Saturday 3 October 2020

After-Effects of Covid-19 & Coping Methods
                                             (Aftermath – Post-Covid-19)

Dear Friends,

I am a Sports Specialist with a vast experience in treating ALL types of patients. Moreover, I have been infected by Covid, and I am now in the post-Covid recovery stage. 

Here is my analysis of post-Covid recovery based on my professional and personal experience. For my analysis of my personal Covid journey, please read my blog titled  [""]

1. Introduction 

After symptomatic Coronavirus infection, the effects of viral damage result in a stage of long-term inflammation in the body and in one or more organs i.e. lungs, heart, liver, gall bladder and kidneys. This condition may continue for next 3-6 months. In this period, people are vulnerable to serious infections with bacteria, virus and fungus. Another severe infection soon after Covid can aggravate the existing autoimmune/other disorders like diabetes.

 Everybody who got Covid must pay attention for next 6 months and watch for these Post-Covid effects. In most people, virus becomes inactive and not infectious to others (cannot spread) after 3 weeks. Some people may test positive even after 21 days. This is because RT-PCR is a very sensitive test and can detect the residual viral proteins and RNA bits for many days after infection. One should not worry about it and go ahead with normal life. 

To know whether we are immune to virus or not, we must check SARS-CoV-2 antibodies after every 3-4 months for a couple of years. This will tell us how long we are going to have immunity against coronavirus.

 There are two stages of damage to humans with coronavirus infection. 

  • Damage during Acute stage of infection (within 10 days; many people died in this        stage all over the world) 
  • Damage to different organs of the body after 10 days (Post-Covid effects)  
  • What are the effects on the body after Covid-19 infection?

Lung damage: There are three popular groups of viruses that normally cause respiratory diseases like the common cold and complications like pneumonia (infection of the lung tissue).

  • Influenza viruses
  • Adenoviruses
  • Coronaviruses

    Now, there are more than 11 genotypes of Novel coronavirus and some of them are known to be very lethal to humans. Coronavirus causes severe damage to lung tissue and other organs also. It's damage to lung tissue is detected in a High-resolution CT scan (HRCT). Grading begins from ground-glass appearance to severe lung tissue damage. 

2. What happens to the lungs and its function after corona                 infection?

        Damaged lung tissue is repaired automatically by the body with fibrous tissue that is not elastic like original lung tissue. It cannot function (conduct gaseous exchange) properly. This will lead to permanent scarring in the lung, thus compromising lung function. This is a serious complication (Ex- 2 percent of my all lobes of lungs are damaged, as seen in HRCT)  

Vo2 max (the ability of a person to extract maximum oxygen during work) is drastically diminished (40%)

Forced expiratory volume (FEV-measures how much air a person can exhale during a forced breath). Forced vital capacity (FVC - the total amount of air exhaled during whole breath). Both are reduced drastically during acute infection. These will recover very slowly. This is the reason why people feel fatigued very quickly.

Chronic cough: People may have a cough for many weeks. This is because of two reasons; firstly, the body thinks that there are viral products leftover in the lung and the body tries to throw out by coughing. Secondly, there are secretions for the same purpose, and these have to be expelled through cough. Cough can make people tired, exhausted, and sometimes interfere in gaseous exchange, thus reducing Oxygen saturation. 

Fatigue and Post-viral Myalgia, Arthralgia: This is quite annoying with pain, stiffness in the joints, muscles, and weakness. It can remain for at least 4-6 weeks after Covid infection. Elderly and seriously ill people may find it very difficult to cope.   

Indigestion is often observed in more than 65% of people. There are many medicines consumed by the person that hurt the gut; and the virus itself causes severe gastritis (infection of the stomach) and enteritis (infection of the intestines). With good dietary regime and discipline, one can recover faster.   

Psychosomatic changes: Going through Covid (symptomatic) is quite traumatic. Some people may continue with anxiety, brain fog, sleep disturbances and unexplained behavioural changes for many weeks to months. Good recovery depends on good emotional status with happiness.  

Secondary Infection: Post-Covid increases risk of infections. The aged, chronically ill, uncontrolled diabetics and people on long time steroids are likely to get secondary infection from common bacteria /fungus. They may require serious long term medical management.

Prolonged inflammation: It is a common observation that 90% of patients continue to have high CRP (C- Reactive protein), hs-CRP (specific C-Reactive protein), IL 6 (Sign of inflammation) and many of them have tested positive for typhoid. This is due to Covid infection. The table given below shows a person who recovered from serious Covid infection. Still, his values are raised so high, even after three months. This shows how one can open the doors for infection after complete recovery from Covid-19.    

  Test                  ESR          CRP             hs-CRP            IL 6

First month         56               46                    3                    200

Second month     38               20                    3                    112

Third month.       21                8                     2                     20

3. How to cope with this situation?

         Lung care

  • Breathing Exercises: Breathing exercises have a tremendous role in lung recovery. Proper and regular breathing exercises help in good recovery and improve Vo2Max, FEV and FVC. Pranayama, Taichi, Yoga, Qigong and Shuang yang are fantastic breathing techniques where lungs and diaphragm are utilized in different formats. Good breathing exercises can reduce the irritation, cough, and can mobilise the secretions from lungs easily. They can be done at home, but better to do outdoors (on your terrace/balcony). These should never be done outdoors during rains. These should be continued for a long time after complete recovery also because the repairing process is an ongoing process in post Covid lungs.     

  • Vapour & Gargling: Vapour therapy that is steam inhalation is number two in the list. One must continue steam inhalation even after recovering completely, for at least for 8-12 weeks. This will help to prevent scarring and adhesions and allow for better expansion of the lungs. Warm water Gargling helps to shed the viral and bacterial residues in the throat.

        Activity & Rest

  • Rest & Sleep: People do not sleep adequately. Less than 7 hours of sleep can increase inflammatory chances and drastically interfere in recovery. Including mildly symptomatic people, everyone must sleep more than 7 hours a day for the next three months. 
  •  Avoid Undue Exertion: This is a very important factor which people often neglect and land-up in trouble. After Covid, there is a drop of muscle strength, neuro-muscular coordination (in Elderly), and shortness of breath. All these reduce fitness and they need a couple of weeks to months to regain their original strength. I am experiencing similar things one month after getting infected. I am getting tired of moderate activities in my garden within a couple of minutes. Sudden undue exertion can cause metabolic acidosis because lungs are not able to pump Co2 effectively out of lungs. Young people may ignore this, and may land in serious trouble. 

  • Smoking and Alcohol and Emotional distress are equally dangerous and seriously jeopardize the recovery. 

4. How to resume Activity and Sports?

    One may gradually start activities, begin with low-intensity domestic work, short walks and gentle exercises. Do not indulge in sudden high-intensity exercises. These may cause sudden death irrespective of their age. Many fit players suffered serious heart problems in post-Covid period. There are guidelines for post-Covid professional players to get their cardiovascular system thoroughly checked. A very fit professional player can have sudden death during high intense activity after Covid infection. It is well documented that heart problems are not uncommon during sudden undue physical exertion, during Post Covid recovery period.

 Active young people who want to participate in serious sports and exercise programmes must undergo thorough cardiac screening such as TMT, 2 echocardiogram and other biochemical tests advised by your doctor.    

• People with Medical Diseases (Comorbidities). These are the high-risk group of people who can have serious complications after apparent recovery from Covid. Vascular & Respiratory damages that happened during active viral infection may last for a very long time. They must keep their blood sugars under strict control, get their BP under control, and they should be under proper medical supervision.   

5. Dietary Habits & Immuno-Nutrition

    The human body has two connections with the outside world, breathing and eating. There are some dietary habits and problems which are common among patients all over the world. 

Untimely food

• Non-staple food

• Wrong sources of food

• Wrong quantities of food  

     There is enough published literature to substantiate the importance of untimely food, resulting in obesity, acidity, and digestion problems. These untimely food habits lead to malabsorption and micronutrient deficiency in the long-run. Doctors somehow are more involved in finding the disease and treating them, but they could not influence the people with the right nutrition. 

People blindly believe in quacks, personal opinions on google, Whatsapp, YouTube and other media on nutritional advises and make drastic changes in their food habits resulting in serious toll on their health.

 We developed our food habits because of their availability and family habits over many decades. Eating food just because they are good for health and somebody told its good for us can be very dangerous. A regional and reasonable quantity of food is essential to maintain adequate immunity in the body.

 In my experience, many people who became critical and succumbed to Covid-19 are either vegetarians (poor eaters with less protein) or people who changed their habits from non-vegetarian to vegans. 

Wrong food sources like completely refined, marketing-hyped food (in India) such as Kenova (Quinoa), Chia seeds, Oats, excess poultry, and many more new things confuse the body's metabolism and lead to malabsorption. 

Excess or poor quantities of food can disturb the body function. One must remember, any problem in nutrition will interfere in digestion, absorption and assimilation. Final outcome is micronutrient deficiency, which means diminished immunity. Eat your own native staple food.

If you belong to South India, coastal areas, North-Eastern states, your basic cereal is              Rice and Rice based products.

• If you belong to Northern and Western part of India, your cereal is Wheat, Jawar,                  other millets.

• Similarly, if you eat your own locally grown nuts, they do not interfere in your body              chemistry.

• Eat on time, correct quantities, variety and taste of your choice. During post-Covid               recovery time, pay attention to protein content, especially vegetarians. If you have a              non-vegetarian habit, eat regularly & happily. 

• Eat seasonal fruits in 2-3 servings and consume large quantities of well-cooked                      vegetables. 

• Hydration: Drink adequate water and check your urine, whether pale yellow (normal)           or crystal clear (Overhydration). Excess water can cause loss of sodium and more                  weakness—increase fluids in the form of buttermilk, coconut water and Orange juice.

6. Medical Supplements

After Covid infection, recovery and regeneration needs Vitamins and mineral supplements to boost the metabolism and restoration of bodily functions. You may take your personal doctor's help because you may already be on these. Don't buy from online stores, it's better to buy good pharmaceutical products. 

My personal advice is to consume the following but with caution, if you have serious disorders like kidney and liver disorders. 

Vitamin D3 2000 IU daily for 2-3 months

• Vitamin B - complex with Zinc

• Cod-liver oil capsules 250 mg once or twice a day 

I don't advise too much of vitamin C because it can cause acid reflux in many people. Ideally, you must have these after a good meal.  

7. Getting Immunity to Coronavirus (Post-Covid status)

    The novel coronavirus is completing 07 months (first case reported in Kerala in March) in India. The world is not clear whether one can get immunity forever after getting infected with the coronavirus like any other viruses. There are few controversial cases with recurrence of infection without clear evidence. 

    A vaccine is unknown, and I feel it will take a long time to reach the common man. After just 7 months, we cannot say whether we get immunity or not. Best thing is to get yourself checked for SARS-coV-2 antibody test every three months. This will help everyone assess the body's ability to get antibodies against the coronavirus and how long they last. 

It is sure that very soon all of us are going to get infected. We may attain herd-immunity (80% of community gets infected; automatically others also get immunity.) But the problem is that many lives (aged, diseased, untreated) have to be sacrificed. Let's wait and watch.

There are a lot of problems in diagnosing Covid. Test like RT-PCR is accurate only in 70-80 %, which means a positive result is positive for disease, a negative result is not negative. Other tests are of no use. CT scans of the chest are ok to understand the severity. Hospitalization is a nightmare and VIPs like S P Balasubramaniam could not be saved. 

8. Post-Covid Period

    Your chances of getting other infections are high due to lowered immunity. You may think you are a free person, no need to wear mask because you have immunity. But you are forgetting that you can still get virus from others on your hands, body parts and things you carry like phone, keys etc. Your chances of getting coronavirus infection are low, but you can transmit from one person to another person by other means.

0 -12 weeks require serious attention (irrespective of age)

12 - 24 weeks require. Good lifestyle routine to get back to full action

Post Covid status is as serious as Active Covid disease. I have gone through this nightmare and hope this will benefit many people who are recovering from the disease.

Prof Maj S Bakhtiar Choudhary (Retd),,, 
Tel: 9849136940

Walking Out of the Doors of Death
                  Story of Covid Survival 

Dear friends’
    I have gone through a serous journey of coronavirus infection past two weeks, the experience is worth sharing, I am enclosing various factors how they influence one’s recovery and damage.
1. Exposure
Day -1- On 29 Aug 2020, I met 15 patients (supposedly not affected by Corona) for their serious painful conditions. One of them accidentally removed his mask and spoke on my face, but I didn’t suspect anything.

2. Initial Symptoms
Day -2- On 30 Aug, Sunday I felt feverish, nose block, mild cough and joint pains. I felt suspicious and started of with conservative medication Dolo 650, anti-histamine like Montek LC, steam inhalation and gargling.

Day -3- On 31 Aug, my wife and son also had minimal symptoms, my cough has increased and felt breathless in the night. I was sure that we were hit by Covid-19 and decided to isolate ourselves in three different rooms. 

3. Became Corona Positive
Day -4- On 01 Sept, we went to laboratory and tested for SARS-cov2 and to my surprise,
I was declared positive; son was also declared positive and wife was negative. I was skeptical about the RT-PCR, the current gold standard test can give false results in 30% of people. This created a trouble to keep her in quarantine from both of us in the same house. We managed to give her food in her room, she did have some diarrhea. Son was largely asymptomatic with a bit loss of taste and smell. 
Medication started: Doxycycline 100mg twice a day in addition to normal ones to all of us. 

Me    -  Corona Positive    -      Symptomatic
Wife  -  Corona Negative  -      Mildly Symptomatic
Son    -  Corona Positive    -      Asymptomatic 

4. Worst times
During Night
My symptoms began vigorously, cough became severe in the night, I was sleeping in the drawing room, breathing became difficult with worsening cough. I walked out of the door and did some Taichi breathing, but in vain. Took steam inhalation several times. Choking sensation continued.     
Day -5- On 02 Sept, discussed with some colleagues, and the was hell of a confusion, there is no single proper methodology of medication, took a decision on my own and started off

1. Favipiravir (Fabi flu) to reduce the viral infection and load
2. Prednisolone 20 mg twice a day to reduce the reaction of the body against the virus
3. Vit D3 60000 IU one dose daily
4. Other vitamins. (I was sure that Ivermectin and HCQS were of no use) 
Fever was on between 100-102 FH; Night was terrific with choking and breathing difficulty and dam medical brain reminding all the complications of Covid. But on the other side, years of martial arts training, control over breathing and not having any disease such as diabetes, hypertension and hypothyroidism (Comorbidities) were the blessing in disguise. Somehow managed that night.

Day -6- On Sept 03, the day of nightmare, day time was better, as the night approached, cough became so terrible, with each bout of cough, bladder and bowel were embarrassingly leaking. Took Oxygen saturation, it was ranging between 85-92%, that means significant less supply of oxygen to my lungs and brain. Whole night I was getting up coughing, doing inhalation, gargling and of course doing some mental training. I had decided, whatever the situation may be, I am not going to go to hospital and die in ICU. I was able to sleep only on my back for few min every hour. I didn’t wake my family members, I had to climb 20 steps to go to toilet with SOB (Shortness of Breath) grade III, barely was able breath. I remember our commando course saying, when going gets tougher, the tough get going”. My experience of motivating thousands of players, patients and students did come handy in driving myself. Fear in the mind pushed me in too many negative thoughts, i.e. I didn’t write my will? Who will repay the loans, who will publish my research works and bla bla…  

Day -7- On Sept 04, Good news was I got up with no fever (probably antiviral did work).  I called my friend John from Tenet to test my blood values to check for complications if any. As expected, D Dimor, IL 6, CBP, HRCRP, Ferritin were all in abnormal ranges indicating that I might go in to vascular complications. I didn’t start any aspirin or HCQS. I knew, as the inflammation comes down things would improve. Nights were still terrible; 

Day 8 –10 – From Sept 05 - 07, day time I was better with no taste and smell, but by night things were same. I called for Oxygen generator to improve my night difficulties; this machine was invaluable in improving my O2 saturation. Night struggle continued with lot of secretions, irritating cough and the miserable nights. We improved our cooking daily mutton, chicken, eggs, orange juice. 

5. Recovery began

Day -11 – 15- From Sept.08 -12, Oxygen discontinued, Saturation improved, cough persisted, Shortness of breath persists. Secretions are still there, sleep slightly improved. Steroid tapering began, stopped antibiotic, breathing exercises and nutritious food are helping me to get back to action. 

Day – 16 – Sept 13 on wards, Things have improved, little cough, weakness and found it difficult to talk more than few minutes. WE are going test on 15 September; post Covid complications are well known and we need to exercise our minds unravelling those unknown dangers.
Day -18  - Sept 15 Our RT-PCR tested negative, all my IL6, D Dimor, Ferritin, HsCRP came down to normal levels. Chest HRCT scans have findings of CO-RADS. 3/4 for both of us and my son got chest clear. Now we need to fight with post Covid complications if any.  

6. Lessons Learnt

Why so many doctors who are dying daily during frontline job? Are there any risk factors apart from direct dose of virus infection?  

Yes, the doctors, medical staff who died due to Covid were largely affected by their pre-existing diseases like diabetes, Hypertension and obesity

Poor Micronutrient status is equally responsible; our dedicated medical fraternity must take care of themselves with regard to timing and composition of nutrition

Body weight management is of paramount importance in maintaining intrinsic immunity
Physical exercise, sleep and rest are three important cardinals of immunity to maintain 
biorhythm of Human body which in turn solidifies the immune system 

Doctors cannot afford to die because of ignorance and inability to protect themselves. They are needed because, the more power the more responsibility…  

7. Vit D deficiency pandemic opened doors To Covid pandemic?

Yes, people with low Vit D status (almost 95% of the world population) are highly susceptible to viral infections including covid-19, but you may then ask me why did I get it? 

The answer is very clear, when I got directly exposed to a Covid person who spoke on my face without mask, probably the dose of infection could not be prevented. 

Because my good Vit D status, probably saved me from hospitalization and allowed faster recovery. One must have an appropriate vitamin status of the body to prevent cytokine storms in the body and complications.

8. Can we boost our immunity all of a sudden?

Absolutely baseless, suddenly eating zinc, vitamins (Few can help), drinking kada, and ayurvedic Kashaya cannot raise your immunity overnight. Immunity is not a ready-made item which can be boosted on the spot.

To your surprise, my wife had a severe gastritis after drinking AYUSH promoted kada made of Tulasi and what not.  

Please improve your basic food habits, abstain from alcohol and smoking and sleep tight to boost your immunity. 

How much you have earned??? all that matters. 
Having affected by covid-19, made me realize to think ‘how much I have earned’?

More than 4000 friends, well-wishers, patients and some unknown people had extended their heartfelt wishes for our recovery, people have called restlessly to know about the progress, many had sent delicious cooked food and there was no shortage of medicine supply. 

People, relatives from my village and patients from far off villages performed prayers for our recovery. Constant blessings from old parents and families were the best vaccines one can afford. 

8. Living in Giving, the philosophy of life…  

Today I walked out of the doors of Death not because of antiviral drug but I believe it’s because of so many factors. I had seen war, met major accidents, had narrow escapes during Motorcycle rallies and worst of situations in my 60 years of life. 

I have saved more than 6000 people from surgery and saved more than 120 people from Covid itself; I had planted more than a lakh of trees to mother earth in my life. 

When it comes to taking back, it took so much of efforts to hold on to one small life for 5 days of life and death during Corona Invasion. 

I have realized that I have yet another chance to give and give to believe in my philosophy of “Living in Giving”

9. Living with Corona

We are going to live with corona for couple of years without any doubt. We may achieve herd immunity as the more numbers get infected, sacrifices of people at risk is going to be inevitable. Vaccine? I am not sure it’s going to work or cause more danger? we don’t know. Life should go on with suitable guidelines and law-abiding attitude (Not spreading virus to others). Let’s respect humans, nature and mother earth. Take care

I thank all of you from the bottom of my heart
All my Friends
All my Doctor Colleagues
All my Family members

Prof Maj S Bakhtiar Choudhary
D.Litt., MD, PhD
Sports Medicine & Occupational Health
Tel 8008123940

Wednesday 19 June 2019

Doctor Killed Him??

“The Doctor Killed Him!”                               
Prof Maj S Bakhtiar Choudhary (Retd)

Just think once,
Are we attacking the pilot for delaying the flight?
Is aviation minister penalized for an air crash?
Are we assaulting Municipal offices for Air pollution?
Are we penalizing electricity board for cutting down the roadside trees?
These questions can go on….

Is doctor a Murderer?

The title seemed to pop out of the newspaper. Would have been better suited in a Robin Cook medical thriller, I thought wearily. In my 35 years of practice as a Medical Doctor, having served from the Armed Forces to private national hospital chains like Apollo, to regional consulting diagnostic centres like Elbit, Vijaya and Tenet, I have yet to come across a doctor who was in the medical profession to willingly take a life (Not to mention quacks, who don’t get appointed in respectable hospitals). Then why do these headlines scream ‘doctor is the murderer’ from the pages of social media every so often, as if it was the spoiler of a movie? Of course, the TRP ratings go up, just like the ‘likes’ to a post of a crime thriller. Why else would our media fan this fire?

Today media is repeatedly showing doctor is being beaten-up by patient’s attendants. Like how people learn things from movies, common man is learning that doctor can be made responsible for not saving life of a person. The result is assault on doctors on duty. Perhaps media is also not realizing their coverage could lead to more irresponsible and foolish behavior.
Doctor is trained to save people
Given the right facilities and the right faculties of mind (unless doctor has become crazy), no doctor would ever kill a patient simply because he is trained to do exactly the opposite-try and save the life! A doctor trains for almost a decade, with sometimes pitifully small remuneration (in the early years of the training), to physically and mentally exhausting working conditions, just because they believe that this is their purpose-to save lives and give patients best chance to live a healthy life. If they are unable to save a life, whose job is it to find out whether it was a mistake of the doctor or not? Not of the people who sometimes, in a fit of frenzy, go after the ‘life-saver’ themselves, as if blaming the death on the doctor and beating him with their own hands is going to bring back the dead. Revenge only leads to greater misery.

Why people behave foolishly?
Sometimes people behave foolishly! Especially the patient’s attendants! They believe beating the doctors is the ultimate solution. For even one second, they don’t think what a grave sin it is to punish the healer. For them, the healer is not God, just a human being. Taking the same argument further, if doctor is human then how can he save all the lives? There are some terminally ill patients who can be saved only by a miracle, not a human doctor. There are babies whose lives are yet so fragile, that saving all babies is impossible. There are such diseases which medical science is yet to understand fully. Statistics or data of any hospital, even the best hospitals in the developed nations in the world will reveal that all lives cannot be saved. Sometimes a mere blood clot can travel and get lodged in a place where it causes a stroke. This in spite of giving blood thinners. There are many such examples.
I welcome those attendants of patients to talk to me or any other doctor, who will patiently explain the no. of things that could go wrong in the human body. I wish doctors would pay more attention to patients’ attendants than they usually do. These attendants are also the sufferers, not just the patients. When a patient is lying on the hospital bed comatose or under influence of drugs, it is the care-givers waiting outside who are suffering the brunt of the situation. They need to be explained tactfully the seriousness of the patient.  It’s better not to give unrealistic hopes.

If the same doctor is busy, the doctor can delegate this task to another doctor. As per research, female doctors are better at this. Their motherly instinct takes over and they are known to give more time to patients and their care-givers than the male doctors. This known fact can be utilized by all doctors. Instead, sometimes doctors speak against their colleagues, which further damages the safety of the entire medical fraternity.
Doctors who handle emergencies and are on night duties are at high risk for attacks. It is better to prevent heated discussions with attendants by assigning a female doctor or an experienced female nurse to talk to them patiently. More than 2 attendants should not be entertained inside the hospital room. Entertaining unrelated people who accompany the patient can create trouble; hence should be discouraged. Some alleged incidents happen in private hospitals perhaps due to marketing strategy and management demands but not because of doctors. Unfortunately, the savior becomes the scape-goat.

Doctors do no possess magical powers
First thing we must understand that Lord Krishna, Rama, Pope, Shankaracharya, NTR, Jayalalithaa and many have died and doctors or priests could not save them. Media should make people understand that doctors are human beings and do not possess magical powers. Instead people have learnt that doctor should save every life. Media should refrain from showing these incidents to increase their TRP rating. Those incidents should be handled independently without major publicity.

Disease patterns have changed over the years and accurate diagnosis is not always possible, Supreme Court has given guidelines that doctor cannot be penalised for not diagnosing accurately. Differential diagnosis and impressions on possible diagnosis are also valid. Pharma industry is not under the control of doctors. They cannot control the molecules which replace the older ones often. Media has the power and widespread coverage to explain this to the common man. Such an article should be printed along with the article reporting the beatings, not on another page, another day alone.

Political leaders should avoid following every case to make their importance in public. They don’t understand the anguish and careful attempts of a doctor and the pathos of an attendant. In case of alleged negligence, a case can be filed in a manner prescribed by law, in extreme situations.

Citizens should take care of their health with pro-active approach. Today majority of Indians are after money neglecting their bodies, I see many youth who visit me with severe disc disease due to sheer negligence and they expect the doctor to save them miraculously from surgery within no time. Doctors are humans. They have spent money and time to study for many years. More than 85% of doctors do not make enough money when compared to their counterparts; they have sacrificed so many nights in attending emergencies, they need peoples’ support and gentle understanding of their occupational needs.. 

Wednesday 17 April 2019

“Vitamin ‘D’ Panacea of Life” Understanding the need of the day (Revelations of study of 9360 people)

“Vitamin ‘D’ Panacea of Life” Understanding the need of the day
(Revelations of study of 9360 people)

Prof Maj Dr S Bakhtiar Choudhary (Retd)

1.    Introduction

It has been estimated that 1 billion people worldwide have Vit D deficiency or insufficiency1. India with its socio-cultural diversity, receiving reasonable sunlight throughout the year, it was believed that Indians would not suffer from Vitamin D deficiency. India’s geographical location extending 8.4° N latitude to 37.6° N latitude with tropical weather conditions should ideally provide ample exposure to sunlight. But Vit D deficiency is very common in India in all the age groups and both sexes across the country2-4. Vitamin D regulates calcium absorption in conjunction with the parathyroid hormone and bone mineralization. Biochemical studies have implicated vitamin D deficiency in many chronic diseases including infectious diseases, autoimmune diseases, cardiovascular diseases, diabetes and cancer. Vitamin D insufficiency leads to reduced bone mass, which can be manifested as Osteoporosis and Osteomalacia in adults and rickets in children5.

Minimum of 30 ng/DL of Vit D required for absorption of Calcium

Vit D is lower than 10 ng/DL, is likely to damage Vit D receptor (VDR’s) sites

Doctors fail to treat Vit D deficiency on long term bases

Avoiding staple food is likely to cause chronic Vit D deficiency

Current Vit D recommendations are under estimates

Vit D deficiency begins as early as 10 years of age or below 

2.    Prevalence of Vitamin D

Vitamin D insufficiency is evident in half of adults in New Zealand 6, one-quarter of Australians 7, 14% of French 8, 36% of US young adults and 57% of US general medicine inpatients 9, and particularly in the elderly, including up to 90% in UK10 and 86% in Switzerland 11.
Table-1. Prevalence of Vitamin ‘D’ in Indian general Population

Blood levels
 People (Percent)
Vitamin ‘D’  ng/DL
Less than 3
More than 30

          Vitamin D was thought to help only bones and prevent diseases like rickets. But today’s research has proved that vitamin D has much more role in preventing multi system disorders. For ex. diabetes, thyroid, pain, dementia, depression, PCOD, and many other diseases. Unfortunately, all tropical countries in southern globe like Africa, Arabian countries & India despite having sunshine throughout the year, have Vitamin D deficiency in most of the population. There are hardly 2.4 % of Indian population who have Vit D more than 30 ng/DL and rest are all either insufficient or deficient (Table -1).
3.    Adequate Exposure to Sunlight
Studies have proved that sunlight exposure for more than 30 mins at one time cannot increase absorption. Instead repeated bouts of exposure are needed.
Fair complexion people are likely to make more vitamin D in a shorter duration of exposure to sun, than their darker counterparts of same age. Darker complexion people have thicker skin and do not absorb adequate Ultra Violet B rays (UVB) to make sufficient vitamin D in the skin, in a short span of time.
For many years people feared skin cancers on exposure to sunlight & thus avoided roaming in the sun or applied sunscreen lotions and other protective measures. This has led to vitamin D deficiency all over the world.
The elderly people are likely to make less vitamin D through the skin, as absorption is poor. People who are on anti-cholesterol tablets for prolonged periods are likely to reduce 7-dehydro cholesterol, a type of cholesterol which is responsible for making vitamin D under the skin with the help of UVB rays when exposed to sun. Hence, they are likely to be deficient, which is a large chunk of elderly population.

4.  Direct and Uninterrupted Exposure- We get 80 % of vitamin D from sunlight in the presence of uninterrupted ultra violet B rays in the sunlight spectrum. These rays are very sensitive and cannot penetrate 1mm glass hence they are unlikely to penetrate normal clothing and make the vitamin in the skin. Atmospheric pollution, dust, suspended particles, & chemical gases may seriously interfere with UVB reaching the humans sitting in closed compartment of offices, vehicles like cars and buses.
5.    Changing food habits & vulnerability to social media
Vit. D is a fat-soluble vitamin, and it is available in fatty food substances. However, today the trend is to reduce the body weight in order to look attractive and feel good about the body image. When trying to do so, first thing people restrict is fatty food and non-veg. In a person who is already deficient in vitamin D, E, A & K, body tries to store fat, thinking more vitamins will be available through fat. So, during this process it becomes hard to lose weight, as body is trying to hold on to whatever fat is there, thinking these fat-soluble vitamins are available in the body’s fat. Hence, most people who are trying to reduce weight find it hard to lose weight, as they are going against the body’s needs.
6.    Their efforts are counter-productive.
People are vulnerable to the information available through social media, and without consulting the experts, they are making changes in their native staple food habits. For ex. people in twin cities used to consume more of regional foods such as rice, locally available fruits, and nuts, like groundnut, sesame (till), coconut and cashew nut, since these are our regional nuts. Now there is an increased awareness of health which has led people to do ‘dieting’, & indoor exercise programs. But four decades ago, diabetes was prevalent in only 13% people in Hyderabad, now it has jumped to 27%, which is contrary to our efforts to obtain better health. Change in food habits that has happened due to various reasons like body image issues, social media etc. is not leading to better health.
Changing food habits from staple to modern leads to intolerance in the gut, gradual villous damage  in the intestine and leads to serious chronic diseases, such as irritable bowel syndrome, ulcerative colitis, constipation, gas etc., and these changes further cause serious micro-nutrient deficiencies. Today we see large no of people suffering from these intestinal disorders, and doctors find it hard to treat them.
People who consume alcohol are likely to disturb their micro-nutrient absorption along with vitamin D.
7.  Vitamin D Rich Foods Non vegetarian sources like fatty fish (big and fat fish, not small fish), whole egg, and mutton are the best sources. Whole milk, butter, cheese, mushrooms, lentils like lobia (black eyed white grams), okra are reasonably rich in vitamin D for vegetarians but must be eaten on regular basis.
Food Intolerance- Persons having intolerance to milk and milk products such as lactose and most of Southern and coastal Indian population who are largely sensitive to gluten in wheat and corn and other cereals, are likely to be seriously deficient hence they need very frequent estimation of the vitamin D and suitable supplementation.
8.    Diseases Affect Vitamin D Absorption
Healthy diet provides 20% of vitamin D requirements of the day. Vitamin D3 comes directly from the skin (with exposure to sunlight), while D2 is from the dietary sources. Both are converted into active form of D called calcitriol, by the liver and kidney. People with liver and kidney disease are most likely to become deficient and need serious supplementation program by a physician.

9.    Socio cultural habits
Habits among Gujaratis, Marwadis and Muslims, such as burkha, purdah (veil) where women are covered mostly from head to toe are at high risk of not getting adequate exposure to sunlight. In recent times, people have changed their habit of dressing. For ex. South Indian women wearing North Indian clothing such as salwar kameez, churidar kurta may lead to deficiency because of less exposure to body parts. Sari, our traditional India dress for women leaves more than 30% body exposed, which is beneficial for absorption. Similarly, men no longer wear dhoti which has more body exposed than the pant and shirt of today.
10.      Sports persons and Vit D Deficiency (Table-2)
Table -2. Vit D Deficiency status
Indian Sports Persons

Table Tennis              

60  %
46  %
41 %
26  %
23  %
17  %
It is unusual to note that many sports persons are found to be severely deficient in Vit D. This may be because of changes in dressing, changes in eating habits and due to sub-clinical mal-absorption. Food intolerance among sports person need to be evaluated as they contribute for poor absorption of Micro-nutrients. Players like cricketers are also found to be deficient because of their dressing - full pants, full sleeves, helmet, gloves, despite playing outdoors. Players should wear shorts and t-shirts for few hours before wearing full uniform.

Sunlight should touch the skin for longer time. Especially in cities, badminton, table tennis & chess players often have vitamin D deficiency, hence they should have outdoor fitness program in sun, 3-4 days a week. Vit D deficiency is very common among many players and this increases their risk for injuries due to abnormal joint stiffness.

11.                     Rural population have slightly lesser deficiency. This may be due to better availability of UVB rays due to less pollution, and better exposure due to clothing such as shorts and t-shirts instead of full pants and shirts.
12.               Women and young girls with severe vitamin D deficiency have higher risk for schizophrenia, asthma, type 1 diabetes, and rickets in childhood.
During pregnancy, vitamin D deficiency can lead to diminished lactation, risk for gestational diabetes, pre-eclampsia, spontaneous pre-term birth, higher risk for c-section, lower birth weight, lower infant size, lesser bone density and health, reduced IVF success and repeated bacterial vaginal infection. 
During adulthood, women without pregnancy are at risk for hypertension, obesity, type 2 diabetes, abdominal cancer, multiple sclerosis etc. In senior women, cognitive impairment, myopathy, osteoporosis, Osteomalacia, frequent falls and fractures can occur. It is found that dietary intake of vitamin D during pregnancy is 80% below recommendation. It is also found, good vitamin D supplementation during pregnancy helps in regulating placental hormones and improves labor.
During lactation, it improves breast milk and increases circulating calcitriol concentration in nursing infants. It also prevents infantile rickets.
13.              Managing Vitamin by testing
Vitamin D is tested by a simple blood test costing Rs 600-2500 in different labs. Although recommendations say 30 ng/dl of vitamin D is sufficient but for good health, body needs 60 and above ng/dl for both sexes. Current recommendations underestimate the body’s requirements. Healthy rural youth were found to have vitamin D 60-70 ng/dl without any supplementation (eat well, exposure to sunlight). For pain relief, for better joint mobility and good proactive health management, one needs to maintain 60-70 ng/dl throughout the year and throughout life, which may be impossible. This is because 6 months to a year, exposure is compromised due to rainy season, winter season, summer heat and fear of going out in the sun. Modern youth are more inclined to exercising in gym, and modern jobs involve long hours of work. Commutation in cities takes away their valuable time, and exposure is neglected. One needs exposure to sunlight at least 3 days in a week, 20-30 mins, once or twice a day, with a direct contact to 30% of the body.

14.                     Extremely Low Levels of Vitamin D
People with vitamin D less than 10 ng/dl in their blood are at the highest risk for pain disorders, thyroid dysfunction, diabetes and people with less than 5 ng/dl may be at risk for cancer. People get relief from most pain disorders when their levels are more than 50 ng/dl. Calcium is absorbed when vitamin D is more than 30 ng/dl.
15.                     Frequent Testing and Prolonged Supplementation
Most of us do not have 100% regulated digestion throughout the month. Minor disturbance in digestion can seriously impair absorption of these nutrients. That means frequent checking and supplementation. Vitamin D test should be done twice a year, before monsoon in June and at the end of winter, in Feb or Mar. Oral supplementation is better than injectable, to encourage absorption in gut. Vitamin D receptor sites become seriously damaged once person becomes deficient, and may take months to years before becoming active again. That’s why one needs prolonged supplementation. If deficiency is noted in children as young as 7-8 years, they are likely to become seriously deficient as adults as receptors get damaged, without any symptoms. Children need to be tested at least once every year.
16.  Vitamin D Toxicity people often have fear that excess vitamin D supplementation will lead to toxicity but fortunately this is not likely. Only 4000 IU or more of vitamin D every day for couple of months may lead to toxicity.

     17.  Self-medication It is not advised to take commercial diet supplements off the shelf without doctor’s advice. Because they may not have adequate vitamin D formulations. Most people need 1000 IU of D3 tabs daily and pregnant women, lactating women, sports persons, and elderly and people who are diagnosed as deficient need higher supplementation under supervision. It is important to note that calcium tablets do not have adequate Vit D. Before you take any pharmaceutical supplements off the shelf, it is important to get advice from a doctor.
     18. Management Advice
          Time management is essential and should begin with childhood so that they develop habit of getting exposed to sun and eating right. But one should protect eyes from the UV rays by wearing UV protective sun glasses. People who are sensitive to UV rays can safely expose to sunlight for up to 10 mins before applying protective cream. Changes should be made in clothing, for ex. half shirts and shorts as school uniforms. Children should be taken for frequent outdoor recreational activities like trips to the zoos rather than be allowed to spend time on phone and TV. Sudden pain, stiffness in joints, tiredness, feeling of bone pain, sudden increase in weight, disturbance in menstrual cycle are most likely due to person being vitamin D deficient.

Note: These predictions are based on my study of more than 9360 people of all ages and both genders. Final publication will be made available soon.
Contact: Pl contact Prof Maj S Bakhtiar Choudhary, Hyderabad Spine Clinics
Tel: 8008123940


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