Withstanding adversity

 A few months ago I was invited to judge a short movie competition for young students organized by the Rotaract club of Nilgiris West and give a talk to the young people at the meeting. The topic was mental health. Judging the competition proved to be tough; all the short movies were very interesting in their content and some were excellently made.

Here’s what struck me. A common theme running through most of the short films was about youngsters experiencing ‘depression’ on facing perceived failure or judgment from peers/family/society.  It was clear that this was an important and relevant area of interest or preoccupation with the young people. In my talk following the short movies I tried to focus on why the concept of ‘failure’ needs to be rewritten and why it’s important to ‘fail’ to learn life lessons.

Over the past few months, with the lockdown and anxiety surrounding Covid 19, a similar pattern seems to emerge. I was invited to a webinar on health/work/life balance organized by Pehla Sukh, India Wellness Initiative. We received over 800 questions prior to the webinar and almost every one of the shortlisted questions was related to ‘stress’, ‘depression’, and anxiety’.  This in combination with the recent spate of suicides over the last month, (two of who I knew very well, were only in their thirties and early forties), leads me to think that there is a kind of collective societal anxiety that is unrelenting and mismanaged.

I am not a psychiatrist and would not attempt to treat or manage clinical depression, but I am fairly certain that many of us today will do very well with meaningful conversations, especially surrounding the meaning of ‘success’ and ‘failure’. There seems to be a generalized angst regarding how we see ourselves in comparison with others and in the context of what is expected of us from others in society. Why this pressure? Are we all not individuals in our own right capable of expressing ourselves in a way we see fit? Do we all need to adhere to societies expectation of what is ‘normal’ in terms of success? What is the definition of success anyway? A flush bank account? An enormous house? An ostentatious car? A  high level job? The number of social media followers? Not that there is anything wrong with any of these aspirations in an of themselves and they can certainly be pursued if one so desires, but, there is no guarantee that any of it will bring happiness or even life satisfaction worth talking about.

The conversation about success, life satisfaction and meaning needs to happen. With the onslaught of social media ‘influencers’ talking about ‘making it big’, it is easy to fall prey to the idea that everyone needs to be ‘successful’ in the way defined by society. Parental pressure may be another reason young people feel less than ‘enough’ and succumb to the anxiety caused by driving too hard or expecting too much, even from themselves.

Having good social connections and at least a few authentic relationships matter in this regard. People who don’t judge you but support and accept you the just way you are matters. If you are fortunate, and if you have put in the effort and investment, (because authentic relationships do require effort and investment), you will have a few such people around you. In times of stress, these authentic relationships are very valuable.

More importantly, the ability to accept oneself even while trying to better oneself matters.  Not allowing other people’s freely given advice, in the pretext of ‘in your best interest’ to adversely influence you is critical.

Stress and anxiety can lead to depression. While depression is very real and may require professional help in the form of psychotherapy, medication, CBT and so on, engaging with meaningful relationships and establishing a supportive environment goes a long way in mitigating stress.

Resilience is the ability to bounce back after set-back. Not just bounce back to your original state but, become even better. Since ‘failure’ is a part of life and every single one of us faces versions of ‘failure’ throughout our lives we need build resilience. Is it possible to build resilience? Some people seem just more resilient than others. What are the common traits and practices of such people? If you have not read ‘Mans search for meaning’ by Victor Frankle, it’s worth reading to understand resilience.

Here are some things we can do to develop resilience –

• Dichotomy of control – Understand what you can and cannot control. Being able to identify what is within your control and trying and change it if required while at the same time letting go of the things one has no control over is an important life view that will serve us all well. In this Covid Pandemic for instance, there’s not much we can do about the decisions governments make regarding lockdowns. There is however our ability to control our own behavior by firstly not giving in to the contagion of fear, maintaining and improving our own immunity by eating healthy, exercising, managing stress, preventing infection to the best of our ability and so on. We can stay responsible for our own health and wellbeing even if we can’t control what is going on around us.
• There is a term in ancient Greek Philosophy called ‘Amor fati’ loosely translated as – love your fate. This attitude of taking on a challenge, accepting it as part of life and even embracing it is an  ‘attitude’ one can develop with practice.
• Surround yourself with authentic, supportive relationships. Social connectedness with the right people can be of great support especially in times of stress. Nurturing such relationships during the long haul, even when you don’t ‘need’ them will ensue they remain when you do. Relationships take effort and time. Take that time and make the effort to maintain good relationships
• Practice self-care. Neglecting oneself by pushing the boundaries of what is advisable health wise for instance or not taking time to cook healthy meals, read, meditate or get help when required can leave us depleted. Have a sound self-care practice. Set aside time to exercise, meditate; take the time to nourish yourself both physically and emotionally. Have a routine. We have to take care of ourselves first if we want to take care of others or withstand testing time.
• Develop self-awareness. Understanding oneself and ones needs is important if we want to be fulfilled. Developing self-awareness is a journey. As we grow in this journey we understand ourselves better, let go of the things or people that don’t serve us well, pay attention to what we truly need and discover what we need to do to achieve it. Sometimes, this journey may be uncomfortable as we discover things about ourselves we don’t like or understand. It’s worth the effort as it makes us more self-reliant and confident.
• Grow in self- confidence. All the above will help one grow in self-confidence. When we lack self-confidence we are inevitably drawn into societal/parental/peer pressure. We don’t serve our own needs but instead are in a constant state of unrest as we look for acceptance and validation in unlikely places. There’s nothing wrong with validation for your efforts. Sometimes it may not come in the time you expect it or from the people you expect it and that has to be accepted too.
• Stay focused. Stay focused on the best route to take to manage the stressful time. You may get plenty of advice on what to do and how to do it. Growing in self-confidence as mentioned above helps us make and stick with our own decisions after contemplating advice if necessary. Stay focused on your self-care, your routine and your own growth. Stay focused on your internal radar.
• Reflect and redirect when necessary – Even as we struggle with decisions or difficult times, we may need to change course along the way. We need to constantly reflect and redirect our efforts. This takes some level of self-awareness and also humility. Accepting our own mistakes or poor judgment, getting help and course correcting is better than bullishly hanging on to an unsound resolution just because you started out with it.

Difficult times are a given. Riding the tide is a challenge but can be managed successfully if we stay mindful of some of the common practices to develop resilience. These will help us thrive instead of just survive.

Dr Sheela Nambiar MD, Obgyn,

Lifestyle Medicine Physician & Fitness Consultant

Sheela.nambiar@gmail.com

Lifestyle change for lifestyle disease.

There’s been a surge in interest in health and wellness among lay people and much of the medical fraternity who are beginning to understand that ‘health & well-being’ is different from ‘medical care’ which is essentially the care of ‘sick’ people. There’s much we can do to prevent disease, especially the kind that is called non-communicable disease or NCD. These chronic diseases, like obesity, diabetes, hypertension, depression, PCOS, metabolic syndrome are lifestyle related and therefore can be prevented, treated and even reversed using lifestyle change.

If we want to change the tide or burgeoning lifestyle diseases in our country and globally, we need to begin by paying more attention to the main pillars of Lifestyle Medicine – Feet (exercise), Fork (diet), Fingers (smoking/addictions), Sleep, Stress & Relationships.   I would add Environment (your immediate home & work environment, sunlight, pesticide, water, toxins etc. etc. ) to the pillars

To many, it seems too simple to be of any real value. Change our daily habits & change our health, wellbeing & lives? Don’t we need medication, tests, surgery and so on? Yes we may need those things. Allopathic Medicine has certainly made tremendous contribution in progressing science and research and  saving lives. But, we also need to be discerning in how we make use of it

There is much of our health and well-being that is within our own control. Let us implement that control using the pillars of Lifestyle Medicine and be empowered to take our health into our own hands.

This webinar on work-life balance that I participated in was based on Lifestyle Medicine and stressed the various modalities one has within ones own power to implement to better health and quality of life. It was hosted by Pehla Sukh, India Wellness Initiative, and CWC from Silicon Valley.

Here’s a part of the webinar on YouTube.

Here’s a link to an article about the event.  

 

 

Dieting Dilemmas – De-stress your diet!

A conversation between Dr Sheela Nambiar (SN) and Shiny Surendran (SS) at the TFL Fitness Studio September 2019

SN: Thank you all for coming.

Shiny Surendran is a nutritionist having passed out from WCC and Ramachandra medical college.

She currently works at Hande Medical centre. What I appreciate about Shiny is her completely down to earth practicality regarding nutrition. I’m hoping that we can have a sensible discussion about diet which is applicable to people in real life.

Those of you who don’t know me, I am Dr. Sheela Nambiar. I am a gynaecologist. I also practice lifestyle medicine which I think is the future of medicine! Lifestyle medicine is an evidence based approach to preventing and managing non-communicable chronic diseases like diabetes, hypertension, depression, obesity using lifestyle measures. It adresses prevention rather than just management of symptoms. We take into consideration – fitness, food, nutrition, sleep, stress, relationships or social connectedness, psychology and so on. Nutrition is a large part.

To set the ball rolling, my first question to you Shiny would be, what is your take on all the popular diets that have been in existence?

SS: The word “diet” itself puts you in a box. It is about a whole lot of restrictions.

Fad diets come around once in 10 years. If you remember, we both attended a conference in 2013. At SRMC. That is when the Paleo and Keto diets made inroads into India and we met a sports scientist from Cape Town, South Africa who talked about the Keto diet.

Keto is a therapeutic diet. it was originally prescribed by clinical dieticians who work with neurologists, largely paediatrics, for children who have uncontrolled epilepsy. The best way to reduce the episodes would be a Ketogenic diet. Now people have taken that and used that for weight reduction. These diets are supposed to be practiced only by dieticians who work with neurologists.

The best thing would be to have a common sense approach to healthy eating because that is what you would sustain for a long time. These restrictive diets do help initially but they are not sustainable because people get tired of eating just paneer, eggs or meat all the time. So when they go back to their traditional food then they are confused! They have forgotten and have even lost touch with what they ate as children. The word carbs or grains really scares them.

SN: Weight is never only about the food that you take in it is? It’s also about many other things in your life like how much you sleep, how much stress you have, psychological factors and etc. Diet/ food/nutrition is only one aspect of it.

If you are obsessed with your diet and if you count every calorie you consume it is a real tragedy! What I find in some clients which is quite disturbing is their preoccupation with the food. They ruminate about what to eat, what not to eat, what to cook, what not to cook, what to order when they go out, what not to order when they go out, what to eat at the buffet and so on. So you wonder, what about the rest of ones life? Are you are so myopic in your approach that everything revolves around food?

SS: Yes.

SN: There is an obsession with dieting solely for the purpose of weight loss right. Like Shiny said the word “diet” itself is restrictive.

I don’t know a single person who has come in and said ‘I want a diet so that I can become healthier’. They only come because they wanted to lose weight. But weight is not the only thing that determines health to begin with.There are healthy people at different sizes simply because a lot of it has to do with your mind and a lot of it has to do with how you live the rest of your life.So for me it is surprising that today you and I have our work cut out for us from the nutritional perspective, just advising people on the simple principles of nutrition which your grand mother could have perhaps advised you on.

SS: So true.

SN:We are now trying to reinforce the same thing, like eat a lot of vegetables, eat whole foods not refined foods, avoid sugar and so on which is old wisdom. We are saying the same thing except that we are sitting in an office talking to people across the table.

I think one of the main problems is the big food companies that make these convenience foods and we have to blame ourselves for buying buying them despite knowing their shortcomings.

SS:Yes.

SN: It started with the whole ‘low fat’ craze. Everything that was ‘low in fat’ was good for you. You never took a look at the labels to see that probably the calories were absolutely the same but worse, the additives for flavour enhancement made these foods more addictive. Now that the whole low fat craze is done with, ‘High fat’ is all the rage. Butter is back!

SS:And coconut oil is back! As you said, “healthy at different sizes”. We are genetically predisposed to be built a certain way, but can you be a better version of you?

Then there is always this emotional aspect of weight. Don’t we all go through challenges?

I would like to share what happened to me. After being married for 11 years and being unable to conveive, we started treatment for infertility. That is when the weight gain started. It was the stress and the medication, the surgeries, the procedures, 3-4 IUIs and then 2 IVFs. At one point I started having suicidal thoughts, I would cry at the movies for no reason or if I was invited to a baby shower, I would find all kinds of excuses not to go.

I went through this for 8-9 years and at one point, somewhere down the line I also became spiritual because when you are pushed to a corner you ask a lot of questions. Then I made peace with certain things. But now, I understand my clients a lot better. I am able to empathize when somebody says I have been trying to conceive, or has a miscarriage, or has lost a child.

The worst part was people commenting on my weight gain! This body shamingis another very important thing. As a culture we are very insensitive. You just have no clue what that individual is going through. There may be tough situations in their marriage, their finances, may have some litigations going on which is messed up, or may have lost their loved ones. They are the ones who end up gaining weight because of the stress, the elevated cortisol, and unstable blood sugar levels. Such patients will need the help of a psychologist to deal with the stress.

SN:. Would you say food is addictive? Particularly Sugar.

SS: Sugar is like a drug. Yes it has to be banned.

SN: Sugar is highly addictive and it has been found to stimulate the same parts of the brain as cocaine which means if you are a sugar addict, getting off the sugar requires help and you really need to take it seriously. There are many clients who would tell me ‘I just want a small dessert after dinner’. Well if you want it every day, if you derive great pleasure from consuming it, if you have cravings and withdrawal symptoms despite understanding the long term effects with consuming sugar and if you still can’t stop, that’s a definition of an addiction.

I think food in general is also addictive simply because unlike alcohol or street drugs, it is easily available, accessible and completely acceptable. Nobody raises an eyebrow when you pile up your plate at a buffet table but they propably would if you go into Tasmac and buy a pile of booze right?

Our society is also geared to encourage this addiction with all the food Aps and so on making even ordering food so easy, especially for the younger generation.

A while ago, there was this craze/popular dietary advise to eat every two hours. What do you think of that?

SS: That messed up a lot of people I know. That was so wrong and I think the big food companies that made snacks made a lot of money.

Guest in audience– It was  the dietician Rujutha that made this popular!

SN: Well there was just no science behind it. I know there is a saying that people love to ‘hear good news about their bad habits’ and this is something like that. If you drink you like to hear that drinking wine is good for you. You start looking for validations.

Guest in audience: Like smoking prevents Parkinson’s.

SS: You are right I think that is a very valid point that you have brought up. Eating every two hours. Every time you eat, the insulin hormone gets triggered. The best solution is to eat 3 well balanced meals or else have two just meals. That is what your ancestors did and they were active all the time. The NEAT or Non Exercise Activity Thermogenesis is increased.

I had a 7-year old with high insulin level and his neck area is darkened (signs of insulin resistance); The parents work till around 7:30pm. The child is taken care of by the grandparents till about 8:30-8:45 pm. The parents pick him up after that and then cook dinner. The kid is in front of the television all afternoon. He is given soft drinks, sweets and biscuits and that’s it; there’s no physical activity. The Indian way of showering love is through food.

SN:It is kind of double-edged sword. And a lot of your childhood experiences, play out in adulthood. If you had a childhood where food has been used as punishment and as reward, it is deeply ingrained in your subconscious mind. You grow up with some mixed messages about food and a very dysfunctional relationship with it. You are constantly guilty about food. You beat yourself up about it so there is a whole lot of psychology and narrative behind it which we need to be aware of.

Shiny, do you think everybody today needs supplements, given the kind of soil food is grown in and the food we eat?

SS: I think it depends on who you are, if you have undergone a surgery, recovering from an illness like malaria or jaundice and where do you live.

I work with a lot of poor income athletes; they don’t even get three square meals, they just grab some street food or tea, butter biscuits and samosas. I have advised them to have fermented rice and peanut. We need to give low cost options. I would tell them to go to a whole sale egg store and usually where the broken eggs are given away; so I said collect that make scrambled and eat that because you are getting protein. Dhal is expensive, about Rs. 80-90/kg

I have seen politician and actors; I have seen an entire spectrum of clients so it is all about customizing. I recommend a multi vitamin if they really need it but otherwise, I strongly believe in eating balanced, nutritious, homemade food.

SN:So what is your opinion on vegetarianism Shiny, with the usual question, can vegetarians get enough protein?

SS:A possible option is to give them moong chila, besan chilla and adai, pesaratuu and dhokla. They largely depend on mushroom, soy protein and milk products like paneer, cheese.

There are people who are allergic to soy and there are people who refuse to eat mushroom That’s when I try to convince them to use some whey protein or flax hem protein.

SN: Tell us something about lactose and gluten intolerance.

SS: You can develop it even as you get older. A Neutrogenomist test would help.

You can either go on an elimination diet where you start avoiding wheat, rice, barley, bakery products, all breads, semolina, sooji, wheat dosa and wheat upma. Biscuits like Marie, Nutri Choice, wheat flakes. So avoid everything of wheat brand and even wheat germ. You will then figure out what causes your allergy.

Or you could just give your saliva sample and get a Nutrigenomics test done.

SN: And do they do it here?

SS:They do it here and they do it in a couple of places in Chennai, one is in Nungambakkam. It takes three weeks for the results.

So if you hav a gluten allergy, you have rice, poha, idli, dosa and idiyappam. Being a south Indian is a blessing, you can do a fantastic gluten free diet..

Guest from audience: What about millets?

SS: Millets are good but only if you stay very active.

Even if you think about food cravings, it may denote a deficiency of a micro nutrient.

If you have cravings for murukku, mixture, fried pappads you could be deficient in Omega 3 Fatty acids for instance. If you have sugar cravings, chances are there that you have magnesium, Chromium and Manganese deficiency. It is about getting these things. Garden crest seeds, walnuts and almonds have Omega 3. At the cellular level, there may be lot of hunger giving rise to these food cravings.

Sleep is also very important as doc said. Sleep-wake timings and circadian rhythm, are important. Years ago, or rather your grandparents, would have eaten dinner ataboput 4-6 pm. They would’ve gone to bed at around 8 or 8.30 and they would’ve woken up at 4 or 4.30 am. That’s Brahma-muhurtham. That’s the most ideal time because we are in alignment with nature. When you do that, automatically everything else falls in place, you don’t mess up with your hormones. So the root cause of all evil is your Netflix, Amazon Prime and binge-watching television and YouTube. You carry the phone to the bed.

SS: Dr Sheela could you throw some light on Positive psychology?

SN: When you think about psychology and psychiatry, it focuses mainly on what is not right with you. Depression, anxiety, schizophrenia and bipolar disorder etc. The main focus was on illness and how to treat it. But when we look at the human beings, there are so many things that are right with us. So, we need to understand how we can we make what is right with us, better. Positive psychology tries to explore how to thrive rather than just survive. There are several studies, which have been done that show that things like resilience, grit etc. which improve life experience are teachable. So, these are the qualities that will enhance a person’s quality of life and enhance a person’s life experience. CBT is part of it.

SS:So, work on your positives, get back to being positive and stronger?

SN:It’s not just about being ‘positive’ or ‘happy’. That’s the misunderstanding of positive psychology. Its more about working on your strengths, and understanding yourself better.  There is a website www.understandmyself.com that you can go to and get the list of your strengths in the order that they work for you.

SS: Very interesting.

SN: Martin Seligman, often known as the father of Positive Psychology came up with the PERMA model.

P is Positive emotion, E – Engagement, R – relationships, M – meaning and A – accomplishment.

So we work on those aspects, that is the positives of a human being rather than only focusing on how to make an ill person better.

Obviously if you are unwell with lets say depression/bi-polar disorder, you will first need to see a psychiatrist to get to ground zero. Then how do you get beyond that? That’s where PP comes in.

Guest in audience –Something that I’ve been facing all my life. It’s the fact that, I think that, this diet or all this restriction is somehow temporary, and you go back to this wonderful world where you can eat everything and then be thin.

SN:That’s exactly what Shiny said about the perception of the word ‘diet’. It has to become a ‘lifestyle’ or a way of eating for life and sustainable.

SS:Let us not focus only on weight. And let us stop the body shaming! At least, the ones here in this audience, I think we can resolve to say let’s not talk about physical appearances alone. Let’s not judge people because we don’t know the kind of battles that they’re going through.

Guest in audience – And we don’t realize that the beauty ideals that we aspire to, the actresses and actors, don’t themselves look like that. She might not look like that the next month.

Guest in audience– Being a sports physician, I’m working with these kids under 16. All these guys want to have six-packs. I told them a body builder, with his wonderful 6-pack is at his weakest when he is posing. I mean, he has dehydrated for 10 days, he has not had any salt. He is probably on some diuretic.

SS:Also on steroids!

Guest in audience –Celebrities have created such unrealistic expectations of the masses and especially young kids, who are so impressionable. And I have to try and convince them that if you look like Salman Khan, you’re not going to be able to throw a cricket ball! That’s what I’m trying to do with these youngsters. To get them to enjoy the game because that’s why they have been selected to the state in the first place, because they’re good at cricket. No one has selected them on the virtue of their height or their weight, so I ask them to focus on their skills and then try to eat the best they can. So we’ve provided ‘sundal’ in the evening for instance. Then I had to fight with the association to get them eggs. Because TNCA is traditionally very bankrupt so getting eggs into the system was very hard.

SN –So now….. we’re way over time and we’ve had a very interesting conversation.

Shiny thank you for your inputs and valuable insights. Thank you all for coming and interacting to make this so much more meaningful!

Establishing the right foundation for fitness!

By Anita Rajesh

Way back in 2006, when I lived in Ooty, I went in for a consultation with Dr Nambiar to talk to her about general wellbeing, weight and so on. As per her advice to start exercising, I joined the TFL group exercise classes in Ooty. To be frank, I was clueless about exercise and the benefits until then. The camaraderie of the ladies in the group class, the music, and the fun fitness clothes attracted me! After that there was no looking back. My form wasn’t great initially,  but I did my best  to keep up, learn the form of exercise, the choreography of the cardio classes and stay with the intensity of the workout.

Graduating in Nutrition and Dietetics complimented my love for fitness, I don’t follow a strict diet all the time, but I am more careful with what I eat or rather, I practice mindful eating!

On relocating to Coimbatore from Ooty, it took me a while to get into a proper routine. Initially I signed up at one of the gyms here. I wasn’t however able to sustain memberships and attendance. I felt there is nothing to beat TFL though! Especially the stretch sessions, the positive vibes and energy.

For me personally, it is important to look healthy, fit and presentable irrespective of the profession I am in or age I may be. Thanks to you Dr Nambiar, who has inculcated this attitude in me, I always keep that in mind! Your books Get Size Wise, Gain To Lose & Fit After 40, the monthly Newsletters and your posts on TFL, Facebook and Instagram page – @tfl.trainingforlife are motivating and indeed very helpful.

Currently, I live in a gated community consisting of about 320 flats. I see that not many women exercise here. It is sad to see that most women, even those much younger than I am don’t seem too concerned about their health or weight. Many a times, they are taken aback, when I say I am as old as I am (at 40).

Lucky me to have been inducted into fitness and trained by a Gynaecologist and Fitness expert. I know that if I hadn’t got trained and motivated in the right way at the start, I would’ve had a very different attitude toward fitness, health and weight. I had a sound foundation in fitness. Thanks again Dr Nambiar for the the education you have been providing for women from all walks of life. You are a real inspiration to many and it’s a pleasure being a part of TFL!

Kudos to you…..Keep rocking!!!

A Woman’s Journey; Changing paradigms.

A conversation between two Obstetricians, Dr Sheela Nambiar (SN) and Dr Uma Ram (UR) at the TFL Fitness Studio, Chennai on their experience with dealing with women through a large part of their lifespan. The paradigm shifts they see, women’s attitudes towards their health and more.

SN – I am sure all of you know Dr Uma Ram. She is a very popular Obgyn in Chennai who runs EVKMC and Seethapathy hospital. She is currently the chairperson for MRCOG south zone and very involved with teaching besides her clinical work.

I wanted to do this with her as both of us are Obgyns. It has been an interesting journey for me over more than two decades as I am sure it has been for you too Uma. This conversation is about insights into what it is like to deal with women through their life spans. For instance, I had a woman who I had delivered 24 years ago bring her daughter, who is now pregnant to me. It’s at times like this that it occurs to me just how long I’ve been doing this!

SN – What has your experience been like over the last 2 decades? Have things changed much? How are women approaching their health today?

UR – Yes and no. Access to information has increased because of the internet. But I think the fundamental issues remain the same because, we as women, don’t prioritise our health.

SN – We often start seeing patients as teenagers, now even earlier, because many of them attain menarche at 10 and 11 years. These kids are brought in by their parents with complaints of a heavy/irregular period or with a ‘diagnosis’ of PCOS. Besides these complaints and ‘labels’, do you think there’s a conversation that’s missing that we, as Obgyns can be part of?

UR – Yes a couple of conversations. I do have them when the opportunity presents itself. One is diet, fitness and lifestyle. Another conversation is about sexual health and hygiene.

SN – The exposure to sexuality is much more prevalent now. The parents may not acknowledge it. As Obgyns if we can broach the subject of protection, and prevention of sexually transmitted diseases and how to say ‘no’, it would help immensely.

UR – I agree. I have run into problems with parents while initiating this conversation. Some feel having this conversation, encourages their kids to go down that road! I find there is a certain level of naivety or blind confidence with many young girls when we have this conversation. They often say, ‘Why are you telling me this? Yes I have a boyfriend, yes occasionally we have sex but I’m sure I won’t contact anythign or get pregnant’.

SN –  What is most tragic is when a young girl gets pregnant and is afraid to tell anyone at home. I have had girls brought to me by the family almost 8 months pregnant, undiscovered until that point having hidden her condition under loose clothes! One can only imagine the trauma she has gone through covering this up for 8 months.

Talking about PCO, and being over weight, the parent often only wants the symptoms to disappear, not realising that the lifestyle is problematic. Can you talk about the future repercussions of a young girl being diagnosed with PCOS?

UR – There’s more to it than just irregular periods. It takes time for the hormonal cycle to settle in and tlll such time you could have irregular period. Every girl with irregular period doesn’t have PCOS but if there is genuinely a hormonal imbalance, then it becomes important to communicate that there is no cure. You can keep it under control with exercise and diet. To some extent medication will work.

SN – The predisposition to gestational diabetes, diabetes, heart problem etc. are more prevalent for a girl who is obese with PCOS. While it seems premature to tell a young girl all these things, these are the realities and they have to be aware that they setting themselves up for all these problems later on in life. If they get themselves a good fitness routine and a healthy diet, it will certainly help them with these very symptoms and later on to prevent other problems

UR –There is also very good data that the babies born to mothers who have had diabetes in pregnancy are more at risk for obesity and cardiovascular disease at a younger age. We don’t realise the potential cardio vascular risk for women. When younger, we are protected from heart disease because of the estrogen. But once you are post menopausal, especially if you are someone who has had diabetes and/or high blood pressure in pregnancy, the risk of having cardiovasuclar disease later on life is quite high.

SN – True. We always consider men as being more prone to heart attacks. The risk is equal once the woman attains menopause and more so for those with metabolic syndrome, obesity etc. I think this has to be stressed to women.

We were just talking earlier about the choices women have. Unlike in the west, where women domostly make their own decisions, here most women cannot. In India everyone from the uncle to uncles uncle … have a say in the matter!

UR – It amazes me for instance that during labour even if the woman wants epidural for pain relief, she will need to ask the mother-in-law! These are upper middle class, educated people who you want to believe are empowered. I sometimes wonder about empowerment if you can’t make the choice for your own pain relief.

I will never forget this incident, wherein this woman had come with her to discuss the date for induction of labor. The very next day someone from her husband’s family, claiming to be the uncle came to ask me if the girl had chosen the date herself. I explained that we had given her an option and she had said she would discuss it and get back to us. When the girl came in for admission, she revealed to me that the husband’s family had been very upset and the husband abusive, short of hitting her, because he thought she had made the decision on her own!

SN –  Is it a no win situation for women in India? For a majority of women they are not allowed to make decisions.

To the audience – how has it been for you all?

Guest 1 – I live in a joint family so I had no choice with even bringing up my children! It was all done very lovingly though. They would tell me it is a ‘joint decision’.

UR – It also depends on the relationship between the couple. If they have a good relationship, they put it across to the elders in the family in such way that they get what they want. That is possible. I am not saying it always goes against what the woman wants but what I am saying is, more often than not, it’s not her absolute decision. It always needs validation from the family

SN – Post 40 years many women start to come into their own.They may say, ‘to hell with society’, not necessarily rebelliously, but they really want to ‘find themselves’. Many find they are bolder and want to make bolder, independent choices. Could that be the age/maturity or hormones. What is your opinion on that ?

UR – I think it’s because they feel that their responsibility to their children is done. They have the time and space.

SN – Around the peri menopausal period, the children have left a home, perhaps the husband has his own life, bunch of friends etc. Maybe she is home and doesn’t have much to do. The hormones are falling….. it’s a combination of many things. Yes depression is very common around the peri menopausal age.

So the conversations usually start with ‘what else can I do?’. I advise them to start with exercise. One can exert control over that one hour in a day and then, when you get control of your body, see it change and feel good, you do feel empowered. Even if you are not able to break out of, lets say the family situation, you feel better equipped to cope with the current situation. Exercise puts you in a better frame of mind. Most of the time that’s what it is. You can’t change the current financial or family situation. You just learn how to deal with it better.

UR – I think it is the way the community and the  family sees the woman’s place in the workforce and in the family.

Q1 – Do you think they are conditioned from their young age that their main job is procreation?

SN – Most definitely!

SN – What’s your take on pre-marital counselling? How many women come for counselling?

UR – It’s increasing, not a lot but yes it’s increasing. They come to talk largely about contraception. Mothers bring their daughter sometimes. Increasingly, couples come for pre-pregnancy counselling.

SN – Can you tell us about the changes that a woman goes through after she is pregnant and has had a child, not in terms of the physicality, those are obvious. Im talking about the paradigm shifts in her emotional and psychological state.

UR – There is definitely a huge change. As we say, when the child is born, the mother is born. She has no idea what to do but it is expected of her to fit into that role with zero preparation. Until that point, during her pregnancy, the focus is on her and then it shifts completely to the baby. Some slip into the role easily, but some find it difficult. They have no time for themselves, they are no longer able to do what they did before. I find sometimes the family is not supportive. They believe you should ‘just do this’.

SN – Do you see a lot of post partum depression?

UR – We see more anxiety in pregnancy. Some of it maybe that our traditional systems exist but we just don’t trust them. Other times, there is no one to give the traditional advice to the women like before. There is much on the internet that produces anxiety. There is this expectation that everything should be ‘just so’ for this generation. Then there is the need for instant gratification. All of this could produce anxiety.

SN –You have been witness to relationships, mothers and daughters, mothers-in-law, aunts and all of that . How influential do you think these relationships between women are?

UR – I think they are very influential. Sometimes the woman has no other female connections and that can have a negative influence.

SN – I find both from my practice and from personal and social connections, the greatest influences have been women for other women. This is the case even when a male in the family may hold the purse strings. The influences run much deeper with women. It need not be a family member, just somebody she can connect with emotionally.

Moving on to another topic, in our culture, perhaps worldwide, having your own child is of paramount importance. You have the trauma of infertility. Irrespective of if the woman really wants a child, often after marriage, having a child becomes almost mandatory.

Now you are seeing a lot of women opting not to have children. Do you see this more often now and how are they coping?

UR – Yes, we are seeing some women choosing not to have a child. The pressure to have a child is still very high. Lots of girls are brought in after just 6-8 months of marriage to help her conceive.

SN –And often the choice is not really hers?

UR – I don’t think they have a conversation around that at all.

Sometimes, 8 months to a year after marriage, some family memeber will bring her to us saying she hasn’t conceived yet. Then when we speak to the girl, she will say, they havent even been trying yet, but they havent told the family as that would upset them!

As the obgyn, we then have to tell the family memeber everything is ok with the girl, give them another 6 months. We have to convince them. This is a role which when I was younger I actually found very difficult to play . My biggest learning experience from my being an Obyn is that women are often in situations that you and I could never imagine. That is the wisdom that has come from so many years of dealing with women.

Q2 – What are your thoughts on delayed pregnancy after 30 years of age?

UR – Biologically, and I am sure Sheela will agree, mid to late 20’s is the best period to have babies. Yes, there are infertility treatments to solve the problem but it’s not smart to push beyond 30 unless there is a compelling reason.

SN – Fertility drops post 30/35. Although we do see first time mothers at 38/40 years, the risks of complications in pregnancy are higher.

Q3 – Is there advancement in the detection of abnormal babies?

UR – Yes there is a lot of advancement in detection of abnormalities. Fact is nearly 98 to 99% of babies are normal even at maternal age of 38/39. Balancing your need for a career and having a baby can be hard.

Q3 – Is that the reason why we see too many fertility clinics?

UR – Yes I think it could be due to the fact that infertility is increasing. It could also be that it’s a much more lucrative prospect for healthcare investors. It’s a bit of both.

SN –  It is definitely lucrative and it is also emotionally charged. People are willing to pay how ever much it takes to have a child. Infertility is much more prevalent now than, say 20 years ago when we started practicing and the reason for that is definitely lifestyle. In women PCOD, metabolic syndrome etc. which can lead to infertility, are definitely lifestyle related. In men, their sperm count may be low because of lifestyle related factors such as smoking, drinking, stress and obesity

UR – Sheela, I don’t know if you see this in your practice, but the pressures of work can prevent conception! I tell them, go take a holiday. So while we spoke about pre-martial sex and early onset of sexual activity, there are couples who simply don’t have the time to have sex! That’s the truth. They come in and say why don’t we consider some treatment because we are unable to coordinate our schedules! Very often couples are investigated extensively over months and bring in huge files, only to find they have not had the time to actually have sex during this whole process! So, to some extent, the medical profession has to take stock of how we manage this problem.

SN – I don’t see too much of that because most of my patient population, which is more rural, don’t work! Yes, the husband may come home drunk often and therefore the opportunity for having sex is decreased, but I don’t think ‘work pressure’ is the main issue there.

UR –When women complain of irregular cycles, it’s becasuse they are not ovulating. When we tell them to lose weight, they are more willing to take medication rather than implement diet and exercise.

SN – But..when obese women do conceive, the incidence of gestational diabetes is higher they are also setting the stage for the child. The child born to gestational diabetes woman, has a greater propensity for diabetes herself. Even the mode of delivery affects the child. A child born by a vaginal delivery, swallows fluid from the mothers birth canal and its gut microboism is different from one born of a cesarean section. There is a study that found that children of caesarean have a greater propensity for diabetes. Everything, from our mode of birth influences our health. So we have to do the best that we can by managing our lifestyle better. Having a caesarean versus a normal delivery may be beyond your control, but how you lead your life is not. We should therefore be more careful during pregnancy, eat healthy and so on.

SN – Moving on to Menopause – What are your thoughts on HRT and should women take them?

UR – Today the understanding is that you don’t benefit much by going through HRT except when you have severe symptoms. We prescribe it for a short while and taper it off. HRT for eternal youth is not acceptable because the risks are much higher than the benefits going forward. If ovaries are removed or one has early menopause it is best to take HR until the age of 48 or so.

Q4 – Sometimes, I feel fear. Is that because of menopause?

SN –Do you mean anxiety? Yes it could be because of the loss of estrogen during menopause. It usually settles down. Natural sources or estrogen like organic soy, exercise and eating a plant based diet does help. Definitely avoid processed foods and sugar as these are pro-inflamatory. Meditation, relaxation techniques help.

I have noticed that women who exercise and eat healthily, seem to sail through menopause. I don’t know if symptoms are less or they are able to handle it better.

It also depends on everything else going in our lives, not just the menopause. Where you are in life, your spouse, your children, in-laws and so on. If you are in a traumatic/toxic relationship, the anxiety levels are definitely higher. Social relationships become very important. Sleep is another important aspect. If your hot flushes are considerable, especially at night, your sleep is disturbed and you’re anxiety increases.

Q5 – What about the feeling for heaviness of the breast?

UR – It is a response to the hormonal change.

SN – Mammogram and self breast exam, are very important.

Q6 – If there is a history of breast ot ovarian cancer, is there a test available in India

UR – Yes, BRACA. If you have 2, first degree relatives, your risk for certain types of cancer is higher. You can do a BRACA testing right here in cancer institute. Then the question arises, what are you going to do about it if it is positive?

The test shows you have the gene for breast cancer and if you have the gene, there is a very high chance that you can develop breast or ovarian cancer. I had a patient who had the gene and she got cancer when she was 58. She wanted her daughter to do the test but the daughter said she didn’t want the test. She was only 28, wasn’t married so knowing she had a positive gene wouldn’t make a difference as she wanted to keep her fertility and have a family.

We would recommend the test if you have a strong family history. If you have the gene, more surveillance is required till you decide what to do about it. That may mean removing your ovaries. If you have BRACA 1 gene and you removed the ovaries and the tubes, you have significantly reduced but not completely eliminated, the risk but the risk of breast cancer.

UR – It’s a good practice to have a mammogram at least once in 2 years and a cervical pap smear atleast once in 3 years. The recommendations are post 40 years but if you have a high family history you start 5 years earlier than the the youngest person with cancer in your family. If you are in high risk and you have your mammogram annually.

SN – Any other questions?

Q7 –What about Soy intake?

SN –That’s a question that’s come very often. The studies done showing soy as a cause for cancer used very high intake of soy on a dialy basis. We can safely eat it a couple of times a week.

If there are no more questions, lets wind up. Uma thank you very much for your time and this very interesting interaction.I hope you all enjoyed it as much as we did!

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Power over diabetes – Conversations at TFL

A conversation between Dr Sheela Nambiar, MD Obgyn (SN) &

Dr Jayshree Gopal Endocrinologist (JG)

Date – 1/6/19 at the TFL Fitness Studio, Chennai

SN – A big warm welcome to Dr Jayashree Gopal, Senior consultant in Diabetes and Endocrinology  at Apollo hospitals, and Seethapathi Clinic. Founder of DiabIndia and recipient of many, many awards. She’s also a very dear friend from way back in medical college and we’ve known each other for over thirty years now!! For those of you who don’t know her, I am really glad you came today because her knowledge & the understanding of diabetes as a disease as well as well as its progression is so well-rounded that I hope we can have an interesting discussion.

One of the reasons I chose Diabetes is, as we all may be aware, we in India have the proud privilege of being the Diabetic capital of the world!!

So my first question is to you Jayshree is, why is our country in such a position today?

JG –That’s actually a fascinating question. A lot of people have propounded theories why so many Indians are at risk of being diabetic.

There are 3 main reasons –

One – our carb intake. We eat a lot of carbs and are unable to burn off the carbs we eat.

Two – we have less muscle mass than the Caucasians.

Three – it is also believed that we inherently also have less pancreatic insulin secreting cells, that is the beta cells.

So it is a combination of genetic factors and the food that we eat.

SN– When you say ‘Carbs’, you mean the bread/cerea/ grain group that is the rice, rotis, poha etc.? Just to be clear, since vegetables also contain mainly carbs.

JG – Yes. A typical Indian diet is about 80 to 90% carbs. Every time we eat carbs, our insulin level tends to spike. Not so much with proteins. There is also some difference between animal protein and vegetable protein like lentils which make your body produce little more insulin. With animal protein like eggs, fish & chicken, the insulin spike is slightly less.

If you load your body, with easily digestible carbs like rice without enough fibre or protein to compensate for it from a very young age, you tire the working of the the beta cells. By the time you discover you have diabetes, you have lost 50% of the pancreatic function. The pancreas has been overworked for years. If your fasting blood sugar crosses100, you are already compromised.

Question from audience –So it has been proven that carb overload is affects your pancreas?

JG –Absolutely

Question from audience – Why are we then not changing our dietary pattern?

SN –It is a very difficult (but not impossible) to change something so deeply ingrained and cultural. If you look at the whole of India, our main food is a carbohydrate, usually reifned.

JG – Thats a good question!!If you can go off carbs, that would be wonderful. I myself have been trying to go low carb for a while. The worst diet to try low carb is a south Indian diet. If you go sit in woodlands for breakfast, you realise that other than the chutney, everything else is high in carbs, be it the dosa, idli or pongal!

The usual question is, we have been eating like this for so many years, how is it that we have changed? If you look at a person working in a construction site they dont have any fat on them, yet they eat a carb rich diet. So physical activity is important. In studies done with people on a low carb diet, those who want to include carb, understand when to include it. They include it just before or after an intense work out. In other words, if you are going for a carb heavy meal, make sure you burn it off.

SN – So you were talking about the Indian pheno type, wherein we Indians are inherently born with less muscle mass. Since that’s the problem, do you think even the way we exercise is really not apt for our body, because most people do a lot of cardio and very few actually train with weights to increase muscle mass. The objective should ideally be to increase the muscle mass as that’s where the problem lies. So, would you say the very approach to exercise could be the reason for this problem?

JG – I think you are the right person to answer your own question!

SN – I think it is, isn’t it?

JG – In fact I will be interested to know what you do in your out-patient clinic. You get women from a wide spectrum of society to exercise in your practice.

SN –Yes I do insist on weight training even for women who are from backgrounds that are not traditionally used to the concept of weight training.

JG – How do you do that?

SN – We start with own-body-weight training and then progress. The interesting thing is, once they start to appreciate the strength of their own body, they are happy to include external weights. Regarding their diet, they are also able to change from the mainly high refined carb diet to a diet rich in vegetables, (which are also carbs but water based like gourds etc). I manage my Gestational Diabeteics with just diet and exercise.

Do you think Diabetes is reversible?

JG – I think it depends if you pick it up early enough! Like I said, by the time diabetes is actually diagnosed, fasting sugars are at 140mm/dl -150mm/dl and Post prandial is over 200mm/dl. By then you have already lost a chunk of your pancreas.

When I say lost, I mean, its just not working and how much of it is reversible varies between individuals. Studies have shown that a person with good insulin sensitivity would probably have a fasting sugar of 80/85mg/dl. 100mg/dl is just a arbitrary number for us. Anything over 100 is impaired fasting glucose. Warning bells go off for me when the levels reach 95mg/dl.

SN – What is the current upper limit for postprandial sugars?

JG – 140mm/dl 2 hours after the start of a meal is ideal. When you start eating, the body starts to make insulin. Ideally the lower the post-prandial, the better. You may have noticed that when you have only protein, lets say an omelette, your PP does not rise above 90mm/dl. If you have even one idli or one slice of bread, it can shoot up to 160 or 170mg/dl depending on your insulin sensitivity.

SN – Besides the food and exercise, what are other factors to consider? Can high stress levels trigger diabetes?

JG – Stress, I think acts in a more indirect way. When you don’t have time to eat right or don’t make the effort to exercise it has an impact on your lifestyle. In that way, stress cn lead to diabetes.

SN – How about the abundant intake of sweets? Is that also directly related to the development of diabetes?

JG – It’s not only the glucose in sweets but ultimately all the carbs. Carbs in any form whether as sugar, rice ragi, oats; even millets that are very popular these days! The main difference with the millets is their glycemic index. GI or Glycemic index is the level to which your blood sugar rises after you eat something. Pure sugar is considered to have a GI of 100. Compared to that plain, white, polished rice would have GI of 95 depending on studies. So it’s almost equal to sugar. Something like red rice or hand pounded rice would have a GI of about 70. I think initially when you are trying to control blood sugars, GI does make a difference, but ultimately it all comes to the carb content

When people eat high carb meals, the sugar levels rise and drop very quickly. This is a very common complaint, (particularly among women). Around 11am, or 2 hours after breakfast, their sugar levels drop, they feel they’re getting into “low sugar” as they call it. They start sweating, get palpitations, just don’t feel well and have sit down for a while. This is to do with the rapid drop in sugar following their very high carb breakfast.

Question from  audience – Are carbs necessary?

JG – We don’t need it at all.

Question from  audience – So what should we should eat when you have a carb craving?

SN – ‘Craving’ for a particular food is more indicative of an ‘addiction’ to that food. Please remember that carbs can be very addictive. Sugar, affects the same parts of the brain as cocaine and heroin.

Comment from audience – But I need to have my sweet after my meal.

SN – So, would you consider that an addiction?

Comment from audience – It makes me feel good and I believe my body really needs it.

SN – Yes, you could interpret it that way. That’s what an addiction is! In a sense you are saying it makes you emotionally comfortable but from a physiological perspective, you don’t ‘need’ it.

JG – You really don’t need it. From a health perspective nothing is going to happen if you don’t eat it.

It is interesting to see how we used to eat 50 to100 years ago. We ate differently, just twice a day. I think that has changed. To answer your question about why diabetes is more common, we are eating 3 to 4 times a day now!

There are other things to consider – Changes occur in our body when it starts to get dark outside. We should try and eat before the sun sets. Now we have artificial light and we tend to eat later and later. Studies have shown that artificial light at night, especially for women, causes more weight gain. Studies on the Eskimo population and light at night indicates that it is one of the reasons for increas in breast cancer.

SN – Speaking of our ancestors, our lives are very different from what theirs used to be. We don’t work like them, our stress levels are different. Like Jayshree said, artificial lighting, our computers, our sleep time, the stressors we have….. everything is different. We need to adapt to our lives today in positive way by eating less refined foods, moving more and so on! What we do however is adapt in the worst possible way by responding to stress with sugary, refined foods for instance.

Jayshree, what do you think about the fad of eating several frequent meals, or snacking every 2 hours?

JG – I think that was the worst fad to come about because every time you eat, you produce Insulin. Insulin is an anabolic hormone. It makes your body store fat. Infact, it is a fascinating hormone because there is no other hormone like insulin. All other hormones are counter regulatory to insulin. One of the reasons a low carb, high protein, keto/ paleo kind of diet works is, your body is not constantly producing insulin. Coming to the question of eating 6 times a day, that’s absolutely the worst thing.

SN – I would also add that there is another drawback to eating frequently – when you eat so often, you stop recognising signals of real hunger. To begin with, right from the time when we were children the hunger instinct is blunted when adults load the plate of the child and force-feed it. Your ability to recognise real hunger is being compromised to the extent you don’t recognise it. You eat a meal because it is 1pm or you perhaps your fear not being able to get food later! We don’t listen to our bodies neither are we mindful of our bodies.

Question from  audience – What if you really can’t get food when you are hungry?

SN – The body can use fat as fuel. When you are hungry and there is no glucose available for energy, your body can use fat as fuel and we have lot of it! You don’t have to be worried that your body will completely disintegrate just because you haven’t eaten a meal. In fact it’s a good thing to be hungry sometimes because then, it can tap into your fat stores.

JG – Most of the glucose in our body is stored as something called glygogen, present in the liver and muscle. If you don’t eat all, it takes about 36 hours for your body to get rid of all the glycogen from the liver.

One of the reasons why carbs is preferred as a source of fuel is that it is very easy to digest. If you look at the bio chemistry of it, it takes very few steps to digest the carb and get the energy out. The body has to work harder to digest fat. That is why we store the fat and use it only when needed.

So when people do a low carb diet like keto/ paleo or other versions of it, it takes about 2 weeks, or 10 days to switch from a carb metabolizing physiology to a fat burning one or what we call ketosis where the body is breaking down fat.

Initially people describe the keto flu that you go through where you get muscle aches and pains. Some people find a change in bowel habits and suffer constipation when they switch to a keto diet.

Question from  audience – Is it good to stop your carbs completely and have only protein and fat?

JG – I think it depends on what you are trying to achieve.

SN – Is that sustainable is another pertinent question?

JG – For about 2 years now we have been running a low carb clinic. I have been looking at people, even those with diabetes attempting it. I have been encouraging even long standing diabetic to try.

An average Indian diet has about 300 to 350 gms of carb/day. Even if you reduce this by 50%, the sugar levels improve. If you want to actually lose weight, then you will have to go further down. We have estimated you can easily cut it down to 50/70 gms carbs in a south indian diet and maintain it there.

Question from  audience – Will your body go into keto-acetosis when you eat a keto diet?

JG – You only go into ketosis. The acid levels do not build up. Acid levels will build up if you have diabetes type 1 that is insulin dependent, where your body doesn’t make insulin. When you go into ketosis however, the ketone levels not the acids, build up. So they are 2 separate things, ketoacidosis and ketosis

Question from  audience – What about carb loading for workign out?

SN – Carb loading is a complete myth

JG – What do they do?

SN – This was practiced for long duration endurance sports like marathons. The night before the event, you would carb load, (eat a lot of pasta and the like). Your liver then stores the glycogen. It was believed that glycogen store was required for a long duration sport like a marathon. Prof Tim Noakes who wrote “Lore of running”  actually talks about carb loading in the first edition of his book. He was a marathon runner and then became diabetic (for which he blames all the carb loading!). He then went on to revise his advise in the book. He has now gone completely low carb/ hi fat.

So this concept of low carb – how do we do this in the Indian setting, especially if you don’t eat meat?

JG – Keto is when you are restricting your carbs to less than 20 gms a day and for people who are not familiar, one idli has 15 gms of carb. One cup of rice is about 40 to 50 gms depending on the size of the cup, one chapati has15 gms, one dosa -15 gms. Lentils also have carbs. Even almonds and peanuts have carbs. If you are able to achieve 70 gms a day, you can find significant improvement in sugar. You will definitely lose weight but more slowly.

I don’t subscribe to the high fat. I don’t agree to it or recommend it. I don’t think it is right at all. One thing I would say however is, when following a low carb, do not be afraid of fat. I have learnt that often, the craving is not for carb but for fat. It’s very counter intuitive but if at the time of a craving, you have a spoon of almond butter or peanut butter, your craving goes away.

Fat however causes problem when you combine it with carbs. So you have to be very strict about the low carb part of it before you start increasing the fat in your diet.

SN – What about refined seed oils (sunflower and so on)?

JG – Avoid refined oils. There is a community out there debating the usefulness of nut oil vs seed oil. They think seed oil is responsible for all our ills and nut oil is ok. Coconut is ok.

Question from  audience – My daughter in law is diabetic. Now she has cut down her food and trains to lose weight.

SN – The weight loss in itself is beneficial for diabetes. A 10 kilo weight loss can lead to the reversal of many of the problems of diabetes depending on how bad they are. Just managing the sugar and staying overweight is not good enough.

JG – the UK has taken it up in a big way. The diabetes association in UK is doing a lot of work in reversal of diabetes. They did a big study and showed that you can reverse and cure idiabetes. They followed up diabetics for 6 months to one year. If you go back to eating the carbs and regaining the weight, the diabetes comes back. If you manage to keep the carbs low and exercise regularly, you are free of the disease. So they actually call that state “post diabetes”.

Question from  audience – We have been told that eating whole wheat bread instead of eating white bread makes a difference. Is that true?

SN – Wheat itself may be an issue for many people. You could be allergic to gluten, so if you have a gluten allergy, it is better to avoid it completely. Having said that, both whole wheat and white bread are high in carbs. They belong to the same bread/ cereal/grain group. You still need to restrict that and I have my own suspicion about it being ‘whole wheat’ when made commercially. More like just coloured bread.

JG – Exactly! I don’t think it makes a difference. Both are bad. The glycemic index is probable less with red rice and something like hand pound rice. It’s to do with the fibre content. So eating whole wheat bead is not the answer.

SN – If there are no other questions, we will wind up here. Thank you so very much Jayshree for this very interesting conversation and for giving us your valuable time to chat about this extremely important subject! Thank you all for coming, We will continue to have more such Conversations.