APRIL JUNE 2013
ISSUE 21
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THE CARIBBEAN HEALTH DIGEST
Questions and answers about Human Papillomaviruses and the
HPV VACCINE One life to live, many to save... BBC’s David James Fenton, introduces us to two young women who have undergone liver surgery and changed their lives. Coconuts Nature’s own sports energy drink. Exercise and the elderly The benefits of exercise and fitness for people of a more "seasoned" age group. uhealthdigest.com
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DISEASE
|
CELI AC DIS E AS E
C E LI AC D I SE A SE
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DISEASE
CELIAC
DISEASE GLUTEN ALLERGY
& GLUTEN
SENSITIVITY
DIFFERENTIATING
BETWEEN THE THREE It seems everywhere I travel lately, there are more and more gluten-free cafes and bakeries. A greater number of restaurants have gluten-free options on their menus. Gluten-free groceries are increasingly visible on the shelves, not to mention from a plethora of online business vendors. It is plain to see that gluten-free has become a multi-billion dollar business here in the United States. WRITTEN BY MEZAAN
BELJIC
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DISEASE
|
CELI AC DIS E AS E
Recently, I had a conversation with a woman who was following a gluten-free diet for the purpose of weight loss. She has never been diagnosed with celiac disease, tested positive for gluten allergy, or displayed signs or symptoms of non-celiac gluten sensitivity, but opted to follow the diet (without the supervision of a doctor or nutritionist) for the sole purpose of weight loss. My research into this diet “fad,” as it has been dubbed, led me to more questions than answers surrounding gluten and all it implies. To help clear up some of the confusion surrounding gluten, I recruited the help of my husband, Dr. Steven Beljic, a gastroenterologist.
CELIAC DISEASE Celiac disease is an autoimmune condition that affects the digestive system; specifically, damage occurs to the inside lining of the small intestine. This damage leads to malabsorption of vital nutrients that are necessary for good health. The consumption of gluten, a protein found in wheat, barley, rye, and perhaps oats, is responsible for triggering this immune reaction which can occur at any point in life.
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There is great variability in the symptoms from one sufferer to another, which likely explains the delay in a confirmative diagnosis of celiac disease. Abdominal pain, nausea, vomiting and diarrhea may occur. However, patients may also report experiencing constipation, bloating, gas or indigestion,
lactose intolerance, increased or decreased appetite, foul-smelling/bloody/fatty stools, or no issues with their stools whatsoever.
uncommon for patients diagnosed with celiac disease to also have other autoimmune disorders such as rheumatoid arthritis or lupus.”
Malnutrition and vitamin deficiencies can affect many important organs and systems including the brain, bones, liver, endocrine organs and nervous system. As a result, a patient with celiac disease may also complain of non-gastrointestinal symptoms such as fatigue, headaches or migraines, joint pain, depression, skin rash (itchy skin—dermatitis herpetiformis), hair loss, mouth ulcers (canker sores), numbness in the hands or feet (neuropathy), dental and bone disorders, anemia, unexplained short stature, growth delay in children, easy bruising and bleeding. Female patients with celiac disease may suffer miscarriages and develop infertility.
“The treatment,” he says, “is to follow a lifelong gluten-free diet. This is a diet that is difficult to follow. You have to avoid such things as bread, pasta, processed and baked foods, cereals and beverages etc. that contain gluten, but doing so will help keep symptoms away and help manage this incurable disease. Celiac disease often runs in families. Fortunately, commercial genetic testing is now available to help determine the risk of developing the disease if you have a relative that has been diagnosed with celiac disease.”
According to Dr. Beljic, “There are blood tests available to help diagnose celiac disease. The most sensitive and specific are anti-tissue transglutaminase antibodies (tTGA) and anti-endomysium antibodies (EMA). These are usually positive in patients with celiac disease, providing the patient has included gluten in their diet prior to testing. Next, a biopsy of the first portion of the small intestine (the duodenum), may show flattening of the finger-like projections (called villi) along the inside lining of the small intestine. Damage to the villi results in less surface area of absorption within the small intestine. Considering that your small intestine is about 20 feet long, this is significant. It is not
GLUTEN ALLERGY With gluten allergy, upon ingestion of gluten (one of 4 proteins found in wheat), one’s immune system perceives gluten as an allergen, considering it foreign and dangerous, and produces an allergy-causing antibody. A hypersensitivity response, or IgE-mediated response, ensues, which includes the release of histamine by mast cells. Histamine is responsible for a lot of allergy symptoms such as a rash, itching, and swelling. One might experience mild symptoms, including shortness of breath, coughing, wheezing, vomiting, diarrhea, and abdominal cramps or life-threatening symptoms consistent with anaphylaxis. Anaphylaxis can include severe breathing difficulty, chest pain, swelling or tightness of the throat, difficulty swallowing, pallor, dizziness and fainting.
C E LI AC D I SE A SE
Wheat allergy is one of the more common food allergies in children but less common in adolescents and adults. It develops during infancy through early toddler years and commonly occurs with other food allergies. Children are at increased risk of allergy if their parents have similar allergies. Most children outgrow wheat allergy by age five. Dr. Beljic clarifies, “Unlike celiac disease, which is an abnormal immune system reaction to gluten, and which affects the small intestine, wheat allergy does not affect the small intestine to cause damage. Once again, avoiding exposure to gluten is the best treatment. Given this difficult task, antihistamines may prove beneficial after exposure. For those with anaphylaxis, injectable doses of epinephrine should be carried at all times. A family physician, pediatrician or allergy specialist can help parents diagnose and manage a child’s wheat allergy.”
NON-CELIAC GLUTEN SENSITIVITY Dr. Beljic reports, “Only in recent years have clinicians acknowledged that gluten may be a problem (at best, a nuisance), for many in the absence of celiac disease. Non-celiac gluten sensitivity is not clearly defined in the medical literature, but it appears more and more people are falling into this category. The prevalence of celiac disease in the U.S. is about 1% but researchers estimate for every celiac disease patient, there is anywhere from 6 to 30
non-celiac gluten-sensitive patients.” He adds, “the symptoms of each can be very similar and often the terms are erroneously used interchangeably, but it’s important to note that celiac disease is an autoimmune disease that attacks the lining of the small intestines, which can lead to malabsorption. There is a clear genetic factor for celiac disease, but more research needs to be done to see if there is a genetic component for non-celiac gluten sensitivity. “Also, the gold standard for detection of celiac disease is detection of flat villi (atrophy) through an upper endoscopic biopsy of the small intestine (although, the aforementioned blood tests are about 98% sensitive and specific). Those with non-celiac gluten sensitivity test negative for celiac disease and wheat allergy but notice that their symptoms resolve when gluten is eliminated from their diet. It is not uncommon for those with gluten sensitivity to also have other food intolerances such as to lactose and soy.” Knowing that wheat proteins are food additives used to help some processed foods stick together and add texture, many theories exist to explain the apparent rise in the number of gluten-sensitive individuals. Increased selective wheat breeding, genetically modified wheats, plants, and foods, environmental toxins, questionable safety standards for gluten (given the majority of gluten is imported from foreign countries), increased hormone ingestions, and increased
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DISEASE
intestinal infections are some of the factors mentioned in association with the recent rise in gluten sensitivity.
THE “TAKE HOME” In summary, regardless of whether you have celiac disease, wheat allergy, or non-celiac gluten sensitivity, the treatment is to follow a gluten-free diet. This is best determined and implemented under the advisement and supervision of your physician and dietician to monitor your intake of vital nutrients and to prescribe supplements accordingly. In the case of celiac disease, severe symptoms and complications may occur, despite eliminating gluten from the diet. These patients would need immunosuppressive medications. A gluten-free diet can be a difficult, frustrating diet but fortunately more and more gluten-free foods are now available. One has to read labels carefully, watch out for cross-contamination of foods, and be wary of products such as cosmetics that also contain gluten. The increased market for gluten-free appears to reflect an increased demand and rise in gluten sensitivity, whose etiology (causes and origins) and long-term effects have yet to be clearly determined by research.
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VIRUS
| QUESTIONS AND ANSWERS ABOUT THE HPV VACCINE
QUESTIONS AND ANSWERS ABOUT THE HPV VACCINE 16 | u
WRITTEN BY STAFF
WRITER
QUESTIONS AND ANSWERS ABOUT THE HPV VACCINE
|
VIRUS
Following the recent wave of controversy in Trinidad and Tobago over the administration if the HPV vaccine, Gardisil, to girls of primary school age, U The Caribbean Health Digest addresses the issue head-on, offering you clear and simple answers to the questions you might have. Advising us is Dr. Kumar Sundaraneedi, Medical Director for Health Programmes and Technical Support Services in the Ministry of Health. Dr. Sundarneedi is in charge of the Ministry’s expanded programme for vaccination.
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VIRUS
| QUESTIONS AND ANSWERS ABOUT THE HPV VACCINE
WHAT IS HPV?
According to a World Health Organisation (WHO) position paper dated April 10, 2009, Human Papillomaviruses are a family of more than 100 viruses, some of which are associated with the formation of certain cancers, especially of the cervix and genital area, and the mouth and throat. Human Papillomaviruses are DNA viruses that cause skin lesions in keratinocytes (cells) of the skin or mucous membranes. There are two categories of HPVs; high and low risk. High-risk papillomaviruses are HPVs-16, 18, 31, 33, 35, 39, 45, 51, 55, 58, and 59, which are often found in cancer cells. HPVs that produce skin lesions are low-risk HPVs, but HPV 6 and HPV 11 are associated with genital warts. HOW PREVALENT IS CERVICAL CANCER IN TRINIDAD AND TOBAGO?
When the infection persists — in 5% to 10% of infected women — there is high risk of developing precancerous lesions of the cervix, which can progress to invasive cervical cancer. This process usually takes 10–15 years, providing many opportunities for detection and treatment of the pre-cancerous lesion.
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Locally, approximately 125 cases of cervical cancer are diagnosed in T&T each year, which is fairly high for a population of 1.3 million people. Of these women, 85-90 women unfortunately die.
Cervical cancer is also the second leading type of cancer in women in Trinidad and Tobago. According to Dr. Sundaraneedi, this high incidence and mortality is due to a general reluctance to have regular screenings, which includes annual Pap smears. By the time an abnormality is discovered, the cancer is often at a late stage that is difficult to treat. Sadly, this is true throughout the third world: 83% of all deaths as a result of cervical cancer are diagnosed in developing countries. This is in sharp contrast to the low incidence of cervical cancer, and very few deaths from the disease, in developed countries like the USA. This is because women there are much more proactive in routine PAP smear screening. WHAT IS THE HPV VACCINE?
There are actually two types of vaccines that are widely available on the market: Gardisil and Cervarix. Both protect against HPV 16 and 18, but Gardisil also protects against HPV 6 and 11, which cause about 90% of all genital warts. They are both licensed and approved for use by FDA. HOW IS THE VACCINE GIVEN?
The vaccines are given as intramuscular injections, at precisely timed intervals. The second and third doses of Gardisil are administered 2 and 6 months after the first, and Cervarix at 1 and 6 months.
WHY ARE ONLY GIRLS GIVEN THE VACCINE?
Boys are also eligible for the vaccine, but most immunisation programmes focus on girls because • Increased coverage for girls is more effective and cost-effective than including boys, regardless of the suggested male coverage level. • Also, the vaccine produces higher antibodies that fight infection when given at this age, compared to later. As a matter of fact, men are far more likely to transmit the virus to their partners, says Dr. Sundaraneedi. But girls are given priority, because, of course, only they are at risk of developing cervical cancer. AREN’T THESE GIRLS BEING GIVEN THIS SHOT TOO YOUNG?
Not at all. “The vaccine is most effective in people who are ‘naive’ to HPV exposure,” says Dr. Sundaraneedi... in other words, before they have had their first sexual experience. “Once they have been exposed to the virus, the vaccine does not necessarily protect them from developing cervical cancer from HPV type 16 and 18.” For this reason, girls are offered the vaccine between the ages of 9 and 13 in most countries. This will also give their systems more than enough time to develop an immune response before they are sexually active.
QUESTIONS AND ANSWERS ABOUT THE HPV VACCINE
DOESN’T GIVING THE VACCINE TO A YOUNG GIRL INCREASE THE CHANCES OF HER BECOMING PROMISCUOUS?
It’s a common fear that the knowledge that she is protected from a serious sexually transmitted disease will encourage a young girl to become promiscuous, and this is probably part of the reason parents are reluctant for their daughters to get the shot. But research has shown no link between immunisation and increased promiscuity. WHY ARE GAY AND BISEXUAL MEN ADVISED TO GET THE VACCINE?
Since men are responsible for most of the transmissions, it’s a good idea for men to have the vaccine. Of course, they can’t get cervical cancer, but they are at risk for many other cancers. The HPV vaccine is also available in the private sector. WHAT ARE THE SIDE EFFECTS OF THE VACCINE?
All medical interventions, including vaccines, bring with them the possibility of side effects. As the HPV vaccines are still fairly new to the market, their effects are being closely monitored by VAERS (Vaccine Adverse Event Reporting System) and VSD (Vaccine Safety Datalink) in conjunction with the Centre for Disease Control (CDC) and the Food and Drug Administration (FDA) in the United States, with countries across the globe submitting their reports regarding adverse events.
According to the CDC, the risk of severe side effects, or even death, are extremely small, with life-threatening incidents being most often caused by severe allergic reactions. However, some of the adverse events related to the HPV vaccine that have been reported include pain, nausea, headache or mild fever. Some vaccinations, regardless of type, may also result in fainting, so it is recommended that patients sit down for 15 minutes following the injection. There have also been reports of blood clots. Overall, however, the reported level of side effects don’t differ greatly from those of other vaccines. WHO SHOULDN’T GET THE HPV VACCINE?
Dr. Sundaraneedi stated that GARDASIL has not been demonstrated to prevent HPV-related outcomes in a general population of women and men older than 26 years of age. Pregnant women are also not included in the recommendations for HPV vaccines. The vaccine appears to be safe in HIV-positive children and adult men. You also shouldn’t have it if you have experience severe allergic reactions to any other type of vaccine. It should also be avoided during pregnancy and lactation. HOW ELSE CAN YOU AVOID EXPOSURE TO THE HPV VIRUS?
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VIRUS
It’s also possible for an infected woman to pass the virus on to her baby during delivery. Proper condom use can minimise but not eliminate exposure, as HPV can live on skin not covered by the condom. “Sometimes infected individuals don’t know they have the virus,” he explained. This makes it easy to unknowingly pass it on. ONCE YOU HAVE THE VACCINE, ARE YOU IN THE CLEAR?
No, as the vaccine only covers cervical cancer caused by HPV type 16 and 18, which is about 70% of cases, you will still have to continue with regular Pap smears: women aged 21-29 still need a Pap smear every 3 years, and women over 29 should have a smear once every year for 3 years, and then every 3-5 years thereafter. Remember that, since the vaccines are still fairly new, having been introduced barely six or seven years ago, there is no long-term data about its efficacy and effects, but so far, post-licensing data suggests that its safety profile is “acceptable”. As parents, therefore, it’s important to consider and help protect your daughters from cervical cancer. Vaccination can help, and it’s a good idea to talk to your healthcare provider about it.
HPV of all types are mainly transmitted by sexual intercourse, but can also result from other types of sexual contact, including manual and oral stimulation.
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FOOD
| IS GENETICALLY MODIFIED SOY AS SAFE AS THEY SAY?
IS GENETICALLY MODIFIED SOY AS SAFE AS THEY SAY?
|
FOOD
IS GENETICALLY
MODIFIED
SOY AS SAFE AS THEY SAY? WRITTEN BY DR
Soy is a food we give little thought to. Yes, soy sauce is a must for our pot of fried rice and we’ll dash some on the Chinese take-away, but, in the Caribbean, soy itself is hardly a traditional food. Pigeon peas and lentils can be found bubbling in our pots, but how many of us cook soybeans? Still, lots of our babies drink soy milk formula and many women consider switching to, or adding soy milk to their diet as they approach age 50, in the hope of reducing breast cancer risk.*
AMANDA JONES
Locally, soy is the main ingredient in meat alternatives on the market for vegetarians. But burger and sausage meat packaged as chicken, beef or pork as well as many snack foods also contain soy by-products. Soybean oil is no longer considered a healthy option, but it continues to be widely used due to cost considerations. You may have noticed it mixed in with less expensive versions of “olive oil”—if you take time to read labels at the grocery!
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FOOD
| IS GENETICALLY MODIFIED SOY AS SAFE AS THEY SAY?
Different types of GM soy are developed to bring different benefits for the industry. The type grown in the USA and Argentina withstands a powerful herbicide known as Roundup.
While the food industry continues to make wide use of soy, production and supply of genetically modified (GM) soybeans has expanded. First introduced in the 1990s, more than 80% of soy produced in the USA now is GM-soy. Argentina now uses more than 50% of farm land for GM soybean cultivation. Much of this GM soy is then fed to livestock all over the world. Though you may be barely aware of it, GM soy has been in the food chain for more than 15 years. Different types of GM soy are developed to bring different benefits for the industry. The type grown in the USA and Argentina withstands a powerful herbicide known as Roundup. How? The Roundup Ready Soy crop can detoxify the herbicide when it enters the plant cells, so the weeds are exterminated and the crop survives.
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COULD THIS PROCESS POSE RISKS? The bio-technology industry predicted less weedicide would be needed with the introduction of Round Up Ready Soy. In the first few years this proved true – till the weeds developed resistance. Now this GM crop needs nearly twice as much weedicide as the conventional crop.
Of course, use of chemical sprays is a standard process for many modern farmers. Yet a closer look at Roundup does raise some concerns.
(The placenta is the medical term for the afterbirth. Do note that these tests are done on living cells in a laboratory and not on live pregnant women!)
Glyphosate, the active ingredient in Roundup, has been found in Denmark’s drinking water at five times allowable levels. However, industry experts had expected glyphosate would be fully broken down by soil bacteria. Was there too much glyphosate for the bacteria to break down?
In an animal cell study, Roundup, but not the active ingredient glyphosate, disrupted the cell cycle. The cell cycle is the routine of cell division used by many types of body tissue for regeneration. Such findings lead to critics’ concerns that Roundup residues may add to cancer risk.
Though glyphosate is highly toxic to human cells exposed directly in the lab, its use pre-dates the Roundup formula by about two decades. Residue limits were established, as for other pesticides, to protect the public from high exposures.
Roundup, unlike glyphosate, can penetrate leaves. Of course, Roundup Ready crops are able to detoxify most of the herbicide within their leaves. But the ingredient which allows this penetration has been explained as the culprit that allows Roundup to penetrate human cells in the labs.
Interestingly, the introduction of Roundup Ready crops meant that regulators in the US needed to increase the allowable residue limits by 3 times so the new system would not breach the limits!
But are Caribbean consumers at risk? After all, though we don’t have tight regulation on pesticide use, we cultivate neither Roundup Ready soy nor canola.
HOW MUCH IS TOO MUCH? The non-active ingredients of Roundup make it more toxic than glyphosate alone. Roundup is at least twice as toxic as glyphosate to placental cells, even at concentrations 90% below those found in agriculture!
Could there be Roundup Ready residues in the processed soy products we and our livestock consume? What about other Roundup Ready crops like canola or corn or beetroot? Are all residues washed off ? As for the absorbed Roundup, do plants detoxify every toxic molecule in their cells?
IS GENETICALLY MODIFIED SOY AS SAFE AS THEY SAY?
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FOOD
What if you knew that mice fed Roundup Ready soy had abnormalities to their liver cells which indicated both increased cellular activity and increased activation of cell genes?
ASSUMING ROUNDUP IS SAFE, AREN’T GM SOYBEANS AND BY-PRODUCTS SAFE? GM foods are classified as GRAS in the USA: Generally Recognized As Safe. The industry says adequate research has been done to assure us that GM food equals conventionally grown food in nutrient balance, allergy risks and safety. Large scale trials involving human subjects are not required for GM foods to be approved in most countries and little industry research is available to the general public or even the independent scientific community. So is the Anti-GM lobby just paranoid? Actually, the fears expressed are not mere speculation. Early alarm bells were sounded by scientists, not a paranoid public. Prior to 1999, allergy researchers in the UK found that soy allergies affected 10% of the public. After the introduction of Round Up Ready soy, that figure jumped to 15%. Later research showed that GM soy and natural soy had different protein profiles after all. Allergy to GM soy specifically (but not natural soy) was demonstrated by a real patient using skin prick testing.
One allergen was found to be 27% higher in Roundup Ready soy than in natural soy, and heating did not breakdown the allergen. If you and your loved ones are not prone to allergies, you might shrug that off, but what if you knew that mice fed Roundup Ready soy had abnormalities to their liver cells which indicated both increased cellular activity and increased activation of cell genes? These changes were reversible on switching the mice to non-GM soy feeds. (Phew!) Russian studies from 2005 are also worrying. In three repeated experiments, rat pups whose mothers were fed Roundup Ready soy before conception, during pregnancy and nursing and who were then weaned onto Roundup Ready soy, had a death rate five times higher than those fed non-GM soy. Two hundred and twenty-one rat pups were studied in these experiments. Vital organs were smaller and body weight averaged 13% less for rat pups exposed to the GM-soy. Both pups and their mothers from the GM-fed group showed anxious and aggressive behaviour. The pups that survived were sterile (unable to conceive) till the females were mated with males who had been fed a non-GM diet.
Animal studies are typically done to look for red flags that could suggest human risk. It is unethical to perform such research on human subjects unless animal studies strongly suggest the safety of experimental products. But until GM foods are required to go through both rigorous and independent studies, we can only hope that we are faring better than the Russian rats.
*Whether soy added to the diet reduces or increases breast cancer risk is unclear, as research findings have not been consistent. Though some women do switch to soy milk hoping to benefit, this observation is not a recommendation. Nonetheless, soymilks labelled as ‘not from GM soybeans’ or ‘organic’ are available. Now that you have more information, you can make a more informed decision about acceptable levels of risks as you choose your food.
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SURGERY
| ONE LIFE TO LIVE, MANY TO SAVE
ONE LIFE TO LIVE
MANY TO SAVE I have filmed all sorts of operations, all around the world — but I doubt if any have affected me as deeply as the surgery which I saw and recorded for the BBC in Trinidad. WRITTEN BY
DAVID JAMES FENTON
BBC TELEVISION HEALTH CORRESPONDENT
WAS AT WEST SHORE MEDICAL HOSPITAL IN PORT OF SPAIN to follow the work of British liver surgeon Dr. Neil Pearce. He was leading a team of British and Trinidadian specialists who were operating on six patients in three days. It was a hectic schedule which involved early starts and late finishes — sometimes the team were in theatre for twelve or fourteen hours a day, without much of a break. But more of that later.
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My job was to tell the story of two of those patients who both happened to be young women. One, Cherise Couri, is 19 years old and well known on the island because of the LIV (Life is Valuable) movement, which she set up to help raise money for her liver operation and for others with similar conditions.
The week before her surgery a huge concert was held in the O2 Park, with Machel Montano and musicians from across the Caribbean supporting Cherise and her family. Everyone I spoke to seemed to have either been at the concert, or heard about it, or had bought the T-shirt.
ONE LIFE TO LIVE, MANY TO SAVE
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SURGERY
INTENSE: Surgeons from left, Dr. Tim John, Dr. Celestine Ragoonanan and Dr. Neil Pearce in theatre at Westshore Medical during one of the procedures.
Cherise needed at least $250,000 TT to remove two tumours from her liver. The surgery was complicated by the fact that she has already had a lifetime of treatment for cancer — having been diagnosed with it as a baby at just 13 months old. The surgery was far from straightforward, but Dr Pearce was hoping to do the operation using keyhole surgery. This is now a commonplace in many operations, but not on the liver. As an organ that is filled with blood, it's technically difficult to operate on laparoscopically (via keyhole surgery), and the skills involved are complex and fraught with difficulties. However, when successful, it affords a much better recovery for the patient, and less pain.
The second patient was Shelomith Thomas — a 16-year-old girl from St. Vincent who was flown in at short notice for her operation. She had a massive and life-threatening tumour on her liver which needed immediate treatment. But there was a problem. Unlike Cherise, her family had not had enough time to raise the $25,000 – $35,000 US needed for her surgery and aftercare. When I spoke to them they had raised less than half. That might have been the end of it, but through a combination of resourcefulness, determination by her doctor in Barbados and the two aunts who accompanied her — plus the efforts of Kathleen 'Terri' Gonzalez organising things at the hospital end — she was able to make it onto the operating list as the last patient of the trip.
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SURGERY
| ONE LIFE TO LIVE, MANY TO SAVE
'I'm excited about it, and little bit nervous,' she had said. 'But mostly excited.' 'Why excited?' 'Because I can't wait to be well again.' I first met Shelomith on the day of her operation. She is a tiny slip of a girl with cane rows and big, watchful eyes. When I interviewed her, my overriding impression was of a young woman who had endured a great deal of pain and uncertainty and who was now confronting major surgery with dignity and faith. I asked her, 'What will you do when you wake up after your operation?' She thought for a moment and said, very quietly, 'First, I will thank the Lord for saving me, and then I will ring my daddy.' It was an answer of such simple honesty and hope that after that there did not seem very much else to say. Oddly enough, Cherise had expressed similar, optimistic sentiments when I asked what she thought of her operation.
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'I'm excited about it, and little bit nervous,' she had said. 'But mostly excited.' 'Why excited?' 'Because I can't wait to be well again.'
Perhaps it was something peculiar to those two young women, or perhaps it is something in the Caribbean nature, but I rarely hear such things said when I speak to people in England about their operations. Nervousness, yes; trepidation; sometimes fear, but rarely excitement about being well again. I could write a great deal about both operations — but as my film programme has yet to be made and will feature Cherise quite prominently, I will use this space to talk a little about Shelomith. She went into theatre with the surgeons knowing they had a difficult job ahead of them. The size of the tumour on her liver was extraordinary - about the size of a small football. This in a slender girl who carried not an ounce of extra weight. The team knew exactly where the tumour was, the problem would be in extricating it from her body without causing major haemorrhages to the important blood vessels which had grown around it. Dr. Tim John led the operation with Dr. Pearce and Trinidad surgeon Dr. Celestine Ragoonanan assisting. It lasted four hours. This was not keyhole surgery — but even though a large incision had been made, extracting such a huge tumour from the body would prove difficult. Inch by inch, the team worked their way towards freeing it. The theatre was full of staff; nurses, doctors and specialists had all gathered to watch and help with the procedure. This is not the place to describe in technical terms the finesse and delicacy of the work, but it was slow and concentrated - and utterly absorbing.
ONE LIFE TO LIVE, MANY TO SAVE
The skill and dedication of the medical and nursing teams had been obvious
but there was something else which struck me about both operations that was equally obvious, but less easy to talk about: and that was the question of money.
Finally, the thing which had threatened Shelomith's life came out. And it was incredible to see; literally the size of party balloon. It weighed more than 2kgs, nearly five pounds. Shelomith of course was completely unaware of all of this. Later, in the West Shore Medical Intensive Care unit, I went to see her. She was sedated and sleeping and her vital signs were all good.
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SURGERY
She plans to return to St. Vincent, to her family and her school, within a month. Hopefully she will then be able to get on with being a teenager and enjoying her life. The skill and dedication of the medical and nursing teams had been obvious but there was something else which struck me about both operations that was equally obvious, but less easy to talk about: and that was the question of money. In one case (Cherise) the funds were available, while in the other (Shelomith) they were not. And yet both young women, with much to live for and with an optimistic hope for the future, were being treated by the same surgeon and in the same hospital. Clearly this kind of healthcare is expensive; equipment must be paid for, staff too. I don't know how West Shore Medical arranged for the aftercare of young Shelomith, or what sort of treatment she will get when she returns to St Vincent. I can only applaud the fact that somehow — by a strange combination of events — a surgeon from England travelled five thousand miles to operate on a seriously ill girl, who was then cared for at a private hospital without having the funds to fully pay for it. Of course, money is important, we all know that. But at the end of the day — as Cherise would no doubt remind us — it is life that counts, and life is valuable.
Two days after that, she was sitting up in bed and four days later she went home to her aunt's house in Diego Martin — where I understand she has been doing well.
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NUTRITION
|
DI ET AND S L E E P
the
connection. WRITTEN BY MICHELLE
ASH, REGISTERED RED DIETITIAN, MPH, RD RD, DIP.
The usual prescription for a healthy lifestyle includes a healthy diet and regular exercise. Most people, however, often overlook the importance of sleep. Experts recommend a minimum of seven to eight hours of uninterrupted sleep every night. Believe it or not, the way you eat can affect your sleeping patterns. And a lack of adequate, restful sleep can lead to poor health. Skimping on sleep speeds the aging process and promotes disease by increasing the level of stress hormones in your body.
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If you are getting less than seven or eight hours of sleep a night, you are probably aging faster than you need to. The good news is that you can undo the damage by reforming your sleep habits.
D I E T A N D SLE E P
|
NUTRITION
facts about sleep • Skimping on sleep increases stress hormones, which
accelerates the aging process. • Under-sleeping increases insulin resistance, which is a
risk factor for Type 2 diabetes (US Dept. Health and Human Services). • Sleep deprivation affects hormones that regulate
appetite—making you feel hungrier than you would if you were well-rested. • If you’re losing weight, getting more sleep enhances fat
loss (as opposed to lean-tissue loss).
Diet is related to sleep, and, conversely, sleep patterns also influence eating patterns and body processes. the diet & sleep link Diet is related to sleep, and, conversely, sleep patterns also influence eating patterns and body processes. For example, food deprivation for a few days increases deep sleep only in the short term, whereas prolonged food deprivation and starving decreases deep, restful sleep. On the other hand, sleep deprivation affects appetite. Having short periods of sleep increases appetite and risk of weight gain.
what should you eat to get better sleep? Carbohydrates Carbohydrates have recently been getting a bad reputation in the dieting world. However, they are actually vital to the human body to carry out everyday living processes. You can improve your sleep by eating more plant foods that are rich in carbohydrates, such as ground provisions, whole grains, peas, beans and fruits. Such foods tend to produce a slow, steady rise in blood insulin that helps a type of amino acid (a protein unit) called tryptophan to enter the brain. Tryptophan is used to make a brain chemical that helps bring about sleepiness and also boosts your mood.
Avoid caffeine, alcohol, excess sugar, nicotine, and other chemicals that interfere with sleep Caffeinated products decrease a person’s quality of sleep. Caffeine is a stimulant that can keep you awake. So avoid caffeine (found in coffee, tea, chocolate, cola, and some pain relievers) for four to six hours before bedtime. Similarly, smokers should refrain from using tobacco products too close to bedtime. Although alcohol may help bring on sleep, after a few hours it acts as a stimulant, increasing the number of awakenings and generally decreasing the quality of sleep later in the night. It is therefore best to limit alcohol consumption to one to two drinks per day, or less, and to avoid drinking within three hours of bedtime. Sugary treats eaten just before bed can also interrupt sleep patterns, since they may cause your body temperature to rise and leave you restless. TIP: Swap your regular pre-bedtime hot beverage for chamomile tea. It works as a mild tranquilizer and a sleep inducer. Lighten up on evening meals Eating a pizza at 10 p.m. may be a recipe for insomnia. Finish dinner at least 2 ½ to 3 hours before bedtime and avoid foods that cause indigestion. If you get hungry at night, snack on foods which (in your experience) won't disturb your sleep; for most persons such foods are usually dairy foods and starchy or whole grain foods. Balance fluid intake Drink enough fluid at night to keep from waking up thirsty—but not too much or so close to bedtime that you will be awakened by the need for a trip to the bathroom. An 8-ounce cup of water, juice or warm milk may be just enough.
Swap your regular pre-bedtime hot beverage for chamomile tea. It works as a mild tranquilizer and a sleep inducer.
Nutrition questions or concerns? Feel free to email the author at michelle.ash.tt@gmail.com and get your answers in your next issue. 33 | u
MENTAL ILLNESS
| THE DISEASE OF STIGMA
You’re married with a happy, healthy baby girl. She grows up and all seems well. As time goes on you sometimes find her behaviour a little odd, but you think she is just being difficult, moody... a typical teenager. She gets older and you become accustomed to her mood swings or often strange behaviour, but she appears to be functioning, capable of a normal routine, so you don’t really pay too much attention. One day her behaviour escalates, becomes more extreme, more bizarre…it scares you. Your husband becomes annoyed, frustrated. He will not talk to you about your daughter. You’re fearful. Your family won’t discuss it with you; they say she’s “gone mad”. You take her to a doctor. Your happy, healthy baby girl has been diagnosed with a mental illness. Your world stands still.
Then come the comments from neighbours, the whispers, the nasty remarks, the crude jokes, the silent retreat of friends and family from your life and your child’s. What do YOU do? How do YOU handle it?
The disease of
Stigma. 34 | u
WRITTEN BY MAIA
HIBBEN
THE DISEASE OF STIGMA
|
MENTAL ILLNESS
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MENTAL ILLNESS
| THE DISEASE OF STIGMA
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Stigma is sadly, but inevitably, part and parcel of the experience of those who suffer from a mental illness, and it brings with it its close comrades, prejudice and discrimination. The word stigma was originally used to refer to an indelible dot or mark left on the skin after stinging with a sharp instrument, but more recently it is used to describe an attribute, trait or disorder that marks an individual as being unacceptably different from the “normal”. Stigma is a worldwide phenomenon and affects not only those with mental health problems, but those suffering from HIV and AIDS; gays, lesbians and the transgender community; obese people; differently-abled people and addicts, just to name a few. It is an extremely powerful tool for keeping people down, keeping people in and keeping people away. The stigma attached to mental illness is often severe, frequently being referred to as ‘the ultimate stigma’, and for many sufferers it is like having a second disease. As one lady openly stated, “The stigma I have experienced as a result of my illness is far worse than the illness itself. In time I can learn to accept my illness and learn to manage it; the consequences of stigma and discrimination you receive are beyond your control. It is a constant source of oppression and heartache”. A double whammy! Not only are these people coming to terms with their problem and learning how to accept, adjust and manage it, but they simultaneously have to deal with the shame, the embarrassment, the exclusion, the lack of education and misunderstanding—the stigma, and not only from strangers, but often from their friends and family, too. Stigma is not only unpleasant and debilitating, it is also dangerous. Research suggests it prevents people from seeking advice and help, it reduces access to care, it causes undertreatment, material poverty and social marginalization.
Although you can access an unprecedented volume of information via the Internet, research from around the globe highlights that people’s understanding and accuracy, when it comes to mental health knowledge, is extremely poor. Trinidad and Tobago are no exception, and this lack of knowledge, coupled with a scarcity of tools, resources and support for families and patients, can result in families or family members turning their back on their loved one, unable to cope with the pressure of the illness, the impact it has on the family, or the stigma that ensues. Those that do try their best to care for their family member do so under enormous strain, with no assistance, no structured support network and no resources, other than what they themselves can find and afford. It was my involvement in psychiatric research that first introduced me to those that care for a loved one with a mental illness, and it is from these people that I learnt the shocking reality of the ‘plight of the carer’: their struggles, the stigma they have faced, their desperation, their fears, but, above all, their absolute determination to do everything possible to support their loved one in every way they can and their desire to re-educate the public and break down the myths and taboo of mental illness. This experience spurred the creation of a Carers’ Support Group which provides a safe and supportive environment for people to come and share, learn and find some level of hope and peace. All those that currently attend the group are looking after a son or daughter in their late 20s to early 30s, with an acute mental illness. And all have shared heart-wrenching stories of suffering, embarrassment, the breakdown of their support networks, their constant anxiety, and their fear of the future – what will happen to their child if they are not there to care for them?
THE DISEASE OF STIGMA
And what will their child’s quality of life be in the midst of this stigma that follows them? The burden they carry is unimaginable. As one mother in the group explained to me, “It is fear and lack of education that makes people turn their backs and stigmatise our children. They don’t understand, they are scared to understand; it is easier to dismiss than confront. But my daughter, our children, are human just like everyone else and they deserve the respect and understanding of their brothers and sisters”. Global evidence suggests that mental health problems are so prolific that it is likely that each one of us will know of at least one person in our lifetime affected by a mental illness. Who do you know? And how much do you know of their problem? Unlike in other countries where mental health has been dragged into the spotlight and openly discussed, here it is still lurking in the shadows; a taboo. But it is ”time for change”—nationwide. Slowly, mental health and the issues of stigma are beginning to be addressed. This March, the Trinidad-born artist Steve Ouditt held an exhibition at Medulla Gallery entitled Proceeds to Mental Health, highlighting issues in mental health using the forum of art. Caroline C. Ravello writes frank and honest articles every Wednesday in the Guardian about mental illness and issues surrounding it; and a fledgling organisation called MoreMental Inc., who formed in 2010, are working hard towards creating change, though awareness campaigns and fundraising efforts. MoreMental formed to provide support for those coping with mental health problems. This support includes raising awareness about the significance of good mental health in negotiating the many issues that compromise living a fulfilled and successful life. It also includes developing strategies to overcome the stigma
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MENTAL ILLNESS
and discrimination that make living with mental health problems so debilitating. Their efforts have begun with a “Fight Stigma, Save Minds” t-shirt campaign, and their fundraising efforts so far have been directed at bringing immediate assistance to those whose mental health problems have affected their capacity to satisfy some basic needs or cope with unexpected adversity. Their efforts are stepping up this year and we can expect to see more events, campaigns and printed literature on a wide range of different mental illnesses. Stigma, discrimination and prejudice ruin lives. They deny people with mental health problems the opportunity to live their lives to the fullest. They deny people relationships, work, education, hope, and a chance to live an ordinary life that others take for granted. Help us start to break down this stigma in Trinidad and Tobago. It requires great changes in mentality, attitude and behavior, and it takes each one of us to review our belief systems and our knowledge of mental health and mental illnesses, and to question whether our beliefs and assumptions are correct! Our mind is our greatest tool, our most powerful asset. Those who engage in stigmatization are allowing incorrect belief systems to determine their thoughts, and therefore their behaviour. We need to seek to nurture our minds and allow them to grow and reach their full potential. Do not allow the disease of stigma to affect your mind. In the words of Professor Gerard Hutchinson, “Open your mind and save it. Save your mind and save your life.” If you would like more information about the Carers’ Support Group, please contact: Maia Hibben, maia.hibben1@gmail.com or 337-3646. If you would like more information about MoreMental Inc., please contact: morementalinc.@gmail.com or find us on Facebook MoreMental Inc.
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FRUIT
|
CO CO NUTS. G OING NU TS THE HE ALTHY WAY
GOING NUTS
THE HEALTHY WAY
WRITTEN BY CAROL
QUASH
ACTOR DUSTIN HOFFMAN ONCE SAID, “THE TWO BASIC ITEMS NECESSARY TO SUSTAIN LIFE ARE SUNSHINE AND COCONUT MILK,” AND IN THE WORDS OF AUTHOR AND VENETIAN MERCHANT TRAVELER MARCO POLO, “ONE OF THESE NUTS (COCONUTS) IS A MEAL FOR A MAN, BOTH MEAT AND DRINK.”
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The Sanskrit word for coconut, is “Kalpa Vriksha,” which means “the tree that gives all that is necessary for living,” as almost all of its parts can be used for healthy food, as well as other useful items. This is all good news for people of the Caribbean, where there is sunshine galore and at least one coconut tree in almost every backyard.
Much like Crix, the coconut has etched its way into the “vital supply” category of the Caribbean household. In Trinidad and Tobago, some people consider it a criminal offence not to wash down tasty doubles with a beastly-cold coconut water. Cooking pelau, oil down, calalloo or corn without creamy coconut milk is a culinary sin. A hot slab of coconut bake without coconut…well that just doesn’t make any sense. Saltfish buljol sautéed in coconut oil tells a blissful story of its own, and where would sugar cake, sweet bread, coconut ice cream, pone or curried crab be without coconut? The merits of the coconut, however, are not limited to its taste. The coconut, or Cocos nucifera, is a member of the Palm family and classed as a fruit. It got its name from Spanish and Portuguese explorers, who found that the three little eyes on the base of a dried coconut looked like a “coco” or monkey’s face.
C O C O N UT S. GO I N G N UT S T H E H E A LT H Y WAY
In her blog post on beyondvitality.com, US-based personal trainer and nutritionist Alison Brown describes the coconut as “a great source of energy, vitamins, and fibre...” Meanwhile, an article featured on bbcfood.com states, “Coconuts are highly nutritious and rich in fibre, vitamins C, E, B1, B3, B5 and B6 and minerals including iron, selenium, sodium, calcium, magnesium and phosphorous.” Coconut water is also said to be low in calories, and rich in potassium, with a little bit of capric acid. It’s no wonder people use it, in its natural form or in by products, for numerous ailments, sometimes without even knowing it. But, for all its benefits, medical experts have warned that the coconut and its by products, like everything else, should be used in moderation. One should note, for example, that the water and jelly contained in one large, ‘jelly-nut’ can contain almost as many calories as a soft drink. Until now, I never appreciated how fortunate I was to grow up with easy access to this wonder fruit – with several trees in our yard and a father who took pride in slashing of the top of a nut with one swipe of his glistening cutlass. To me coconut water was always just a great thirst-quencher, with a bonus of the sweet jelly. That is, until I started doing research for this article.
|
FRUIT
physical exercise, as studies have shown that the electrolyte level in coconut water is similar to that contained in sports drinks. It also replenishes the hydration levels in the body with its contents of simple sugars and minerals. In adulthood, during early pregnancy, it was probably the only thing my body could tolerate during my long battle with nausea and vomiting. In many countries in the tropics, the water from the young nut is used to treat patients with diarrhea and who are vomiting, as a means of replacing the fluids that are lost. It worked for me. Coconut milk (see method for making below) is rich in lauric acid, the medium chain of fatty acids (MCFAs) also found in breast milk. In the body, the fatty acid is converted into the compound monolaurin, and forms an antiviral and antibacterial, which increases immunity and helps protect the body from infections and viruses. And since it is lactose free, anyone with lactose intolerance can use it as a substitute for cow's milk when baking, or in shakes and smoothies. Cooking with coconut oil has been a controversial issue for a number of years, because it is rich in saturated fats. Like all other oils, it is a blend of fatty acids. However, its unusual blend of the properties of the lauric acid and the heart-friendly myristic acid offers a number of health benefits.
My life in the Coconut Republic is fraught with childhood memories of guzzling water from several nuts after a series of games in the blazing sun, before running off for another round of play. In retrospect, the water served as a rehydrant, just as it now does to people who undergo long periods of intensive
But for all its health benefits, it is rumored that 150 people worldwide are killed by falling coconuts every year. Therefore, you may want to think twice about reading this article while lying in that hammock under the coconut tree in your backyard.
Coconut and cucumber shake*
Making coconut milk
1 cup coconut water 1 small cucumber 1 pinch of sea salt A squeeze of lemon A few drops of stevia Blend all ingredients in a blender until smooth Serve chilled
Crack open a dried coconut and remove the nut/flesh Grate/grind Mix the grated nut with water Separate the milk from the husk by straining in a fine sieve or muslin Refrigerate or freeze unused milk
*Recipe courtesy Marlene George
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5
6
7
8
9
10
& Any type of sexual contact can transmit HPV
HPV has been found in semen HPV can cause oral, anal, penile and cervical cancer HPV can lay dormant in the body for years Condoms are not full protection against HPV HPV has been found in saliva Men exposed to HPV are at risk of cancer There are over 13 high-risk type HPV's Genital warts are caused by low-risk type HPV Abstinence is the only 100% protection against HPV
TRANSPLANTATION
| SAVING LIVES THROUGH ORGAN DONATION
SAVING LIVES THROUGH ORGAN DONATION Gift giving is a year-round activity: Christmas, birthdays, anniversaries, Valentine's Day if only because gifts are always a pleasure to give and receive. But how would you feel if you could give or receive the gift of another shot at life?
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WRITTEN BY CAROL
QUASH
SAVING LIVES THROUGH ORGAN DONATION
“Every time I look at him, I thank God for the miracle of giving him a second chance,” says television personality Jessie May Ventour of her brother Matthew Ventour, to whom she donated a kidney in 2011. "The experience was so surreal. I just thank God my sister made it possible for me to live," Matthew declares. In another household across the country, the circumstances were not much different; neither were the decisions. Having a transplant was not a difficult decision to make. I just wanted to get back to a normal life with my family,” says 19-year-old student, Akila Aqui, who was the recipient of a kidney from her father Richard Aqui. "It was devastating seeing my daughter so sick. When we found out I was a match for a transplant, I couldn't give her this life-saving part of me fast enough," Richard says. Both families placed their trust in God and the capable hands of head surgeon of the National Organ Transplant Unit (NOTU), Dr. Malcolm Samuel, at the Eric Williams Medical Science Complex — a decision they have never regretted. But they weren't the only ones who've been fortunate enough to receive the life-saving surgical procedures. From April 6 to May 5, 2013 the unit, headed by Medical Director Dr. Lesley Roberts, hosted a series of events in celebration of a landmark feat of having
performed 100 kidney transplants since its establishment in January 2006. Ninety-five of the organs were from live donors and six came from cadaver or deceased donors. The NOTU programme covers both kidney and cornea transplants, although the latter is not readily available to everyone, as corneal grafts have to be imported from the US in the absence of a local Eye Bank. Trinidad and Tobago is the only country in the Caribbean with the appropriate legislation for organ transplants. Amid the celebrations, though, NOTU Social Worker Nadine Spencer laments that the programme remains one of this country's best kept secrets. "Awareness has increased since the unit was established, but a lot of people still don't know we exist. A lot of people don't know this is happening in Trinidad," Spencer says, despite the fact that companies such as Repsol have assisted in enhancing and building awareness of what happens at the NOTU. She says the company has joined forces with the unit and the Ministry of Health to encourage cadaver donations, which would greatly augment the donor pool. In November 2011, the Repsol Foundation sponsored a project that gave local doctors the opportunity to get advanced international training in transplant co-ordination, under the tutelage of Spanish surgeon Dr. Jose Manuel Garcia Buitron. The doctors were trained in the legal, technical and social aspects of organ harvesting, and keeping the body and organs in a condition that can be used for transplant. They subsequently participated in a hospital internship at the Complexo Hospitalario Universitario in Coruna, Spain.
|
TRANSPLANTATION
The Ventours and the Aquis concur that the unit, with its mandate "to facilitate the safe and equitable transplantation of organs and tissue to patients living with organ failure," and to provide continuous care to organ transplant recipients, has been going beyond its call. After Jessie proved to be a possible match, she and Matthew began the long road to preparing for the surgery in December 2009. “The sacrifices I had to make for this child,” Jessie chuckles, as she recalls how she had to lose weight, as organ donors are required to have a Body Mass Index (BMI) of between 25 and 30. “But right through it I kept reminding myself why I was doing it. It was depressing when I saw him sick.” She says she did a pap smear, a series of blood tests, 24-hour urine collection samples to monitor the quality of her urine, and other tests to ensure she was in good medical condition suited to organ donation. “I took bottles of water everywhere I went. It was a trying journey, but the folks at the NOTU were amazing. You really have to be a special type of person to do their job. They were always encouraging, always patient and generous. And they are like that with every patient, because someone on dialysis is living on borrowed time.” On the day of the surgery, Matthew says he saw his sister briefly. When he woke up some time later in the High Dependency Unit (HDU), he could hardly believe that “they really did this.” Jessie, meanwhile, was feeling the temporary after-effects of her generousity. “I don't even know how long I was under. My mouth and throat were so dry, and I abused the patient control button
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TRANSPLANTATION
| SAVING LIVES THROUGH ORGAN DONATION
E
ventually, she was able to look in on her baby brother. “He looked scary with all the tubes and wires and beeping. But I was overjoyed that it was done.” A week following the surgery, Jessie’s and Matthew's father succumbed to a battle with cancer. Matthew was unable to attend the funeral, but, with his face covered by a mask, went to the funeral home to say his goodbyes. Jessie went to the church service but was unable to make it to the cemetery. “That was the sad part of the whole thing. But we were happy that he knew we were okay before he passed.” Now, almost two years later, Matthew keeps a detailed record of his daily intakes, including meds, and attends appointments at the NOTU clinic. Jessie has since willed all her organs to be donated. "That is as close to immortal as you can get on this planet,” she opines.
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However, Dr. Roberts advises potential donors that, even though they may agree to donate their viable organs when they die, by law the approval of their next of kin is needed before these organs can be used for transplants. “A person basically needs to die in a special way and the organ needs to be viable if it is to be used for transplant. It must be vascular, meaning there must be blood circulation going on,” Dr. Roberts explains, which rules out victims of fatal vehicular accidents and those who have been fatally shot. “Unless they die at the hospital and their kidneys are in good condition,” she says. “A typical cadaver donor is
someone who is in the hospital with a bad neurological injury and no longer has basic brain functions, and is tested and found to be brain dead. But even if their kidney function is good, unless their family gives consent for the organ to be donated, we cannot touch it,” she says, and pleads with those wishing to donate their kidneys to inform their families of their decision. “Talk to your family about what you want. Build awareness. This is something important. There are so many people waiting for transplants. We need to expand our donor pool.” Akila, who was just 15 years old when she was diagnosed with lupus and end-stage renal failure, was on dialysis for almost a year before she heard about organ transplants from Dr. Roberts. "When we decided to do the transplant, the doctors began doing a series of tests on me and family members. My identical twin sister was too young to be a donor. We were so relieved when my dad proved to be a match. He is a vegetarian and does not drink alcohol or smoke." Following the transplant, Akila stayed in the HDU for approximately two weeks. "The first three months after the surgery were critical, because my immune system was suppressed. I had to wear a mask even when I was discharged from the hospital. Thank God there were no complications." Now, she has follow-up appointments at NOTU clinic, visits the dedicated nurses on the dialysis ward, and tries to encourage patients on dialysis. "I can never forget where I came from. Near death."
According to Dr. Samuel, in all cases both the potential recipients and donors are required to undergo a series of cross-match tests prior to the transplant. Both of the donor's kidneys must be in good condition and they must not have any infections, cancers, etc. that can be passed on to the recipient. The recipient must not have any major medical problems, cancers, etc, and tests are done to ensure they will be able to accept the kidney. Once the transplant is successful, the kidney starts to work right away. "The recipient is taken to the HDU and must be closely monitored. Their urine output, blood pressure, oxygen saturations, etc. have to be monitored hourly to ensure that the kidney keeps working. They are given immune suppressants to avoid rejection of the kidney." He describes the first three to four days after the transplant as critical, but says by the fourth to fifth day the patient usually begins to feel a lot better. "By that time, the patient can begin eating things he or she could not eat before." The follow-up treatment, he says, is life-long. "Transplant recipients are patients for life." And the donor? "Donors can live completely healthy lives with one kidney." But as a precautionary measure following the transplant, they are required to visit the NOTU clinic once a year. For more information on organ donation and transplants, call the NOTU from Monday to Friday from 8:00 am to 4:00 pm at 662-7556, 645-2640 ext 2580, or 800-DONOR.
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EXERCISE
|
EXERCI S E AND THE E L DE R LY
E X E R C I SE A N D T H E E LD E RLY
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EXERCISE
EXERCISE AND THE
ELDERLY CHRONOLOGY VS BIOLOGY IN OUR CARIBBEAN SOCIETY, “THE ELDERLY” IS OFTEN ERRONEOUSLY PORTRAYED AS A GENERAL MASS OF SENILE, DEPENDENT AND FRAIL PEOPLE. IT IS UNLIKELY THAT ONE WOULD SEE AN ELDERLY PERSON FREQUENTING A GYM OR RUNNING A MARATHON, AND A HIKING TOUR GUIDE MAY BLANCH AT THE THOUGHT OF HAVING TO “TOTE GRANNY” JUST IN CASE ANYTHING GOES AWRY ALONG THE TRAIL.
WRITTEN BY ROBERT
TAYLOR
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EXERCISE
|
EXERCI S E AND THE E L DE R LY
HIS AGEISM IS REGRETTABLE, TAKING INTO ACCOUNT THAT TECHNOLOGICAL AND MEDICAL ADVANCES HAVE ENABLED ADULTS TODAY TO HAVE GREATER LONGEVITY IN TERMS OF ACTUAL YEARS, AS WELL AS IMPROVE THE QUALITY OF THESE YEARS. In the early twentieth century, medical practitioners believed that older adults should not engage in too much physical activity after a particular age, and persons over the age of 60 were discouraged from exercise. They were taught that a decreased quality of life was acceptable as one got older.
Physical component • Favours energy balance • Maintains or increases bone density • Increases lean mass • Reduces risk of fractures Muscular component • Improves muscle strength • Improves muscle endurance • Reduces risk of musculoskeletal disability • Improves balance Motor component • Improves balance • Improves strength and flexibility • Improves co-ordination • Increases mobility
Thankfully, contemporary medical practitioners and the fitness industry on the whole now strongly support the belief that exercise is very important for the elderly as it relates to their quality of life, and can deter various diseases and markers of poor health.
Cardiovascular and respiratory component • Increases heart muscle contractility • Increases aerobic capacity andimproves endurance • Improves heart and lung functions • Reduces systolic blood pressure, and improves diastolic blood pressure
As Nicholson and Czerniewicz point out in their 2004 article “Hale and Hearty – The Benefits of Exercise in the Elderly”, chronological age is the passing of time since birth, but biological age takes into account each person’s multiple functional abilities, and should be considered to be a more accurate marker of age as it relates to exercise.
Metabolic component • Decreases blood triglycerides • Reduces low-density lipoproteins • Increases blood HDL-cholesterol • Improves insulin sensitivity of tissues
It is now quite possible to be at a chronological age considered to be “elderly” (as defined by the World Health Organisation to be over 60 years of age) and yet still be biologically much younger in terms of health. Exercise has a tremendous part to play in this.
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SOME BENEFITS OF EXERCISE FOR THE ELDERLY ARE:
Behavioural component • Improves cognition • Improves sleep • Increases speed of movement and decision making • Improves interest in sexual activity (And yes, folks – interest in sexual activity is important to old folks, too!)
E X E R C I SE A N D T H E E LD E RLY
Despite disabilities and chronic health conditions that may prevail due to chronological illnesses, many older adults today are independent community dwellers who are robust, resilient and, in fact, quite capable of doing some form of regular exercise.
Category 2 – (65-80 years of age) Modified programmes based on medical recommendations. Special attention should be paid to ROM (range of motion) limitations, signs of fatigue, muscle weakness and joint pain.
Where exercise and the elderly are concerned, the only real factor that should be used to determine whether one should exercise or not is biology. The law of individual differences does apply, and especially so for individuals who have had pre-existing medical conditions.
Category 3 – 81 years of age and above Closely monitor, set low exertion levels, and focus on individual muscle groups. Care should be given to enhancing one’s overall posture and avoiding injuries.
Contraindications, conditions or factors that serve as a reason to withhold a certain medical treatment, towards exercise may be absolute, meaning that exercise should be limited or not indicated at all; or relative, requiring special exercise prescriptions and safety considerations. Absolute contraindications may include but are not limited to acute coronary heart disease, decompensated congestive cardiac failure, uncontrolled ventricular arrhythmias or recent pulmonary or deep vein thrombosis. Relative contraindications may include but are not limited to diabetes (type II), Alzheimer’s disease and related dementia disorders, progressive neurological disorders, Parkinson’s disease, multiple sclerosis or osteoporosis. Barring the absolute contraindications, and with special attention to any relative contraindications, older adults should be encouraged to partake in regular exercise.
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EXERCISE
GENERAL GUIDELINES FOR TRAINING THE ELDERLY Strength programmes – low to moderate intensity with higher amounts of repetition. Machines can be substituted for free weights if the latter proves to be difficult. Frequency – two to three times per week Duration – approximately 30 minutes total cardiovascular and 30 minutes resistance training, dependent upon the state of fitness of the participant Intensity – low to moderate Flexibility training – this should be done after each session The stigma of slow decline associated with aging is no longer an issue for those who show interest in fitness and health. In fact, athletically and nutritionally fit individuals can measure out at 10-20 years biologically younger than their chronological age. While particular attention should of course be taken with regard to the individual’s health, it is safe to say that exercise and the elderly should not be mutually exclusive categories.
CHRONOLOGICAL CATEGORIES OF ELDERLY In the fitness industry, there is a general recognition of three groups of older persons. While these categories are chronological in nature, there will be some variations based on the individual. Category 1 – (55-64 years of age) The persons may participate in moderate weight-training routines with only slight modifications.
In fact, to quote Dr. William Evans and Irving Rosenburg, authors of Bio-Makers, “Exercise is the prime mover in the drive to preserve vitality. While exercise may be merely an option for the young, it is imperative for older adults.” So…that said…the next time you see “Gramps” or “Granny” jogging around the block, cheer them on!
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ttle more) little (a lit WRITTEN BY DR.
DAVID BRATT, MD. MPH. CMT
COUGHS THAT LAST LONGER THAN TWO WEEKS ARE AN IMPORTANT PART OF THE CHILDHOOD EXPERIENCE IN TODAY’S CARIBBEAN. THESE ARE THE SO CALLED “CHRONIC COUGHS” THAT AFFECT QUITE HEALTHY CHILDREN, BUT COST PARENTS WORRY, SLEEP, AND MONEY, AND, FINALLY, FRUSTRATE THEM.
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COUGHS THAT LAST LONGER THAN TWO WEEKS IN PREVIOUSLY HEALTHY CHILDREN HAVE MANY CAUSES. IT MIGHT BE A PNEUMONIA OR PROTRACTED BACTERIAL BRONCHITIS; A BAD CASE OF CROUP; GASTRO ESOPHAGEAL REFLUX DISEASE, A FOREIGN BODY STUCK IN THE RESPIRATORY TRACT; WHOOPING COUGH OR; EVEN TUBERCULOSIS.
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However, by far the most common causes are allergic rhinitis (rhinitis simply means runny nose); bronchial asthma; a combination of allergic rhinitis and asthma, or simply a prolongation of the common cold. All of these causes are worsened by common environmental factors like dust (from outside the home, e.g. Sahara dust or from dust indoors collecting in carpets, heavy drapes and the like); smoke (indoors from cigarettes and outdoors from the burning of backyard rubbish or hillsides or sugarcane); industrial estate waste pollution; pollens; pet dander; cockroach parts and the now ubiquitous air conditioning in homes and schools with its cold, dry air that exacerbates any cough. Allergic rhinitis is called “sinusitis” or “sinus” in the West Indies. But it really is an allergy. The suffix “itis” means inflammation but most people think it means infection. Infection in people’s minds equals antibiotics so “sinus” in the West Indies is treated with antibiotics. This may be adequate for adults with “sinus” but the sinus problem in children is not due to infection but to allergy. Allergies run in families. If you have “sinus”, then the chances are very high that the persistent cold that your child has is due to allergic rhinitis and should be treated with anti-allergic medications as well as cleaning up the child’s environment. There are some special features about children who have allergic rhinitis. As babies, they are often “mucusy”. The nurse or doctor in the hospital will tell you that it’s because “mucus got into her nose”
during the birth. That’s possible but the effect does not last for weeks. A runny nose that lasts for more than two weeks is the second major symptom of allergic rhinitis and is the most important. A real “cold” (viral infection) lasts under two weeks. Any child with a “stuffy” or “runny” nose for longer than two weeks in the Caribbean has allergic rhinitis, until somebody proves otherwise. Most children with allergic rhinitis “live with a cold” or seem to go from one cold to another with scarcely a break in between. These kids walk around for months with “runny” noses or “stuffy” noses, constantly sneezing, snuffling, snorting and “hawking” or “clearing their throats”. For many it becomes a way of life and no one notices the abnormalities. Often they rub their noses. This is called “nose picking” in the West Indies. In other countries, this nose rubbing is called the “allergic salute”. Untold West Indian children have been unfairly punished for this nose picking business. The children cannot help themselves. They have allergic rhinitis and their noses itch. After many years of rubbing they develop an “allergic line” running horizontally on top of their nose just where the soft cartilage meets the bony part. Many adults have this line. Check it out! Morning sneezing or “hay fever” is another common symptom. It is so common that people often pass it off for normal. It is not. No one should wake up in the morning and sneeze.
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These are the s y m p t o m s directly related to the nose. Indirect symptoms include: “night cough”, “allergic shiners”, “tooth grinding” and “snoring”. The most important cause of children coughing throughout the night in the West Indies is bronchial asthma. But allergic rhinitis is almost as common. Allergic shiners are the puffy, purplish swellings around so many of our children’s eyes that are put down to not sleeping properly. Of course children with stuffy noses and coughs do not sleep well at night. Their breathing is audible, hoarse, and irregular. Or they may sleep with their mouths open and dribble or froth.
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Tooth grinding is thought to be associated with “worms”. There’s no truth to this widely held claim. It is associated with a blocked nasal passage due to allergy. It is also generally believed that snoring is normal. Snoring is always abnormal. It is abnormal in adults and in children. The fact that the father snores is no reason for the child to snore. It means the child’s nasal passages are partially blocked, usually with excessive mucus from the allergic condition or from
enlarged adenoids (structures similar to tonsils that are located at the back of the nasal cavity). When loud snoring is interrupted by frequent episodes of totally obstructed breathing, it is known as obstructive sleep apnea. During these episodes, the child actually stops breathing for several seconds. Serious episodes last more than ten seconds each. Apnea patients may experience hundreds such events per night. These episodes can reduce blood oxygen levels, causing the heart to pump harder and the child to awaken.
BRONCHIAL ASTHMA IS NOT A DISEASE OF THE LUNGS THEMSELVES BUT OF THE TUBES THAT CARRY OXYGEN INTO THE LUNGS. The immediate effect of sleep apnea is that the snorer must sleep lightly and keep his muscles tense in order to keep airflow to the lungs. Because the snorer does not get a good rest, he may be sleepy or grumpy during the day, which in the case of a child may mean poor school performance.
In an adult, work suffers. After many years with this disorder, elevated blood pressure and enlargement and weakening of the heart may occur. Sudden death from a heart attacks or stroke can then occur. Snoring means obstructed breathing, and obstruction can be serious. It’s not funny. If you sleep with someone who snores loudly, get them checked out soon. Bronchial asthma is not a disease of the lungs themselves but of the tubes that carry oxygen into the lungs and carbon dioxide out of the lungs. One of the characteristics of the respiratory tract is that it produces mucus or “cold”. This mucus production is normal and has many functions. One of them is defensive, and during an attack on the respiratory tract, the system responds by producing more mucus. This is easy to note when you have a “head cold” and mucus pours from your nose. Bronchial asthma is characterized by excess production of mucus inside the bronchial tubes, or “chest cold”. This excess mucus blocks up the tubes making it difficult to get oxygen into the lungs and carbon dioxide out of the lungs.
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f the mucus is produced in large quantities then you will have a dramatic reaction with lots of cough and difficulty breathing in and out. If there is less mucus produced, then all you may have is a “wheeze” or in minor cases only a cough. The rapidity at which this mucus is produced is surprising. A child can go from breathing normally to coughing, to wheezing, to gasping in four to six hours. Accompanying the excess mucus is contraction of the muscle fibres that surround the bronchial tubes and make the blockage worse.
IT IS USELESS TO EXPECT A CHILD TO IMPROVE WHEN HE SPENDS ALL DAY INSIDE AN ENCLOSED, CARPETED, AIR-CONDITIONED ROOM WITH TWENTY OTHER CHILDREN. Bronchial asthma has a wide spectrum of expression. When you say the word asthma, most people think of the worst-case scenario, i.e. the frightened, gasping, air starved child who needs to be admitted to hospital urgently for nebulized medication and oxygen.
Most children who have asthma never develop this. Instead they manifest their asthma by coughing for weeks at a time, especially while sleeping at night. In most cases, this is the only sign of asthma. Other children develop a wheeze. Sometimes you can hear the wheeze. Occasionally you can see the wheeze manifesting itself with a breathing difficulty, (breathing fast or struggling to breathe or sighing deeply) when the child is sleeping at night (the cooler night air does indeed make the asthma worse). Often, however, the doctor has to listen to the child’s chest with the stethoscope to make the diagnosis or, if the child is over five years, ask the child to blow into a piece of office equipment called a flow meter.
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But manipulation of the child’s environment is needed, too. It is of little use prescribing medication if the father refuses or, because of his nicotine addiction, is unable to stop smoking. It is just as useless to expect a child to improve when he spends all day inside an enclosed, carpeted, air-conditioned room with twenty other children. And it’s equally ridiculous to accept having your next-door neighbor burning debris at night, or the government burning material in the city dump, while your child lies coughing in bed.
Most children with allergic rhinitis or asthma can be diagnosed on clinical grounds in the office. It is rare for other tests to be needed. It does become a bit more difficult to diagnose when both diseases are present, as happens frequently. Pharmacological treatment of any of these three conditions remains the judicious use of inhaled or oral corticosteroids.
Dr. David Bratt is the author of The Book of Brats: Bringing up Children in the Caribbean.
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