressive and liver injury enzymes being abnormal or very high. Secondly, if somebody is also mixing alcohol with Corona pills and ppl were staying home, they were drinking.

Question: Dr. Arora, I know a lot of patients, not liver patients but younger ones who are comorbid, have diabetes etc. The day they recovered, the first question they have in mind is that can I have a drink now? What would you say to those who have liver diseases, perhaps got Corona, have recovered and are craving a drink?


Dr. Arora: See drinking as a habit, when it is harmful for you, it is not recommended. If you look at our baseline population, which has non-alcoholic fatty liver disease coupled with so many metabolic abnormalities like diabetes, hypertension, these are all the risk factors that will aggravate the injury related to alcohol. Once in a while, socializing is understandable, but the problem is that alcohol is an addictive agent. If you look at the data from the US, the maximum number of cases that are being reported after cure from hepatitis is related to alcohol.

This is something that is absolutely preventable. Not only on its own it causes problems, but in patients with underlying fatty liver or those with hepatitis B or C, this alcohol is an added synergistic effect to cause further liver damage. So, unless you are sure that there is nothing wrong, you should avoid alcohol.

Question: Does Covid affect them more severely if they have liver cirrhosis? And what about those who have had a liver transplant?

Dr. Kaushal: There is ample data to suggest that patients who have fatty liver disease have a very severe lung disease when they acquire Covid. They have very poor outcomes and more of them end up in the ICU, end up with ventilatory support. Patients who are just at the stage of waiting for a transplant, are the ones who have advanced liver diseases. So, obviously, if they acquire Covid-19, they are at high risk of dying. If they have a new liver, they already are immunosuppressed. Some schools of thought say that since they are already immunossuppressed, they’re not able to mount an immunoinflammatory response to Covid so they may have mild disease. But this is a controversial issue and more and more data is coming in.

Question: Is the severity or risk of Covid a lot more once they catch it? Secondly, is the treatment for them different? Is it special treatment or they take the same medication as the general population who catches the virus? And if someone has liver disease, generally when people catch Covid, they go to general physicians. Should they also consult their liver doctor in the loop about the medications they are taking?

Dr, Sarin: If the transplant was done within the last three months, corona can be very severe, and you should act quickly. People who are on heavy immunosuppressants have rejections even after a year, and if they get a corona infection, there is a problem again. Corona does not make people worse, but they are already predisposed to other illnesses.

Liver is the root cause of diabetes and blood pressure and high triglycerides. If you have fatty liver or is obese, diabetic, is comorbid, he must look at the liver enzymes. Covid gives you all a chance to lose weight. Become healthy, lean and thin, so that unfortunately, if the third wave comes, you are strong, your liver is strong and your body is strong.

Question: What about liver patients? Once they recover, what is the post-Covid care that they need? What are the tests which are required and why would you say they shouldn’t throw caution to the wind? Perhaps why would you say that those who have liver diseases have recovered from Covid should still be cautious and should still measure their parameters? 

Dr. Arora: All those who suffer from Covid are likely to come down with something called ‘Long Covid’ There is a multitude of reasons for that. You may have a bit of virus or the immune process which may still be simmering around the body. Or you may have an immune complex disease that may be present or activation of the immune system. Now coming back to the liver, in patients with liver disease, if you have a concomitant Covid, you may have multiple reasons why the liver can get affected. It may occur because of the hyperinflammatory syndrome which comes out from the lungs and gets disseminated in the body, of which the liver gets the major share of the blood.

A number of drugs that are given to treat Covid have indirect toxicity on the liver. If you have had a recent infection, you are likely to come down with more complications. You have to regularly follow up with a liver specialist if you have underlying liver disease.

Question: what would you tell all your patients, should they go, and get vaccinated at the earliest? Perhaps it is these patients who already are susceptible, who already have compromised immunity, who need to get vaccinated at the earliest.

Dr. Kaushal: I totally agree. I feel that there is a lot of vaccine hesitancy, especially in patients who have comorbidities. Since they have an underlying disease, they have anxiety that whether the vaccine will suit them or not or whether it is going to cause harm to them. So we keep getting phone calls and patients want to ask one thing that should we get vaccinated? So answer for all of that is whether they have early liver disease or advanced liver disease, they are best in a vaccinated state. So they should all get vaccinated, whichever stage of liver they are in. Because if they don’t take and if they have advanced liver disease and if they catch the infection then definitely the outcomes are going to be worse. So one-line answer is that any patient who has any kind of liver disease must take a vaccine.

Question:  What is the post-Covid care? I would like to ask you also this question because a lot of people seem to be ignoring that.

Dr. Sarin: First, patients with liver disease have weak muscles. We call it sarcopenia. Even if they are obese, they have very limited muscle power. If your liver is weak, your muscles are also weak and after Covid there is extreme fatigue, loss of appetite. You have to work extra, be more careful about this, and get your antibodies done if you need them.

The second important thing for a patient with cirrhosis after Covid is gone is to remember that the liver can digest more fats than it can digest pure carbohydrates. So just avoid carbs. Your main diet should remain protein-based, good whey protein or something and then next, the energy source can be fat. But yes exercises are very essential. It’s very difficult for patients who have got cirrhosis and Covid.

Question: A question that comes to the mind of liver patients is that they already have compromised immunity, they may not have enough antibodies. So, is the vaccine even good enough for me? What if I don’t end up making antibodies?

Dr. Arora: If you look at the various registration trial which was conducted in both US and UK, the initial registration trial excluded patients who had chronic liver diseases or those with an immunocompromised state. In fact, there is data published on Pfizer’s registration trial which has shown that in patients who have advanced liver disease and those who had undergone liver transplantation, the chance of development of antibodies is only 20%. So not all those with the immunocompromised state will develop antibodies. All patients who have an immunocompromised state will not produce antibodies. But in case you have developed antibodies and you can be more confident that you won’t have the viral infection, do not be under the wrong impression that you have been protected. If you do not have antibodies even after vaccination, you have to be extra careful. You have to use double the precaution which a normal person uses. You just cannot move out to public places. You must be extra cautious.

Question: As we conclude what will be your one message to all the liver patients, all those who are suffering from liver diseases, one as far as prevention is concerned and two, in case they get Covid?

Dr. Kaushal: So I think in terms of prevention, I think everyone knows in the last one and a half years what they have to do in order to prevent getting Covid, that is masking, social distancing and washing hands. So that is one message which is true even for patients who have underlying liver disease. Second, they should not fear. Patients who have the early liver disease may not fear. They will have outcomes that are similar to the normal population. Only, those patients who have advanced liver disease, advanced fatty liver, obese, diabetic and post-transplant patients are the ones who need to fear and therefore need to take more precautions and they should get vaccinated as early as possible. And they should avoid like we said the herbal and these kinds of concoctions which contain unscientific mixtures of medicines that might harm the liver. So these are my messages.

Question: What would you say to assuage the fear of perhaps those who already have liver diseases and generally have a fear of Covid? We were speaking earlier of transplant as well, should perhaps people keep such procedures at bay or go ahead with them?

Dr. Sarin: Well the first message for those who do not have liver diseases is to reboot yourself. Lose weight, be careful. Only a healthy body will sustain the onslaught of any Covid infection. So be ready and be healthy. For those who have liver disease, be extra cautious. Transplants are going on and in fact, nearly a hundred have been done during the Covid era at ILBS and I’m sure at many many other centres. So please if you need a transplant, you should go, get yourself transplanted. But yes those who are not… one in a hundred gets a transplant, all other patients, 99 out 100 please be careful. Be in touch with your doctors and specialists. Do not miss your drugs and get your regular screening done. Must get vaccinated for Covid and do not let your guards down. Have Covid appropriate behaviour. You will live normally and you will pass through this Covid. Don’t be worried. But be careful, don’t make a mistake. 

Question: as far as Covid is concerned, we were speaking of course in extensive detail about managing your liver diseases, preventing Covid. Final question for those who have liver diseases, should they continue the medication which they were taking earlier or should they halt at a time when they have Covid and perhaps are taking Covid medication coz there is a lot of confusion amongst the laymen on the same?

Dr. Arora: Ya. I think almost all medication that is necessary for the management of liver diseases can be continued under the supervision of a trained doctor. That goes without saying. We have very few active Covid cases now and I am sure that doctors are good enough to know what sort of combination is safe for them. Coming on to the message that I have to give. Starting with what Dr. Sarin said about the liver on the right side, I think you should always listen to your heart. The heart is always on the left side but it is always right. So if you have learnt any lesson during this devilish perfidious second wave which has killed millions of people. If you have learnt something then have some civility, behave properly, get vaccinated and do not just move out of the house. You should remember till everybody is safe, you cannot be safe. The whole world has to get vaccinated before you can lower your guard. So listen to your heart if you have understood something from this devilish virus.

One clear message coming from all the doctors collectively here is that prevention is better than cure. Stay home. It gains all the more significance considering we have those viral pictures of people holidaying in Manali. Don’t do that. We have these doctors who are working a lot for us. Let’s keep ourselves safe.

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Medically Speaking

FASTING REQUIRED TO SEE FULL BENEFIT OF CALORIE RESTRICTION

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Over the last few decades, scientists have discovered that long-term calorie restriction provides a wealth of benefits in animals: lower weight, better blood sugar control, even longer lifespans.

Researchers have largely assumed that reduced food intake drove these benefits by reprogramming metabolism. But a new study from the University of Wisconsin-Madison researchers finds that reduced calorie intake alone is not enough; fasting is essential for mice to derive full benefit. The team published their findings in the journal Nature Metabolism.

The new findings lend support to preliminary evidence that fasting can boost health in people, as trends like intermittent fasting continue to hold sway. These human and animal studies have added to the growing picture of how health is controlled by when and what we eat, not just how much.

The research further emphasizes the complexity of nutrition and metabolism and provides guidance to researchers trying to untangle the true causes of diet-induced health benefits in animals and humans.

The researchers discovered that combined with eating less, fasting reduces frailty in old age and extends the lifespan of mice. And fasting alone can improve blood sugar and liver metabolism. Surprisingly, mice that ate fewer calories but never fasted died younger than mice that ate as much as they wanted, suggesting that calorie restriction alone may be harmful.

The research was led by UW School of Medicine and Public Health metabolism researcher Dudley Lamming, his graduate student Heidi Pak and their colleagues at UW-Madison and other institutions.

Pak and Lamming were inspired to conduct the study because researchers began to realize that previous studies had unintentionally combined calorie restrictions with long fasts by providing animals with food just once a day. It was difficult, then, to distinguish the effects of one from the other.

“This overlap of treatment — both reducing calories and imposing a fast — was something that everybody saw, but it wasn’t always obvious that it had biological significance,” said Lamming, who has long studied the effect of restricted diets on metabolism. “It’s only been in the past few years that people started getting interested in this issue.”

To untangle these factors, Lamming’s group designed four different diets for mice to follow. One group ate as much as they wanted whenever they wanted. Another group ate a full amount, but in a short period of time — this gave them a long daily fast without reducing calories.

The other two groups were given about 30 per cent fewer calories either once a day or dispersed over the entire day. That meant that some mice had a long daily fast while others ate the same reduced-calorie diet but never fasted, which differed from most previous studies of calorie restriction. It turned out that many of the benefits originally ascribed to calorie restriction alone — better blood sugar control, healthier use of fat for energy, protection from frailty in old age and longer lifespans — all required fasting as well. Mice who ate fewer calories without fasting didn’t see these positive changes.

Fasting on its own, without reducing the amount of food eaten, was just as powerful as calorie restriction with fasting. Fasting alone was enough to improve insulin sensitivity and to reprogram metabolism to focus more on using fats as a source of energy. The livers of fasting mice also showed the hallmarks of a healthier metabolism. The researchers did not study the effect of fasting alone on lifespan or frailty as mice age, but other studies have suggested that fasting can provide these benefits as well.

While the mice that ate fewer calories without ever fasting did show some improved blood sugar control, they also died younger. Compared with mice who both ate less and fasted, these mice that only ate less died about 8 months earlier on average.

“That was quite surprising,” said Lamming, although other studies have also shown some negative effects from restricting calories. The team also measured frailty through metrics like grip strength and coat condition. “In addition to their shorter lifespans, these mice were worse in certain aspects of frailty, but better in others. So, on balance, their frailty didn’t change much, but they didn’t look as healthy.”

The primary studies were done in male mice, but Lamming’s lab also found similar metabolic effects of fasting in female mice. The research reveals how difficult diet studies are, even in a laboratory environment. That difficulty is magnified for human studies, which simply can’t match the level of control possible in animal models. The new study can provide direction to future work trying to answer whether fasting improves human health.

“We need to know whether this fasting is required for people to see benefits. If fasting is the main driver of health, we should be studying drugs or diet interventions that mimic fasting rather than those that mimic fewer calories.” Lamming said.

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Common dialysis treatment for patients with acute kidney injury can lead to poor outcomes

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Patients with acute kidney injury who receive continuous renal replacement therapy (CRRT), a common dialysis method, have a high incidence of needing this dialysis method reinstituted after having it removed. This contributes to poor 90-day outcomes, according to recent research led by an international team of scientists.

The study was published in the journal Mayo Clinic Proceedings. Though CRRT is a common dialysis method for critically ill patients with acute kidney injury, little research has been performed to determine at what point in kidney function recovery the patient should be “liberated” from CRRT.

This study, by researchers at Mayo Clinic and Zhongnan Hospital of Wuhan University in China, is believed to be the first to investigate outcomes for patients with acute kidney injury who were not successfully liberated from CRRT.

The retrospective cohort study examined the records of 1,135 patients with acute kidney injury who were treated with CRRT at Mayo Clinic in Rochester between January 2007 and May 2018. Of those patients, 20 per cent were successfully liberated from CRRT. In 39 per cent of patients, CRRT had to be reinstituted within 72 hours, and 41 per cent of these patients died.

Successful CRRT liberation was marginally associated with fewer major adverse kidney events and improved kidney recovery at the time of 90-day follow-up, though the causal relationships could not be established.

“In current clinical practice, CRRT liberation is typically based on physicians’ personal experience because there has been only limited and inconsistent research available,” says Kianoush Kashani, M.D., a nephrology intensivist at Mayo Clinic and the study’s senior author.

Kianoush added, “Our study demonstrated a high occurrence of CRRT liberation failure, as well as poor 90-day outcomes. Thus, there is a critical need for identifying preventive measures to avoid the need for CRRT or interventions that lead to early liberation from CRRT among critically ill patients with advanced acute kidney injury.”

Acute kidney injury is a common complication for patients in ICUs. As many as 57 per cent of ICU patients have acute kidney injury. Dialysis is used to treat about 13 per cent of those patients, and this treatment is associated with 60 per cent mortality, according to research.

“There are limited data and little consensus on how and when to liberate patients from CRRT properly, the high rate of liberation failure observed in our study may reflect variations in clinical practices. Development of consistent approaches that can guide decision-making on when to remove CRRT should be a top priority of future research,” he added.

CRRT is frequently used as a dialysis mode for critically ill patients because it provides continuous control of fluid status during treatment and doesn’t interfere with the body’s normal blood flow while achieving uremic control.

But recent studies have found that prolonged CRRT may lead to adverse events and impede kidney function recovery, while premature CRRT liberation also can lead to complications.

Other dialysis options are associated with even lower changes in kidney recovery, says Dr. Kashani, the study’s senior author. The study clearly indicates that CRRT liberation, when successful, can be associated with improved clinical outcomes for critically ill patients and lower costs of care, he says.

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INCREASE IN DAIRY INTAKE LOWERS RISK OF FRACTURES AMONG OLDER HOME RESIDENTS

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Increasing intake of foods rich in calcium and protein such as milk, yoghurt, and cheese, reduces falls and fractures in older adults living in residential care, finds a new study led by an international team of scientists.

The randomised controlled trial was published in ‘The BMJ’ (British Medical Journal). This is one of only a few studies to examine whether getting these nutrients from foods (as opposed to supplements) are effective and safe, and the researchers say this approach has “widespread implications as a public health measure for fracture prevention.”

Older adults living in residential care often have low calcium and protein intake, which can lead to weak bones and an increase in the risk of falls and fractures. It is estimated that older adults in aged care are the source of about 30 per cent of all hip fractures.

It is well known that foods rich in calcium and protein, such as milk, yoghurt, and cheese help prevent bone fragility, but few studies have investigated whether increasing daily intake of these foods is an effective and safe way to reduce fracture risk in older adults.

So researchers based in Australia, the Netherlands and the US set out to examine whether achieving recommended daily intakes of calcium (1,300 mg) and protein (1 g/kg body weight) from food sources would reduce the risk of fragility fractures and falls among older adults in residential care facilities.

The two-year trial involved 60 aged care facilities in Australia housing 7,195 residents (72 per cent women; average age 86 years) replete in vitamin D but with daily calcium and protein intakes below recommended levels.

Thirty intervention facilities were randomised to provide residents with additional milk, yoghurt, and cheese, achieving intakes of 1,142 mg calcium/day and 1.1 g protein/kg body weight/day. The remaining 30 control facilities continued with their usual menu (700 mg/day calcium and 0.9 g protein/kg body weight/day).

Data from 27 intervention facilities and 29 control facilities were analysed and a total of 324 fractures (135 hip fractures), 4,302 falls, and 1,974 deaths occurred during the study period.

The intervention was associated with risk reductions of 33 per cent for all fractures (121 v 203), 46 per cent for hip fractures (42 v 93), and 11 per cent for falls (1,879 v 2,423). There was no group difference in all-cause mortality.

The relative risk reduction for fractures was similar to that found in trials using potent drug therapy to increase bone strength in people with osteoporosis.

A randomised controlled trial is considered the most reliable way to determine whether an intervention actually has the desired effect, but the researchers do point to some limitations. For example, the loss of participants limited their ability to examine the possible mechanisms that may contribute to fewer fractures and falls.

Nevertheless, they say, improving calcium and protein intakes by using dairy foods “is a readily accessible intervention that reduces the risk of falls and fractures commonly occurring in institutionalised older adults.” They also added that this nutritional intervention has widespread implications as a public health measure for fracture prevention in the aged care setting and potentially in the wider community.

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ENHANCING VACCINATION IS THE RIGHT STEP IN CURBING SPREAD OF COVID

Mumbai for the first time has recorded no Covid-related deaths recently.

Dr Rahul Pandit

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From battling the most tumultuous second wave of Coronavirus to driving the world’s largest vaccination program, India’s journey in tackling Covid-19 has been exceptional. Today, India has achieved a milestone by inoculating 100 crores of its population. Adding to this, Mumbai for the first time has recently recorded no Covid-related deaths. This is truly a moment of pride as we can now be certain that we can tackle Covid-19 in a better way and save more lives. If we continue following protocols and actions to save more lives, we will be able to achieve the goal of zero deaths due to Covid in India.

India has already provided more than one billion vaccinations covering around 1/7th of the population. So about 70% of the eligible population has received at least one dose, and nearly 25 % have received both the doses. With the introduction of vaccines for children, this program will take a new leap. The progress made so far is thus, commendable. It takes 5-10yrs to test and develop vaccines, but India researched and developed an in-house vaccine, ensuring that all necessary arrangements such as complex manufacturing, the humongous logistics involving setting up cold chains, airport transfers, vaccines to states, local storage, and last-mile connectivity were set up in no time. Moreover, India devised an excellent strategy to encourage pharma companies to produce vaccines within the country. This coupled with the efforts put by healthcare providers, media, and health activists in spreading awareness and reiterating time & again the significance of vaccination in saving lives, has been huge.

Enhancing the vaccination process is the right step in curbing the spread of the virus, as well as saving as many lives as possible. Mumbai is a case in point. After a concerted effort made by the government, local bodies, private hospitals, doctors, nurses, paramedics, and the public at large for the last 18 months, the city saw a day with zero deaths. This is how the nation needs to work against the infection. However, one needs to note that Mumbai’s achievement is a result of multiple factors put together, and among these, vaccination is the key. Around 50% of Mumbai’s population has been fully vaccination and more than 90% have received the first dose. Maharashtra’s vaccination drive across districts has brought the state closer to the 10Cr mark; that too, at record breaking speed.

For any infectious disease, the first line of action is to save lives and prevent the spread. That’s what Mumbai did. From being a highly impacted region, to becoming a city with zero deaths, our actions delivered.

However, staying cautious is critical, as it is yet too early to declare victory over the virus. At present, we are better equipped to confront any new challenge. People should however, not lower their guards and continue following Covid-19 protocols. Even after vaccination continue to mask up and follow Covid-19 protocol. Get vaccination and encourage others to do so. Only then can we together someday win the war against Covid-19. It’s not too long before we’d be vaccinating another 10Cr nationals, setting golden examples for the world to follow.

The writer is Director-Critical Care, Fortis Hospitals Mumbai & Member of the honorable Supreme Court appointed National Covid-19 Task Force.

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PGIMER releases documentary titled ‘Front of Package Labeling: A Game Changer for Healthy India’

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A documentary titled ‘Front of Package Labeling: A Game Changer for Healthy India’, prepared by the Department of Community Medicine and School of Public Health (DCM & SPH), Post Graduate Institute of Medical Education and Research, Chandigarh.

This documentary is a part of a project being undertaken by the Institute in collaboration with Government of Punjab and Strategic Institute of Public Health Education and Research (SIPHER) and is supported by Global Health Advocacy Incubator, USA.

“A rapid rise in hypertensive cases is being observed in Punjab, which is worrisome. Through the project, we are collaborating with the Government of Punjab to prevent and better manage hypertension through sensitization of media and the general public regarding the risk factors like trans fats in food. We strongly feel that warning labels on food items are effective way of helping people to make nutritious food choices. The documentary drives home the importance of Front of Package Labeling (FOPL) for averting a cardiovascular health, obesity and diabetes crisis in India.” said Dr. Sonu Goel.

As per WHO, Non-communicable diseases (NCDs’) account for 70% of the global deaths. The state of Punjab has become a capital of hypertension with one out of three people suffering from this silent killer.

Excessive intake of fats, sugar and salt available in packaged foods such as cake, pizza, pastry, french fries, ice cream, etc. are the primary cause of NCDs. Under this project which started in 2019, PGIMER Chandigarh has signed a pact with Food and Drug Administration, Punjab to implement and regulate the trans-fat surveillance in Punjab.

The documentary highlights key features such as transition of food practices from traditional to modern, ways to making healthy food choices, identifying good and bad food, diseases associated with bad food. etc.

It was released at the juncture of festivals such as Diwali, aims to generate awareness among policymakers, implementers, and the general public about the importance of healthy and wholesome food to keep Non-Communicable Diseases (NCDs’) like hypertension at bay and to generate support for an intense Front-of-Pack Labelling (FOPL) policy to be developed by Government of India. It took around two months to prepare this documentary of approximately 7 minutes, which is a collaborative effort of the project team. The documentary has been conceptualized and narrated by Dr. Sonu Goel, Professor, Dept. of Community Medicine and School of Public Health, PGIMER, Chandigarh and Principal Investigator of the project.

Dr. Geeta Mehra, Head, Dept. of Food Sciences, MCM DAV College, Chandigarh emphasized the importance of reading food labels while purchasing any packaged food product. She stressed that “FOPL, if implemented in India, will allow the consumers to identify products containing excess sugars, trans-fats, oils, and sodium easily, quickly, and correctly and help them to make informed food choices.”

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Medically Speaking

STUDY SHOWS REGULAR MILLET CONSUMPTION CAN COMBAT ANAEMIA

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A new study has shown that regular consumption of millets can improve haemoglobin and serum ferritin levels to reduce iron deficiency anaemia, which is rising globally.

The findings of the study were published in the journal ‘Frontiers in Nutrition’. The research, a meta-analysis of 22 studies on humans and eight laboratory studies on millets consumption and anaemia, was undertaken by seven organisations across four countries and was led by the International Crops Research Institute for the Semi-Arid Tropics (ICRISAT).

“The study concluded that millets can provide all or most of the daily dietary iron requirements of an average person. Although the amount of iron provided depends on the millet variety and its form of processing, the research clearly shows that millets can play a promising role in preventing and reducing high levels of iron deficiency anaemia,” highlighted Dr S Anitha, the study’s lead author and Senior Nutritionist at ICRISAT.

The researchers found that millets increased haemoglobin levels by as much as 13.2 per cent. Four studies in the review also showed serum ferritin increasing by an average of 54.7 per cent. Ferritin is an iron-containing protein in the blood and is a clinical marker for iron deficiency.

The studies in the analysis involved nearly 1,000 children, adolescents and adults, and six different millet types – finger millet, pearl millet, sorghum and a mixture of kodo, foxtail and little millets. The participants in the studies were found to have consumed millets for anywhere between 21 days and 4.5 years. The findings were published on 14 October in Frontiers in Nutrition.

“1.74 billion people were anaemic in 2019. That number is rising,” said Dr Jacqueline Hughes, Director General, ICRISAT.

“It has been proven that iron deficiency anaemia affects cognitive and physical development in children and reduces productivity in adults. The need for a solution is critical, and therefore bringing millets into mainstream and government programs is highly recommended,” added Dr Hughes.

“Now that there is strong evidence of the value of millets in reducing or preventing iron deficiency anaemia, it is recommended that one major research study be undertaken on anaemia covering all the different types of millet, common varieties and all major forms of processing and cooking, using a uniform testing methodology. This will provide the detail required for designing interventions needed to have a major impact on reducing anaemia globally,” said Professor Ian Givens, a co-author of the study and Director at the University of Reading’s Institute of Food, Nutrition and Health (IFNH) in the UK.

“It has often been claimed that iron in millets is not highly bioavailable due to the supposed high levels of antinutrients. Our analysis proves this is a myth. Instead, millets were found to be comparable to typical iron bioavailability percentages for plants. Also, the levels of antinutrients in millets were identified to be similar or lower than common staples,” said Ms Joanna Kane-Potaka, former Assistant Director-General, ICRISAT, and Executive Director of the Smart Food initiative who is a co-author of the study.

The research also showed that processing can significantly increase the amount of iron bioavailable. For example, millet snacks made by expansion (extrusion) increased bioavailable iron 5.4 times, while fermentation, popping and malting more than tripled the iron bioavailable. Germination (sprouting) and decortication (dehulling) more than doubled the bioavailable iron.

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