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Keeping an eye on glaucoma

Be aware of the symptoms of glaucoma and avoid the overuse of steroids and over-the-counter eye drops, suggest top eye specialists and doctors.

Shalini Bhardwaj

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Glaucoma cannot be cured but it can be treated. However, awareness is key as a delay in detecting the problem can lead to a worse situation for patients. Top eye experts Padma Shri Dr J.S. Titiyal, Professor, Head of Cornea Services and Chairman, National Eye Bank, AIIMS, Padma Shri Dr Harsh Kumar, Director, Glaucoma Services, Centre for Sight, and Dr Viney Gupta, Professor of Ophthalmology at the R.P Centre, AIIMS, explain what is glaucoma and why people need to undergo regular check-ups, especially if they have a family history of the disease.

Dr Viney Gupta

Dr J.S. Titiyal

Dr Harsh Kumar

Q: What exactly is glaucoma?

Dr Kumar: Glaucoma is a dangerous disease that is known as the silent thief of sight. It is a group of diseases which raises the pressure of the eye and leads to damage in the nerve that collects all the vision signals and sends it to the brain. In India, and even in the USA, it happens that by the time people realize they have glaucoma, 50% of them have lost 90% of their eyesight. So, it is an extremely dangerous disease.

Q: What are the symptoms of glaucoma?

Dr Kumar: Glaucoma cannot be easily detected because there are hardly any symptoms. There are two types of glaucoma: angle closure and open angle. In angle closure glaucoma, the patient actually gets an attack and develops redness, pain and watery eyes. When he rushes to the doctor, the problem is detected. But unfortunately the angle closures usually present themselves silently. The pressure starts increasing and we do not realise it. What you should be careful about is that if you are not able to see something at night, which you could before, or your distant vision is getting blurred, you are developing headaches, seeing coloured halos around bulbs in the evening, or your number is changing every six months or so, you may have early glaucoma.

Q: Does it occur only in people above 60 years of age?

Dr Kumar: Dr Viney is a specialist in children’s glaucoma and operates on children below two years of age also. But usually it occurs in people above 40 years of age unless there is a secondary cause like use of steroids, surgery or other reasons. 1 in every 8 persons are either suffering from or may develop glaucoma, which is why we suggest annual check-ups.

Q: Is glaucoma in children also a congenital disorder?

Dr Gupta: There are many children in our country who develop glaucoma at birth or within a year. It is called infantile glaucoma. It can be detected in children early as they have large eyes. If a doctor detects it, he may refer to a specialist earlier. Although rare, 1 in every 3000-4000 children born in India will have glaucoma so it is necessary to diagnose it early. Adolescents can also develop glaucoma, which is called juvenile glaucoma. Both of these are primary glaucoma and have hereditary components. It is ideal to treat it early.

Q: Can it be cured if detected at a young age?

Dr Gupta: Glaucoma does not have a permanent cure generally. Treatment continues life-long. The patient needs to be monitored throughout their life.

Q: How can stem cells treatment help in curing glaucoma?

Dr Titiyal: As far as glaucoma is concerned, no research is going to help in curing it because the damage is to the nervous tissue and the regeneration of this tissue is one of the toughest things possible. But studies in genetics might have a better option for treating it, especially the congenital variety.

Q: Have gene therapies for glaucoma been conducted in other countries?

Dr Gupta: They have done so in animal models, where they induced the glaucoma-causing gene in the animal and corrected it through gene therapy. But human trials are going to take a very long time.

Q: Are we doing such trials in AIIMS also?

Dr Gupta: Currently, we have not started any such therapies. We need to try it first on animal models and after we are confident enough, we will start human trials. For gene therapy you need to identify the genes responsible for the disease. In glaucoma, only 30% of the cases have known genes. So, unless we do not identify the gene, we cannot correct the disease.

Q: What causes glaucoma?

Dr Kumar: First of all, it is very important for people to know that there is no possible cure through stem cells, so if anyone promises a cure through it, don’t believe them. Secondly, there is an area in the eye through which water percolates through the eye. Due to certain genetic modifications, these holes keep closing by the age of 40 and the water starts collecting in the eye which causes pressure on the optic nerve. This can also be caused due to surgery, trauma or steroids. Whenever children have allergies and are taken to a doctor, the doctor gives them steroids, but if parents continue the use of the same steroids it can have severe repercussions. So we request people to halt the use of steroids without consulting a doctor.

Q: Some people use gulab jal whenever their eyes feel itchy. What would you say about that?

Dr Kumar: When I was at AIIMS, we did research on the use of drops like gulab jal, Itone and Drishti and the studies concluded that these are totally useless.

Dr Titiyal: These drops are quite popular among the public because it is propagated that they are capable of treating every possible disease in the human eye which is not exactly true. We have not tested these medications at all. As far as glaucoma is concerned, these drops are not going to be useful. If the gulab jal is freshly prepared, it may give temporary relief, but when stored for long, it may cause infection. We would definitely test the use of these drops, especially Drishti, in the future.

Q: Many parents admit giving their children these drops from a very young age. Have you seen any cases related to this in your OPD?

Dr Gupta: Yes. If you are using them once or twice, it is okay, but it may cause problems when used for a long time. There used to be a tetracycline ointment that was available in the form of capsules. A lot of such drugs are easily available in the market and are easy for parents to buy. But using these drugs for a child may cause glaucoma, which can then become difficult to cure. We have seen many cases where children have gone blind due to the carelessness of parents and pharmacists. One should consult an ophthalmologist before putting these drops in their child’s eyes.

Q: What is the latest technology available for the treatment of this problem?

Dr Kumar: There are several surgeries available for glaucoma but they are available for very advanced situations. A lot of new medications are coming up and that is why the number of surgeries has actually gone down drastically all over the world. Newer drugs are available now. There was a time when only two drugs like pilocarpine and beta blockers were available in the country.

Q: What would you say about the new mobile app that claims to diagnose glaucoma?

Dr Gupta: In these apps, you enter your data and they work as a risk calculator. But this information must be entered by the doctor because it includes parameters like pressure of your eye, corneal thickness, degree of myopia you have, etc. Only then can the risk be detected for the patient. People who have a family history have to be very careful because the risk is almost 10 times higher. It is ideal to screen and inform members of the family and refer them to an ophthalmologist.

Q: Around 1.2 crore people in India have glaucoma and around 5 lakh of them are from Telangana. What can be the reason behind this concentration?

Dr Titiyal: It depends upon the place of study. Currently we cannot calculate the prevalence of the disease in the country because it is very difficult to conduct surveys on glaucoma. Telangana must have done this study and come out with this report. If you look at blindness, glaucoma-related blindness may not be prominent, but if you look at eye diseases, it would be very common. In other countries, there are a lot of myths related to glaucoma and cataract. So there is a definite need for a good survey in the country so that we come to know about the prevalence of the disease. Rehabilitation and treatment will have to be implemented accordingly. Glaucoma blindness, unlike other blindness, cannot be reversed. I am sure we will be able to conduct a survey in the whole country—if not all districts, important ones can be taken up. According to a study by MPCB, glaucoma is already the third leading cause of blindness in India.

Q: How have glaucoma patients suffered during Covid-19?

Dr Kumar: A lot of people could not visit us and some of them could not get their medications due to which the pressures were not checked. I have seen that most of them had good vision but went on to develop poor vision. Most of them were elderly people. But the first thing often is to save their lives rather than sight. We would request everyone to stock medicines for an adequate time so that in case of a lockdown for 2-3 months, they can be well prepared. Glaucoma patients should never stop their medications. People who have a family history may also develop glaucoma, while others at risk are those who are diabetic, hypertensive, suffering from thyroid or myopic.

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Medically Speaking

PREDIABETES CAN BE REVERSED, SAYS DR PANKAJ AGGARWAL

Shalini Bhardwaj

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Senior endocrinologist Dr Pankaj Aggarwal tells The Sunday Guardian why the idea of prediabetes is getting popular and it is so important. Excerpts:

Q. What is prediabetes?

A. As the name suggests, it is the stage between normalcy and frank diabetes. Actually, the three entities are in a continuum. When blood glucose value starts rising above normal, initially it enters the zone of prediabetes and when it progresses further, it enters the zone of frank diabetes.

Q. Why is it gaining so much popularity? Is there any clinical significance of this entity?

A. Traffic light has three colours and the same is true for the spectrum of blood glucose levels as well. The green zone is normal wherein you are free to move; then comes yellow, which warns to be careful; and then it turns red, which orders you to stop, else you will be punished. Prediabetes is the intermediary warning zone before reaching the zone of actual harm or punishment.

Q. Does it mean that prediabetes itself is a harmless entity?

A. No, many population studies have proved that some complications of diabetes actually begin in the stage of prediabetes. It is particularly true for similar lifestyle disorders such as high blood pressure, high blood cholesterol and even heart attack or paralysis. Controlling blood glucose level and decreasing it from this zone to normal, can prevent development or progression of these dieters.

Q. What is normal blood glucose levels and their cut-offs for prediabetes and diabetes?

A. We derive glucose mainly from our food and so our blood glucose levels actually vary with intake of food. After an overnight fast, it is between 70 mg/dl and 100 mg/dl which increases to 100-140 mg/dl after 2 hours of having a meal. When blood glucose level rises beyond 126 mg/dl in fasting state and 200 mg/dl after 2 hours of meals, it is termed diabetes. Values between 100 mg/dl and 126 mg/dl (fasting) and 140 mg/dl and 200 mg/dl (after meals) are labelled prediabetes.

Q. Is it certain that a person who has become prediabetes will progress certainly to diabetes?

A. No, actually here lies the importance of detecting it at the level of prediabetes. It is the warning zone or ‘no man’s land’ between the borders of two countries. You can’t come back to your motherland easily after entering the neighbour’s territory but can still be brought back from the intermediate no man’s land. Prediabetes can be reversed.

Q. So what are the ways through which it can be reversed?

A. The two most common factors behind development of diabetes of adults or type 2 diabetes are, genetic predisposition and faulty lifestyle. The former is non-modifiable as we can’t choose our parents. But if one has a family history of diabetes, it should serve a warning signal that one should resort to adoption of a healthy lifestyle to prevent its progression into the state of diabetes. Correction of faulty lifestyle is actually the major route through which prediabetes can be reversed.

Q. Can you please detail upon the healthy lifestyle here?

A. Management of diabetes or prediabetes revolves around management of calories. If calorie intake is more than required, it accumulates in the body and predisposes a person towards development of diabetes, hypertension, high blood cholesterol and heart attack. Since fats in our diet are most calorigenic, it increases these probabilities to its maximum. So, reducing extra calories in diet in the form of paratha, poori, kachori, namkeen, samosa, pakoras, meat and sweets, remains the cornerstone of this management. Instead, one should have plenty of whole grain cereals (roti, daliya), dal, green leafy vegetables, fruits, low fat milk and milk products and white of egg. One should avoid frying or adding extra ghee or butter in the food to prevent weight gain. Regular exercises are most helpful in reducing the extra body fat if it has accumulated. These measures can help in reversing prediabetes.

Q. Do we have any medicine as well to help in reversing prediabetes?

A. Frankly speaking, medicines are meant for treating a disorder and not for preventing it. Though some anti-diabetic medicines like metformin, thiazolidinediones and acarbose have been tried to prevent the progression of prediabetes into diabetes but lifestyle interventions have been found to be most successful in this regard. 

Q. Has any study been tried to see whether reversal of prediabetes is possible or not?

A. A number of studies have been conducted so far wherein reversal of prediabetes and even diabetes has been studied. The Diabetes Prevention Programme, both global as well as national, is pioneer amongst all to show that this is possible and achievable.

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Death rate also increasing with cases this time: Dr Guleria

Covid-appropriate behaviour and vaccines are the two weapons needed to fight the war against the novel coronavirus, says AIIMS director Dr Randeep Guleria.

Shalini Bhardwaj

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In an exclusive interview with The Sunday Guardian, Dr Randeep Guleria, Director of the All India Institute of Medical Sciences (AIIMS), explained the reasons behind the recent record surge in Covid-19 cases, the susceptibility of youngsters and people with comorbidities, and how the infection can be tackled by a combination of isolating and treating patients and vaccinating others.

An artist makes a mural of Monalisa wearing a face mask to spread awareness for the prevention of the coronavirus in Mumbai on Thursday. (ANI Photo)

Q: Why is the second wave of Covid-19 in India progressing so quickly and why is it targeting so many people?

A: One of the two main reasons for this is that when cases started decreasing and the vaccines started rolling out in January and February, people thought that Covid has ended and ignored Covid-appropriate behaviour like wearing masks and socially distancing. As a result, the virus got another chance to spread. Secondly, the mutant viruses, especially the UK mutant, are more infectious and spreading faster than the previous one. We can see that the spike is very steep and cases are increasing at a very fast pace as we have now crossed an average of 1.5 lakh cases per day.

Q: When talking about specific mutants, like the UK variant, why are they spreading more in metropolitan cities?

A: The coronavirus is a respiratory virus that spreads through droplet infections. Wherever the population density is greater, like in metropolitan areas, urban slums or metro stations, the virus spreads faster. An asymptomatic person can also cause infections when present in a crowd. Moreover, in rural areas, the air is fresh and people tend to stay outdoors and maintain social distancing due to which the virus cannot survive for long in the environment.

Q: Keeping in mind the pace of the spread of the virus, do you think we need to make some changes in the guidelines?

A: We don’t need to change the guidelines, but need to follow them strictly. We have been testing, tracking, treating and isolating. If there is a Covid-positive case in the family, we need to isolate the patient. If they cannot be isolated, admit them to a Covid care centre so they don’t spread infections in their area. We have to see where the most cases are being reported from and divide areas into red, orange and green zones, just like we did before. The more the cases, the more the people will fall ill and need ICUs and hospital beds.

Q: More youngsters are getting affected by the infection this time. What should we do in this situation?

A: This time, cases in the younger age group are comparatively higher. This is because we saved children from the infection last time but just as we became more casual and ignored Covid-appropriate behaviour later, they got exposed to the virus immediately. Secondly, the younger age group thinks that the disease is not as severe in their age group and so they need not worry due to which they have started partying and clubbing again. However, if they are infected and unaware about it, they may spread the infection to more friends and colleagues.

Q: How can we protect kids?

A: Since the vaccine has still not been approved for kids, we need to take precautions just as we did before. Avoid crowds and non-essential activities, wash hands properly and wear masks when going out. We have started behaving casually and the virus has grown more infectious, due to which entire families are getting infected together.

Q: What is the reason for the increased mortality rate this time?

A: Last time we assumed, and the figures also showed, that the death rate is low. This time, as the cases increase, the death rate is also increasing. When a person gets infected, they go home and infect their family as well. In case any of them has a comorbidity, it may get more serious and hence chances of mortality are greater. Many people are not taking the infection seriously and visiting hospitals only when it gets serious. This is causing a delay in treatment and getting medicines, hence increasing the risk of death.

Q: Do you think a second lockdown is a solution?

A: Weekend lockdowns are okay but we need to take aggressive action. We have to contain the areas reporting the most number of Covid cases and test and treat the people in those areas. Also, we need to keep a check on travel because people travelling from red to green zones can spread infections.

Q: People, including many doctors, are getting infected after taking the second dose of the vaccine. What is the reason behind this?

A: First of all, we need to understand the purpose of the vaccine. After we receive the vaccine, we will not catch the disease even after getting the infection. Catching an infection means coming in contact with a Covid-positive person, when the virus may enter our nostrils and throat. But since we are vaccinated, the antibodies in our body will not allow the virus to spread further in our body. Therefore, we need to follow Covid-appropriate behaviour as the vaccines may save us from serious illness, but we are still able to spread the infection among others who are not vaccinated.

Q: We talked to a lot of professionals about the lack of antibodies in many people, even after vaccination. What is the reason for this?

A: Nowadays, we test upon G-antibodies, whereas we need to look for neutralizing antibodies. Cell-mediated immunity is long-lasting immunity created by the vaccine. There is another cell called the T-cell, that is also called a memory cell, which starts creating antibodies once exposed to the virus. Looking for antibody creation after vaccination is one thing but there are a lot of things apart from it like cell-mediated immunity and T-cell immunity. Research is being conducted for a booster dose vaccine which might be needed after 1.5 years.

Q: If someone receives Covishield, can the person receive Covaxin or other vaccine?

A: Right now, that is not possible due to a lack of stock of vaccines, but once everyone gets all the doses of the vaccines, we will see if we can inoculate people with a third dose as well. Some studies are being conducted upon the mixing of the vaccines and whether that will create more immunity. Until now, only a single dose was being administered during the vaccine trials.

Q: Do you think we should reduce the age limit for inoculation in view of the increasing Covid cases?

A: When talking about the vaccine, the first criterion is to reduce the mortality rate. Thus, we started by vaccinating people above 60 years of age as they are at the highest risk. Then we came down to people 45 years of age with comorbidities and covered healthcare workers and frontline workers, also to ensure that the healthcare system remains efficient. After this we have to vaccinate people who are of lower priority. But if we open vaccinations for all, we won’t be able to cover everybody because we will need a minimum of 2 billion doses to vaccinate a population of over 1 billion in our country. And if we inoculate people in the age group of 25-45 years and have no doses for people above 60, it will increase the risk factor for the country. Thus, we need to balance out the vaccine doses among the population.

Q: A lot of states are reporting a lack of vaccine doses. Many people could not get the second dose. How can we deal with this?

A: This issue is arising due to a supply-demand issue and it is not a matter of a lack of doses. Also take into account the eligibility of the people taking the doses. If at a centre, 50-75 people are visiting, we keep a record of those people and maintain the chain. But if 500 people arrive suddenly at the same centre on a given day, the chain cannot be scaled. At first, there was vaccine hesitancy but due to the sudden spike in cases, people started crowding immediately at the centres. It can so happen that if there is vaccine hesitancy at some place, we can move the surplus vaccines from there to a place with higher demand.

Q: How can vaccine wastage be controlled?

A: Vaccine is supplied in vials. A vial contains 10-20 doses. This means that we need to use all the doses when a vial is opened. Each vaccination centre needs to make a strategy and check if there are people waiting for doses before opening a vial.

Q: Do you think people need to get some tests done before receiving the first dose of the vaccine?

A: Many people tend to get their blood tests done, take Crocin and anti-allergy medicines, which are not at all needed. No tests need to be done before getting inoculated. Even if you get any side-effects after the vaccines, they can be treated. The side-effects are not major and are usually treatable.

Q: How can people with cardiac disease, high blood pressure, diabetes or any such issues take care of themselves?

A: 80% of such people are above the age of 45 and should get vaccinated quickly as these people may get severe Covid. Also, they should follow Covid-appropriate behaviour and avoid crowded places. Also, they should take proper precautions at home like maintaining hygiene and maintaining distance from people with possible symptoms of Covid.

 Q: When will the curve flatten? What would you say about the future possibilities of the disease?

A: The curve may not flatten in the upcoming days and it is difficult to say anything about the future. It completely depends upon us. If we follow Covid-appropriate behaviour, work from home and avoid going to public places, cases may reduce. 80% of people in India are still susceptible to the infection. The fight against Covid can only be won with the active participation of people. If we stop the droplet infection by maintaining social distancing, wearing masks, sanitising and washing hands, we can stop cases from increasing. Thus, everyone must take precautions.

Q: When is the Remdesivir injection needed and how does it work?

A: The timing of a drug is very necessary to be taken care of. Remdesivir is anti-viral but has not shown reduced mortality rates till now. It does reduce hospital admission. It only works when you have a moderate illness and your oxygen saturation is reducing, fever is high or there is a patch in the X-ray or CT Scan. In later stages, Remdesivir does not work. A treatment strategy needs to be implemented.

Q: As hospitals do not have enough beds, how can one treat Covid at home?

A: First, we need to check if the person has a home isolation facility or not. If not, they should be sent to a Covid care centre. Next, see the condition of the patient. Does the person need hospitalization, what are his/her symptoms, and do they have any comorbidities? The government has demonstrated the process of home isolation already. 85%-90% people catch mild symptoms of Covid and can be treated at home. Only 10%-15% of people need to get hospitalised and out of them, only 5% need to get admitted to the ICU. Thus, many can treat themselves at home.

Q: What last message do you want to give?

A: The fight against Covid is not yet over and we have to fight it together. Covid-appropriate behaviour is very necessary in this pandemic. The vaccine is a great weapon against this virus and it will assist us in this fight. If we use both these weapons together, we will get rid of this pandemic quickly.

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ASTRAZENECA VACCINE, BLOOD CLOTS LINK ‘PLAUSIBLE’ BUT UNCONFIRMED: WHO

Shalini Bhardwaj

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New Delhi: A link between AstraZeneca’s Covid-19 jabs and blood clots is plausible but unconfirmed, the World Health Organization’s vaccine experts said, stressing that reported occurrences were “very rare”.

“Based on current information, a causal relationship between the vaccine and the occurrence of blood clots with low platelets is considered plausible but is not confirmed,” the WHO Global Advisory Committee on Vaccine Safety said in a statement. “Specialised studies are needed to fully understand the potential relationship between vaccination and possible risk factors.”

There have been 79 cases of rare blood clots, resulting in 19 deaths, in people who received the AstraZeneca vaccine in Britain, the country’s medicines regulator who is chief executive of MHRA reported on Wednesday.

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JOHNSON & JOHNSON SET TO BEGIN INDIA TRIAL OF ITS SINGLE-SHOT VACCINE

Shalini Bhardwaj

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New Delhi: US pharma giant Johnson and Johnson will soon begin clinical trials of its single-shot Covid-19 vaccine in India, the company told Indian regulators. In a letter to India’s Central Drugs Standard Control Organization (CDSCO), the US-based company said that it would “very shortly to apply for permission to conduct clinical bridging trials in India”. The news has come at a time when India is going through second Covid wave. India is looking to ramp up its vaccine doses amidst high demand due to the second surge of coronavirus in the country, with several states saying they are running out of supplies. In February, the US regulators had issued Emergency Use Authorization for the Covid vaccine developed by J&J’s Janssen Pharmaceutical Companies.

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Stress caused by Covid-19 can lead to diabetes: Top doctors

Healthcare experts and doctors discuss the impact of novel coronavirus on diabetic patients.

Shalini Bhardwaj

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What is the impact of Covid-19 on diabetic patients? Dr Nikhil Tondon, HoD and endocrinologist at AIMS, Dr Pankaj Agarwal, senior endocrinologist, and Dr Ashok Jhingan, chairman of Delhi Diabetic Research Centre, share their views on this and more. Excerpts:

Q. What is the commonest form of diabetes?

Dr Tondon: The commonest form of diabetes is non-insulin-dependent diabetes or type 2 diabetes. 85% or more of all people with diabetes have this particular type, which in earlier years used to be starting at the 30s, 40s, and 50s and was invariably associated with being overweight and responded to oral medication. The part about responding to oral medication remains intact but unfortunately, the age at which it is starting to appear in our population has progressively reduced with time so much so that even people in their late teens have now started developing this particular problem.

Q. Why are Indians prone to diabetes?

Dr Tondon: To understand that we need a little bit of historical context. There is a study or an editorial which is the Journal called Lancet. Lots of paper came out in 1907, about 115 years ago, which is around the time of the aristocracy of Britain. Diabetes is to the aristocracy of India, suggesting that this is a diabetes of the affluent, the disease of the rich who ate and put on weight. Over time that has changed with which improvement developed indices or disease which seemed to have been restricted to the extreme right of social-economic growth has now spread across. We possibly have all genetic trait predispositions. We were not exposed to the role of environment, eating habits, or lack of exercise before, now we possibly have the same genetic exposure. The disease is becoming progressively adverse with environmental exposure. By putting on weight, eating the wrong food, and exercising very little, people who are prexposed are getting this disease.

Q. What are the common symptoms of diabetes?

Dr Jhingan: The common symptoms are excessive thirst, frequent urination, and increased appetite, or loss of weight at times. These were quite common earlier. But now so many people are experiencing other symptoms like fatigue, excessive tiredness, weakness, lethargy and sometimes itching all over the body and many times that’s why we always say it’s a silent disease as people say they’re not having any symptoms. They are going for some executive health checkup or going abroad and then they get examined. A routine examination is required but a large number of hypertensive people are overweight and obese. As Doctor Nikhil has said, they all are prone to developing diabetes and these symptoms are quite common many times in the males and females itching around the genitals. That’s one of the important manifestations because of which the person goes for an investigation and then it is found that he/she has diabetes. Many times when young married girls are not getting pregnant or have frequent abortions and after an investigation, they get to know that they have diabetes. 

Q. What are the common types of diabetes?

Dr Jhingan: I think as Dr Nikhil has said very clearly about 85% of patients have type 2 diabetes, while 10% of patients have type 1 diabetes. There are gestational diabetes and diabetes mellitus which is caused by pancreatic exocrine disease. There are other types of diabetes besides these as well. 

Q. India has around 77 million diabetic people which makes it the second most affected in the world after China. What is the reason behind it?

Dr Agarwal: Yes, this is a big issue for Indians. At one time we used to top the list in the world, now China is heading. The reason is that we are genetically predisposed, which has been mentioned by Dr Nikhil. But we were genetically predisposed for a pretty long period. What happened in recent years that it has manifested in terms of diabetes is because of our change in lifestyle from an active lifestyle to so much mental stress, superseded by this covid era, all this led to having a sedentary lifestyle. All these things are bringing this problem earlier in our lives and increasing its incidents as Dr Ashok has said. The commonest symptom of diabetes is having no symptoms. So, most of the Covid cases are asymptomatic. Lots of patients we were having initially as well were undiagnosed. Now with improved diagnostic techniques and more awareness about the disease, we are detecting quite a good number of those patients. So, genetic predisposition, our lifestyle changes superseded by mental stress and if at all there is any physical distress in terms of infections and other things, then that has led to the increased privilege of diabetes in India, especially in recent days.

Q. Can Covid-19 cause diabetes?

Dr Tondon: No, Covid-19 can’t cause diabetes by itself. It is with any stress, physical or mental in terms of any injury, infection like pregnancies is the stress on the body so it predisposes the likelihood of diabetes. Similar is the case with Covid-19, it may precipitate diabetes in predisposed individuals who already have increased chances of having diabetes. Also, a more precipitous or severe form of infection in some individuals imposes a severe chance of getting diabetes. We use some agents like glucocorticoids to prevent certain complications of this infection. For many individuals, the use of those also increases the likelihood of having diabetes. The stress caused by Covid infection and the use of some medicines to prevent its complications can lead to diabetes.

Q. How has it affected Covid-19 patients?

Dr Tondon: If I tend to diabetes or pre-diabetes, infections will then unmask of that value. That’s one thing and the other equally important thing is, suppose a person with diabetes develops Covid-19, what do we need to do? We need to be worried that a person with diabetes is more likely to have a serious disease, require hospitalisation, intensive care and unfortunately that person is also more likely to die as a result of the infection. Firstly, as opposed to the appearance, he does not have that. Secondly, a person who has diabetes on exposure to certain drugs which are now an essential part of the Covid-19 treatment will also worsen their sugar and thus will need much more aggressive management. Thirdly, there are not two categories, one where people do have diabetes and developed Covid and another where they didn’t know about diabetes and develop Covid. The first category of people can take appropriate metrics. Also, your likelihood of catching infection becomes less and your doctor will be able to treat you much better. But what about the second category? During the treatment, coming to know that they have diabetes is even more dangerous. The message for doctors is that anybody who comes across a Covid patient measures the blood sugar, even if they don’t have diabetes as he might be unaware that he has diabetes. So that the doctors can aggressively manage them. 

Q. What are the latest treatments for diabetes? 

Dr Jhingan: With diabetes, there has been much more improvement but lifestyle change is the basic requirement. So these genetic backgrounds get precipitated with the environmental factors like change in food habits and exercise. The disease can get aggravated because of physical and mental stress. A balanced diet and exercise are a crucial part of the treatment strategy. Do 50 minutes of regular exercise. Then comes the role of oral medications. There had been a paradigm shift in the management part. There’s been a different type of class of drugs. Now very good drugs are there which have good control over sugar but there is again a limitation on the part of each group. So now we have plenty of drugs looking after the various pathways by which diabetes happened and these drugs are quite effective. And once these drugs also with all these things, if we are not able to get our target levels of Hba 1C to 7% that means we have to now try insulin and again in the insulin category, we have all those latest analogues. There is very good insulin which helps to control diabetes. Different types of regimes are there by which today we are in a position to keep the blood sugar levels around 7% Hba1C. This is there as higher HB1C increases the chance of complications of diabetes. With the latest available medications and insulins, we can keep the blood sugar under control.

Q. How gene therapy can be useful for diabetes. Are we doing it in India?

Dr Agarwal: This isn’t still in the investigational phase so the therapy is very promising. No doubt the problem lies with type 2 diabetes. There is no single gene that is leading to the development of type 2 diabetes which is happening in around 85% of cases. For type 2 diabetes, there is no single cause that can lead to diabetes. There is no single gene causing diabetes, so by intervening with one gene only, we cannot cure it. But for type 1 diabetics, there are certain promising things. Not exactly in terms of gene therapy but otherwise, the damage is being inflicted in the same target areas in type 1 diabetes. Those can be prevented to a large extent by some information. By interfering with the immune mechanism of the body, it can be changed by pancreatic beta-cell transplantation or distant cell therapy. 

Q. If diabetes is not treated timely, how chronic can it be?

Dr Jhingan: Yes, the problem and significance of diabetes lie in the complications which are produced because of it. If somebody is having diabetes without symptoms, it doesn’t mean he is fine. It will create more impact on the body and will affect many of the systems and it will be a problem forever and once anything happens, once the target organ, nothing can be done. Every organ is unique and once damaged it can’t be repaired. So we have to maintain the glucose level at its normal limit throughout life to protect those organs and the symptoms or the features associated with organ involvement are unique with their setup. Like for eyes, it will be blurred vision and blindness. With kidneys, it will reduce your urine formation, swelling and then later on kidney failure. With nerves, the feeling of burning sensation of cold, not feeling anything, pricking sensation and later on developing frequent ulcerations. And gangrene leading to the importation of limb with heart, pain, breathlessness, and heart attack. With brain stroke, paralysis and all these things may happen. All this can happen due to continuously raised glucose status which needs to be tackled in its early stages. Once it affects our organ of the body, nothing will change, there can be no cure. It won’t be too clear what the problem is but even if you lower down, even if you normalise global levels thereafter, once destroyed it will be destroyed forever, so we must treat diabetes, control diabetes to prevent the target organ from getting damaged which may happen in future.

Q. What are the five tips to manage diabetes?

Dr Jhingan: Do regular exercise for 50 minutes and to control the stress, do meditation and yoga. Also, have a balanced diet; have regular intake of medicine; regular monitoring; and regular treatment for sugar to be under control. After all, prevention of a complication is most important. Expenses for the treatment are high but once the complications develop it will be very expensive. The person who knows about his diabetes and keeps it under control can live the longest. Awareness and education are the cornerstone of the treatment of diabetes 

Q. Would you like to give any message?

Dr Tondon: The statement made by Dr Pankaj that the most common symptom of diabetes is a lack of symptoms is the message. People should periodically get tested for diabetes or blood pressure so that they are identified early and treatment starts. Awareness is needed, if your parents have diabetes or some uncle or aunt has diabetes, it means that there is a problem in the family. So they should get themselves checked even more frequently as they are more likely to have diabetes. Earlier women who got pregnant, it was mandatory to get checked for gestational diabetes but it’s not done very often now. They should get tested. Screening is required; one must incorporate a healthy lifestyle right from childhood. It’s very difficult if people over 40 often have fried food, they should change their diet and eating habits. Regular exercise will help from the beginning so that you don’t encounter it. Also, you are much more likely to have diabetes if your periods postpone. You will be able to handle diabetes well with a balanced diet and healthy living and regular physical activity. These things should be a part of our lives from the start and not only after we develop diabetes.

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VACCINATION AT WORKPLACES FROM 11 APRIL FOR THOSE WHO ARE 45 YEARS

Shalini Bhardwaj

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The government on Wednesday said that it will allow—from 11 April—Covid-19 vaccination at workplaces (public and private offices) to ramp up the fight against the pandemic in the country. The offices that have more than 100 beneficiaries are allowed get vaccines at their workplaces.

The Union Ministry of Health and Family Welfare decided on Wednesday to increase the accessibility to the vaccines amid surge of Covid-19 infection. The programme will be launched on 11 April, and states and UTs have been asked to make adequate preparations.

According to a letter from the Union Health Secretary, “With support of the state governments and UT’s administration the efforts have been to consistently make the vaccination drive more pragmatic and also more acceptable and purposeful to the beneficiaries.”

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