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.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Depression – the 21 century epidemic? Conversations at TFL

A conversation between Dr. Sheela Nambiar MD, Obgyn – (SN) and

Dr. Ennapadam S Krishnamoorthy  – (ESK), Behavioural Neurologist & Neuropsychiatrist.

SN – Welcome to you all. We are happy to be here to discuss this important topic of depression. Dr Ennapadam Krishnamoorthy is a Neuropsychiatrist and Behavioural neurologist. He is the Founder of the Buddhi Clinic chain which offers complementary and alternative medicine, in addition to, standard neurological & psychiatric care and psychotherapy solutions.

SN – Why would you say the disease of depression has become an epidemic of the 21^st century? Is it something that we are calling out more or are people more depressed than say, 20 years ago?

ESK –We understand today that depression is one of the most common medical problems worldwide, a cause of dysfunction and debilitation. At one end it is just a feeling most of us will experience at some point in our lives, due to life circumstances or, a loss. Sometimes it might last for a short spell. At other times it may last for a longer period of time and affect our lives. That is when it becomes a disability.

Let’s say, I break a leg – it is a very apparent disability. But, when I am depressed, no one else may know what I am going through, because it is so personal and internal that it cannot be communicated to others. It is a transient feeling but that which disables an individual and prevents her/ him from having a normal life.

A meta-analysis from BMJ looking at how depression has progressed actually shows that the rates have dropped from 36% to 24% in patient clinics. The paper also says you are more likely to be depressed in your 30s and 40s and then late in your life. So it’s a “U” curve. So I’m not sure if it is indeed more common than before.

SN – So what is the difference between feeling low and having a clinical depression?

ESK – The difference is in the severity.  Is it significant enough to need attention?  How long has this gone on? The duration can be as less as two weeks.   But the most important thing to ask oneself is – ‘is it preventing me from having a normal life?’ If it is, one needs to pay attention to it.

SN – What is really interesting to me is that everybody has problems. I don’t think anyone gets away without problems. How is it that some people are able to withstand them and not become depressed, whereas others having similar issues get depressed?

ESK –  So in your introduction you used the term “bio-psycho-social”. The Bio part of it is how each of us is wired. This is a combination of genetics, early upbringing and the like.  This is when the brain develops.

Your ‘Bio’ is influenced by your genes, by the chemistry in your brain, certain inflammations like the antibody syndrome when your body is attacked by something, the body responds by creating antibodies but which then turns against your own body’s cells.

There are metabolic factors that cause depression. These could be hypothyroidism, low B12, D3, having diabetes, and certain skin conditions like atopic dermatitis.

We, then, come to Psyche which is your temperament.  Certain temperamental patterns, like worriers, obessesive anxious people may be more prone to depression.

There are Social-environmental factors which include parenting, family, outside influences etc

So, the question “why am I getting depressed”? has multiple answers – we all have emotional scars of various kinds, some we may not even remember. We also have nurturing factors that make us stronger. People who are worriers, obsessional, anxious, tend to be more prone to becoming depressed than people who take things in their stride and just move on.

SN –And there is some research on how more creative people tend to be more prone to depression is there not?

ESK – Oh yes. There is a lot of literature on mood swings and creativity. There are a number of examples of poets, artists and people in the creative field who were depressed. That’s also because depression is more of a right-brain than a left-brain phenomenon. Having said that, there are forms of depression that are left-brain too. There is a social aspect to depression, one interesting statistic is that you are seven times more likely to have a mental health problem in the 6 months after your marriage than in any other time in your life!

But interestingly there is another counter-statistic is that one of the things that makes sure that you have a good outcome from a mental health problem is being married.

ESK – Women are twice as likely to experience depression in their lives than men are. Due perhaps to all the life events they go through and the hormonal changes.

SN – Hormonal fluxes can be quite drastic from menarche, to pregnancy and delivery to menopause. These events do influence a woman’s mood. Would you say that social support also plays a role in depression?

ESK – Absolutely. Both in protecting you against depression and in helping you overcome it. Having a good social support system, work and employment, activities you resonate with and a healthy financial status.

SN – I deal mainly with women being a gynaecologist.  I find that women, once they cross the age of 40 or so, find themselves wondering what else to do, now that their children are independent, and probably have ;eft home. Once they are given the right support, they make a change that they perhaps could not attempt in their 20s and 30s. It may be maturity or that after a point they no longer want to please society, norms or the people around them all the time. One of the triggers for this change is that they start to feel depressed about their situation. Have you come across situations like this?

ESK – Absolutely! Menopause/Perimenopause also plays a role. Mood, memory etc. are affected around this time. Apart from life circumstances, there are biological changes that are happening so symptoms of depression etc. can set in.

SN – What do you have to say about this concept of depression being connected to ‘weakness’ and the stigma behind it? Does this hold back people from coming forward to get help? In fact, even family members may brush it off saying, “you need to get over it”.

ESK – That is the most common thing we say, “pull yourself together’. But they cannot! That is why one needs to understand that it is a disability. If one were paralyzed, one would not say “get up and walk”.

There is, also, a burden of expectation we all place on ourselves. The expectation – to be normal and fulfil our obligations. When you are depressed, however, these obligations may seem big.  Getting better, just like with a paralysis, is a slow process.

SN – Can you tell us the different symptoms experienced by a depressed person? Do different personalities express depression differently?

ESK – Children and elders express depression differently. A child might be irritable, agitated or angry. Elders might also show similar signs. Though they are both likely to be depressed. In adults, it can be expressed as low moods, or

“Anhedonia” which is the inability to feel pleasure in things you would normally find in, “Hedonism”- to seek pleasure mindlessly, or “Alexithymia” which is the difficulty in verbalizing an emotion.

Language has an interesting connection with depression. There is no word for depression in Tamil for instance. There is no word to say I am depressed in Tamil. You only express things like ‘the mind is tired”.

There are linguistic barriers to expressing depression. Our culture does not encourage you to express your emotions like Western cultures do. Most of us would not for instance, go on the Oprah Winfrey show and talk about our glorious or miserable lives! This is because our culture does not encourage us to express our emotions. People often use ‘as if” terms to talk about emotions rather than talk about their emotions directly. In a number of Indian and other native languages also lack words for certain emotions. Friends from Africa tell me they don’t have a word for depression.

SN – Coming to the treatment of depression, can you tell us something about anti-depressant drugs?

ESK – Anti-depressants have had some bad press. But they have a unique mechanism of action. We used to think they correct the chemical imbalance in the brain and that is what relieves symptoms depression. We now know that some of these drugs actually help to grow new neurons. They have a neuro-protective effect. This may be why they take a long time to produce relief from symptoms.

Antidepressants take a long time – 6 weeks to 3/6 months. The most common reason for ineffectiveness of treatment is non-compliance to treatment. The second is the failure to try a drug at an adequate dosage for an adequate period of time. So, often, if 3 months later you don’t feel better, you may change your doctor, your drugs etc.

 All drugs have side effects, of course. I think a patient should try anti-depressants under the guidance of a good doctor before they give up. In my experience, most people give up the treatment too easily. It requires a therapeutic alliance between patient and doctor.

SN – Can a patient go off the drugs completely at some stage?

ESK –You cannot stop them suddenly, they need to be withdrawn slowly and gently. Typically, the drug needs to be taken for at least 6-9 months.

SN – Have you come across many patients who complete the course of drugs and do well?

ESK – Depression is one condition where you can actually say you are “cured”. The chances of cure become better when besides taking medication you do other things like psychotherapy.

Psychotherapy helps you understand the roots of your depression. Where is it coming from? It reflects the gap between expectation and reality. So, it is important to engage in good therapy and use this opportunity to understand oneself.  Good psychotherapy will help you prevent further episodes as well.

SN – So Cognitive Behavioural Therapy would be one such form of Psychotherapy?

ESK – Yes, absolutely

SN – Talking about prevention and lifestyle management of depression, I would like to add about why exercise is so important for the management of depression. Exercise does produce endorphins; it makes you feel better and puts you in a better frame of mind.

Diet is also of utmost importance. The gut produces as much if not more serotonins than the brain. The microbiome in the gut is responsible for much of your mood. If you do not feed the gut with the right kind of food, the microbiome in the gut is altered. It has been shown that people with very poor eating habits – highly processed food, sugar and so on have altered microbiome and are more prone to depression. Something as simple as a change in your diet and exercising on a regular basis can be a support system to the medication if you need it.

SN – What can you typically expect from a psychotherapist?

ESK – A good therapist is not someone who will tell you what to do. They will not advice you what to do. Instead a good therapist will show you a mirror to yourself. She/he will be able to help you understand your emotions and verbalize them.

A therapist is a professional, and has no prejudices. All the solutions are within us. We may not see them. So, we may need the help of a good therapist.

SN – Is depression genetic?

ESK – Yes, when the Human genome project was underway a number of single gene disorders were discoved. Certain  disorders of brain and mind also got unlocked. General thumb rule is that 10% of people have a genetic form of neurological or mental health condition.

Talking of psychotherapy – Everyone may not be suitable for psychotherapy. You cannot offer psychotherapy in all stages of depression. You may need to work with some people in other ways.

SN – Lets open the floor for questions

Question – When you are looking after family member with depression, how do you deal with them when they don’t comply with medication? What is the right approach when they refuse to take responsibility?

ESK – The role of the family and in having someone empathetic is important. Sometimes, when the patient refuses to come to the hospital we, at Buddhi Clinic will send someone to their home to try and engage with them. Using holistic care like Yoga and Ayurveda, (which is offered at Buddhi clinic), we can get them started on a self-care journey.

So, engagement, having the family involved, offering people courses that they truly believe in and are willing to explore have a hugely beneficial effect on the management and better cure of depression. I became interested in these other forms of treatment after I found that often people with mental disorders when they try alternative forms of treatment like yoga etc. they are told to stop all other forms of treatment. So I decided why not offer them everything so they can continue their medication when required and also have the option of other treatment under supervision. We don’t understand the power of what other systems can offer.

A friend of ours who does research on Yoga has shown that after a set of Yoga sessions which are aimed at improving mood, the brain changes are the same as taking medication.

SN – With reference to this first question it is important to also rule out other disorders isn’t it? It may not be pure depression. It is possible that it may be a combination of mood disorders, psychosis and so on?

ESK – Thank you for pointing that out. It is important to recognize that what seems to be depression may be something else. It could be a disorder of the brain or body.

SN – It could be a simple deficiency like a B12 or D3 deficiency.

ESK – Yes or it may be an inflammatory condition of the thyroid for instance. Thyroiditis that is completely treatable.

Question – Is it true that depression can teach you something and it is there for a reason? Can the person be depressed because he needs to withdraw and ponder?

ESK – That’s a very interesting question. If you read the life stories of Ramakrishna Paramahansa, Jiddu Krishnamurthy and others you will find that for many, transformation and realization started with depression. “Pathos” is the word used. That does however, not hold good for everyone.

ESK – One of the things we have not mentioned about depression is the Becks Triad – this is the negative view about the world, the self and the future.

CBT is circled around this thought process to identify the thoughts that are making you depressed and work on how you can re-think.

Today we also have Transcranial Magnetic Stimulation TMS. For some this works very well. It modulates your brain and makes the chemicals more available. We have this treatment available at Buddhi Clinic. You need 20 sessions of about 30 minutes each. No anaesthesia is required.

Question – What do you advice people who are the caregivers of depressed people?

ESK – It has a profound effect on the family and caregivers. Caregivers go through a lot of stress. An important part of caring is to also extend it to the caregiver.  Caregivers go through guilt, blame and remorse. Usually the psychotherapist is the best person to discuss this with.

You don’t always have to do something active with a person who is depressed. Just sitting with them, going for a walk with them, listening to music may be sufficient. Just being there sometimes makes all the difference.

Question – What is the relationship between substance abuse and depression and what effect do they have on each other?

ESK- It is a kind of chicken-and-egg story. With some, being depressed may make them turn to substances like alcohol.  In others, the alcohol is the problem and leads to depression. So, the drinking and the mood may be cyclical.

Questioner – What about food? Is that also a form of substance abuse?

ESK – There is a lot of association between eating disorders and mood. Anorexia and bulimia are associated with mood disorders. So, eating disorders and mood disorders can co-exist in a number of people. One can influence the other, the treatment of one can cure the other.

SN – There is evidence that obesity is related to depression and vice versa. So, when you are depressed, you reach for food as comfort, gain weight and then you get more depressed. Frankly I think food is as addictive as any other substance (abused), because it is so easily available, acceptable and accessible unlike alcohol and drugs. Especially sugar, not just white sugar but processed food that has added sugar is highly addictive.

SN – I would like to thank Dr. Ennapadam S Krishnamoorthy who has been so generous to spare his valuable time to come here and spend this hour with us to discuss depression. It is silent, pervasive and so easy to miss. If you have any doubts about anyone (including yourself) heading down that road, there is no stigma. It is like any other disease. Just as you would not hesitate to go to a doctor to treat gastritis, there should be no stigma associated to going to a psychiatrist. I hope Dr. ESK has made it clear and that is all the more reason we should pay close attention to it.

You can connect with him at the following address – poorna@buddhiclinic.com

Phone -+91 9500010065/67