Fight breathing problems due to cold and dry air in winter!

A deep breath of cold winter air can be risky for people with asthma, bronchitis, or COPD. It can trigger wheezing, coughing, and shortness of breath. It can irritate the airways, causing the upper airways to narrow and making it a little harder to breathe even in healthy individuals.

1.    Get your drugs titrated: Work with your doctor in advance to optimize medications for the winter months. Patients with asthma who are sensitive to cold air may be asked to use an inhaler; short-acting bronchodilator

2.    Moist your nose: A dry nose generally feels like a congested nose, which results in mouth breathing. Regular use of a nasal saline spray help decrease the sense of nasal congestion, which will decrease mouth breathing.

3.     Cover your nose and mouth: with a scarf when you're outside. It reduces symptoms by warming the face, warming the air you breathe, and increasing the moisture in the air you breathe

4.     Stay indoors: People with respiratory conditions should avoid spending time in the cold whenever possible

5.    Avoid exercising in cold as it will further increase the dryness of the airways and potentially increase symptoms or the risk of an asthma attack. The need to move your exercise routine indoors during the winter months is a good opportunity to take an exercise class at a gym, start a home workout program, or join a walking club at a local mall.

6.     Adjust the indoor air: Keep the air warm and moist. Don't let the indoor air temperature fall below 64 degree F and use a humidifier to keep the air from becoming too dry.

7.     Avoid lung irritants like wood-burning fireplaces

8.     Take annual flu shot

9.    Complete your pneumonia vaccine protocol

10.  Make sure you do not miss heart symptoms as lung symptoms, as both are common in winter.

Dr KK Aggarwal

Padma Shri Awardee

President Confederation of Medical Associations in Asia and Oceania (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA

The top 10 causes of death in India

India continues to face a twin burden of diseases, both communicable and non-communicable diseases (NCDs) as is evident from the list of top 10 causes of death in the country. Cardiovascular diseases (CVDs) are the leading cause of death in India as they are globally. Diarrheal diseases come next.

As per data, the top 10 causes of death in India are:

1.     Cardiovascular diseases

2.     Diarrheal diseases

3.     Neonatal disorders

4.     Non-communicable diseases

5.     Chronic respiratory diseases

6.     Diabetes

7.     Mental disorders

8.     Unintentional injuries

9.     Neoplasms

10.  Nutritional deficiencies

(Source: World Bank India, Population Reference Bureau (2017) India)

The major risk factors for CVDs include high BP, abnormal blood cholesterol, tobacco and alcohol use, diabetes, obesity, unhealthy diet, sedentary life, psychosocial stress.

The factors responsible for the rising prevalence of type 2 diabetes are again unhealthy diet, lack of physical activity, harmful use of alcohol, over-weight/obesity, tobacco use etc.

Common mental disorders such as depression, anxiety often coexist with other NCDs and they share many risk factors. They occur not only as an outcome of NCDs, but mental disorders are also associated with behaviors (alcohol use, tobacco smoking, unhealthy diet, reduced physical activity), which increase the risk of other NCDs.

Unintentional injuries are an important cause of death in India. Road traffic injuries, falls and drowning constitute the three leading causes of deaths due to unintentional injury. Diabetes is an important cause of falls in the elderly.

The traditional risk factor for chronic respiratory disease such as COPD, asthma has been tobacco smoking. But, now, non-smoking risk factors such as air pollution, occupational chemicals and dusts are emerging as important contributors to chronic respiratory diseases in developing countries like India.

Air pollution has now emerged as a major environmental risk factor for health. It is a major potentially modifiable risk factor for chronic diseases as well as acute disease events such as stroke, acute heart attack and acute bronchial asthma.

When we talk of communicable diseases, the major risk factors for diarrheal diseases, the second largest cause of deaths in the country include poor sanitation and lack of hygiene. Around 1.1 million children die each year in India, including approximately 1.1 lakh deaths due to diarrhea. Although other factors such as low socioeconomic status, poor maternal literacy, low birth weight, inadequate breastfeeding, malnutrition also contribute the disease burden.

Enlisting the risk factors shows that poor sanitation and lack of hygiene are the major risk factors for communicable diseases. While, most NCDs such as heart disease, diabetes, cancer, respiratory diseases share common behavioral risk factors (lack of physical activity, unhealthy diet, tobacco use, excessive intake of alcohol) and metabolic risk factors (obesity, hypertension, dyslipidemia, diabetes).

The INTERHEART study published in the September 3, 2004 issue of the Lancet identified nine traditional risk factors for an acute heart attack: Abnormal lipids, smoking, hypertension, diabetes, abdominal obesity, psychosocial factors, consumption of fruits, vegetables, and alcohol, and regular physical activity. As per the study, more than 90% of the global risk for acute MI is predicted by these nine traditional risk factors.

Hence, preventive strategies for NCDs must focus on these overlapping risk factors. Diarrheal diseases can be tackled via safe drinking water and improving hygiene and sanitation.

Much of the disease burden in the country can be prevented by behavioral changes and adopting a healthy lifestyle and practicing good hygiene.

Swachh Bharat mission, which promotes hygiene and sanitation and also aims to make India completely Open Defecation-free (ODF) by October 2019, is a step to reduce the burden of diarrheal diseases in the country. A WHO report in 2018 estimated that at least 1.8 lakh diarrheal deaths have been averted in rural areas since the launch of Swachhta Bharat Mission (TOI).

India has a National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS). In the interim budget, the budgetary allocation for NPCDCS, national mental health program, tobacco control program were reduced.

India will soon elect a new government.

It remains to be seen if the next government will have the political will to tackle the epidemic of NCDs in the country and according increase the budgetary allocation when they present the full budget.

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA

Should air pollution be named as one of the causes of sudden death?

Nine out of ten people now breathe polluted air, which kills 7 million people every year, says the World Health Organization (WHO).

Air pollution has now emerged as a major environmental risk factor for health. “The health effects of air pollution are serious – one third of deaths from stroke, lung cancer and heart disease are due to air pollution. This is having an equivalent effect to that of smoking tobacco, and much higher than, say, the effects of eating too much salt” (WHO).

In 2016, as per WHO, ambient or outdoor air pollution caused an estimated 4.2 million premature deaths worldwide in both cities and rural areas; 58% of outdoor air pollution-related premature deaths were due to ischemic heart disease and strokes, while 18% of deaths were due to chronic obstructive pulmonary disease (COPD) and acute lower respiratory infections respectively, and 6% of deaths were due to lung cancer. More than 90% of these deaths occurred in low- and middle-income countries.

And it’s just not outdoor air pollution; household (indoor) air pollution also causes 4 million deaths annually.

Pollutants with the strongest evidence for public health concern include particulate matter (PM), ozone (O3), nitrogen dioxide (NO2) and sulfur dioxide (SO2).

Air pollution has been identified as a trigger of acute cardiovascular events (myocardial infarction and stroke). A recent study presented at Heart Rhythm 2018, the Heart Rhythm Society's 39th Annual Scientific Sessions, which evaluated 112,700 women in the ongoing Nurses' Health Study showed that lower-risk women exposed to particular matter (PM) for even a short amount of time are at an increased risk of sudden cardiac death. This association was significant on cold days - at low temperatures below 13°C.

In a report published by the ICMR in The Lancet Planetary Health in December 2017, ICMR clearly stated that 1.24 million deaths in 2017 were caused by exposure to air pollution; one in eight deaths was due to the constantly deteriorating air quality.  ICMR also observed that life expectancy in India is reduced by 1.7 years on an average due to bad air quality.

This report was considered devoid of merit by the Environment ministry.

But, prior to the ICMR report, in 2015, the health ministry had released a report saying that air pollution causes impacts similar to that of tobacco smoking. The report also said that there was evidence of adverse pregnancy outcomes, tuberculosis, asthma exacerbation, cancer and thus, air pollution needs to be addressed during public health programs.

The environment ministry maintains that since no death certificates have pollution listed as the reason of death there is no correlation between air quality and deaths due to the same.

Doctors do not mention pollution as a cause of death, because pollution is not recognized as a cause of death and has no insurance cover. Natural disasters are generally not covered in routine insurance.

However, these statistics only serve to emphasize that perhaps the time has come to declare pollution as one of the causes of all sudden deaths, particularly when the pollution levels in the city are high.

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA

Always enquire about chronic rhinitis in asthma and COPD patients

Patients hospitalized for either asthma or chronic obstructive pulmonary disease (COPD) have a higher risk of being readmitted for a hospital stay within 30 days of release if they also suffer from chronic rhinitis, says a new research from the University of Cincinnati.

The study, published in the Journal of Allergy and Clinical Immunology: In Practice, examined 4,754 asthmatic patients and 2,176 patients with COPD for a five-year period between 2012 and 2017. The 30-day asthma- and COPD-related readmissions of patients with allergic and non-allergic rhinitis with those patients without that diagnosis were compared using multivariate hazard models adjusted for relevant patient comorbidities.

Patients with asthma and allergic rhinitis were 4.4 times more likely to be rehospitalized within 30 days of discharge compared to those patients who did not have allergic rhinitis. Asthmatics with non-allergic rhinitis were 3.7 times more likely to be re-admitted within 30 days of discharge than asthmatics without non-allergic rhinitis.

Examination of COPD patients also revealed higher probability of rehospitalization when allergic rhinitis was also present.

COPD patients with allergic rhinitis may be readmitted 2.4 times the rate within 30 days of discharges compared to COPD patients without allergic rhinitis. Similarly, COPD patients with non-allergic rhinitis were 2.6 times more likely to readmitted within 30 days of discharge vs COPD patients without non-allergic rhinitis.

This study highlights the significance of a thorough history-taking, an art which many of us might have forgotten about, perhaps to meet the rush of the day.

Whenever treating a patient of asthma or COPD, one should always enquire about comorbid chronic rhinitis – allergic or non-allergic rather than treating or managing just the asthma or COPD. And, also treat it, if present.

Sir William Osler said, “Listen to your patient, he is telling you the diagnosis.”

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA

World COPD Day: Indoor air pollution is a major risk factor for COPD

COPD or chronic obstructive pulmonary disease is an often overlooked but serious global health threat. It is often underdiagnosed in India because spirometry, which can confirm the presence of COPD, is often not conducted during preliminary examination.

COPD is a gradually progressive disease characterized by airflow limitation. Cigarette smoking is the major etiologic factor; however, exposure to other chemical irritants also plays a role in the pathogenesis.

Indoor pollution is also one of the risk factors for COPD. Indoor air quality can be determined by outdoor or ambient air pollution, fuels for heating and cooking, tobacco smoke, second hand tobacco smoke, poorly ventilated and overcrowded living conditions.

When outdoor levels of pollutants are high, their levels also increase indoors. Poor ventilation and structural designs can trap volatile organic compounds, bioaerosols and particulate matter so, the indoor air quality can be up to 10 times worse than outdoor air pollution. In a country like India, it becomes increasingly important to address challenges associated with indoor cooking, especially in rural areas.

Lung is a major site of interaction with environmental particulates. Pollutants such as particulate matter can affect the lung in numerous ways causing inflammation, oxidative stress, and cell cycle death. Therefore, air pollution is strongly associated with the risk of COPD or aggravating pre-existing COPD triggering “exacerbation” episodes. Exposure to second-hand smoke may sometimes cause never-smokers to develop COPD.

Individuals, who have COPD should consult their doctors about need for increasing the dose of their medications. They must use a mask when they step out of the house.

Air quality in Delhi is “very poor” and this has been the case not only since the last few days, but also the past few years. It is becoming a recurring public health problem that needs urgent attention. However, air pollution is mainly man-made and since it harms human health, it is of immediate concern to all. It is not just the responsibility of the government, it is a collective responsibility.

We too can make a difference by adopting measures - at an individual level - to prevent or at least help control the air pollution levels and keep the environment healthy.

Here is what each one of us can do to make a difference and we can start right away.

• Walk or cycle for short distance commutes or to the neighborhood market.
•  Plan and combine all your errands (in one area or close by areas) for one trip.
• Limit driving and carpool.
• Use public transport, as much as possible, for longer distances.
• If you have to use your vehicle, keep it well-maintained for efficient functioning with regular servicing to reduce harmful exhaust emissions and get pollution check done as required. Follow speed limits. Avoid buying diesel vehicle.
• Avoid burning candles, dhoop or incense sticks at home or workplace.
•  Quitting smoking.
• Plant more trees.
•  Limit the areas of bare soil by growing grass to reduce the amount of dust.
• Sprinkle water on exposed soil or construction sites regularly to reduce generation of dust.
• Wet mopping the floors at home or workplace.
• Avoid organizing outdoor parties or any other events when AQI crosses 200.
• Be a strong advocate for measures to control emission of air pollutants. Be active participants in activities to fight air pollution such as odd/even vehicle rule.
• Follow all rules and laws as enforced by the state.

It’s “Never Too Early, Never Too Late”, as is the theme of the World COPD Day, falling on Wednesday, this year,

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA