Tag Archives: Hypertension

Doctors Open Doors To Sick Punjabi Truckers

The doctor leaned over Jitamber Singh Bedi and inserted the needle of the injection into his eyeball. Jitamber had a blockage in his vein that was causing his eyesight to cloud up. Vision problems are a side effect of diabetes. Like eighty-eight percent of truck drivers, Jitamber Singh Bedi too had Type 2 diabetes. 

In order to operate a commercial vehicle on the road, a driver must be able to prove they are maintaining stable blood sugars. Jitamber medical exam report is part of his driving record. It is filed electronically by the Medical Examiner (ME) with the US Department of Transportation (DOT) bi-annually. Any drop in health indices would mean he loses his license or at best, gets recertified every year. 

Over half of all long haul truck drivers suffer from hypertension and/or diabetes. These comorbidities put them at a higher risk for COVID.

“Sedentary lifestyle and erratic sleep gets you, if bad food on the road doesn’t,” says Jitamber Singh Bedi. “Sitting for ten hours a day for ten days at a stretch, the truck driver is a sitting duck for diseases like diabetes. And when they do take a break it is easy to pull out a cigarette.”

“At every rest stop I ended up smoking,” says Jitamber. 

Irregular eating habits and dehydration further strain the system. Jitamber is always worried about taking restroom breaks and therefore restricts the intake of fluids and food which can lead to the taxi cab syndrome. The inability of drivers to relieve themselves regularly throughout the workday leads to voiding dysfunction, infertility, urolithiasis, bladder cancer, and urinary infections as compared with nonprofessional drivers wrote Alon Y Mass, MD, David S Goldfarb, MD, and Ojas Shah, MD. from the Department of Urology, NYU Langone Medical Center. Paid by the mile, every restroom stop costs precious time.

“Sssssslow suicide behind the wheel,” says Jitamber, “with the pandemic that could take a quick turn for the worst.”

Jitamber graduated from Mayo College, where he went to school with the sons of India’s upper classes, princes, and nobles. After immigrating to the US, he worked for ten years as the Assistant Manager, Special Reporter and Editor for India Post, a California publication. Jitamber started driving a truck in the US in 2012.  

Jitamber & his wife Lisa

He still maintains his A1 license to drive a truck and is married to Lisa, a librarian at the county library. Jitamber is on his wife’s medical plan. Kaiser is their health insurer. Kaiser, a California company, has agreements with other providers to provide coverage all over the US thinks Jitamber. He does not really know how his health insurance will play out if he falls sick on the road.

Raman Dhillon of the North American Punjabi Trucking Association (NAPTA) has negotiated a health plan that truckers can buy into. Portability of insurance plans from one state to the other has been a bottleneck to seamless healthcare access. NAPTA wants to ensure that the trucker has access to pharmacy anywhere and medication can be prescribed to and picked up by the driver from the pharmacy closest to him. 

President Trump’s Emergency Order in the face of the COVID pandemic opened up anywhere anytime access to healthcare.

Anywhere Anytime Access 

Of the 1.5 million truck drivers on US highways, says the Punjab Truck Association, about 150,000 Punjabis are working in the trucking industry. The South Asian gene makes the Punjabi drivers more vulnerable to acute myocardial infarction (MI). Studies by UCSF, Stanford and El Camino hospital’s South Asia Heart Center, show that heart disease strikes South Asians at a younger age and more malignantly than the general population. “South Asians represent approximately 17 percent of the world’s population – yet they account for 60 percent of the world’s heart disease patients,” says Anita Sathe of the South Asian Heart Center which runs a program to help South Asians manage their heart risk.

The ability to access and monitor healthcare on the road is crucial to the health of Punjabi truckers.

COVID-19 opened the door for truckers to access technology-based ubiquitous healthcare. Under the 1135 waiver authority and Coronavirus Preparedness and Response Supplemental Appropriations Act, the incorporation of telemedicine into routine medical care on a temporary and emergency basis, has lightened the burden on truckers. The waiver has loosened former requirements that the patient and provider be in the same state or that the patient must be in physician shortage areas to access telemedicine; so a doctor in New York now can be reimbursed for consulting with a patient out of California. 

The rule that a new patient could not use telehealth and must have an established relationship with the doctor has been relaxed as have some of the HIPAA requirements like data transfer and storage. The new criteria allow the use of tablets or smartphones, so a driver can call a nearby doctor from his smartphone. However, all calls must be video calls;  audio-only calls may not be made. 

“From March 6, 2020, a range of providers, such as doctors, nurse practitioners, clinical psychologists, and licensed clinical social workers, offered telehealth to all patients,” says Apexon Healthcare executive Siva Sundar. “Meeting the doctor through zoom or Facetime has become the norm for everyone during the quarantine.” 

Telemedicine and walk-in medical clinics located at truck stops and Pilot and Flying J Travel Centers proliferated with the advent of COVID. For the sake of the truckers, these new rules must outlast the pandemic and become the new normal. 

Checking For Sugar On The Road

Jitamber Singh Bedi would find it useful to wear body sensors that alert him, his family, and his doctor to potentially serious changes in his health status. 

Continuous glucose monitoring devices to monitor the driver’s blood sugar – motivates healthy behaviors says Rajeev Sehgal, Jitamber’s classmate from Mayo College, who has been wearing the Dexcom 6 device for over 6 months. “In the same way that wearing a Fitbit can be motivational for meeting daily fitness goals, real-time monitoring of blood sugar levels might reinforce good behaviors around eating and exercise,” he says. 

The tiny sensor he wears on his stomach sends real-time reading of his blood sugar levels to his phone every 5 minutes.  “It is extremely comfortable to wear. I can swim with it. I change the device every ten days,” says Sehgal who highly advocates its use by drivers. The device allows quick remedial actions for timely diabetes management and the information can be kept private or shared with family members when the driver is on the road.

If the sensor indicates high sugar and blood pressure levels, the trucker can consult with a doctor by teleconference over Facetime. If they’ve embarked on a trip without getting a refill or forgetting to pack their meds Telemedicine can get them their meds at a pharmacy close to where they are. 

“At present, the sensor is prescribed and covered by insurance for people who have uncontrolled type 2 diabetes but it should be authorized for truck drivers who are managing their diabetes,” says Sehgal. 

Monitoring blood sugar levels on the go will allow the trucker to take immediate remedial action. A brisk walk could fix a spike in blood sugar levels following a sugary lunch or in case of a drop in sugar levels, a quick pop of sugar will prevent deterioration in vision like the one Jitamber had to face. A year ago he noticed he couldn’t read street signs. Retinal vein occlusion and macular edema caused big brown blobs to float in front of his eyes. After a series of shots at regular intervals, Dr. An Ngoc Huynh, MD at Kaiser Irwindale California declared his vision to be 20:25.

“The main thing I want to better understand is, how different things I do affect my glucose levels,” says Jitamber. “I will track my blood sugar levels to see how it responds to food, sleep, and exercise. Fasting, exercise, stress, or sleep can be tweaked to get the marker to the right place. Precision in targeting our health issues can prevent shots in eyeballs,” said Jitamber.

Read other articles in this series:

Road Warrior

Punjabi Truckers Find A Warm Welcome At US Highway Dhabas


Ritu Marwah wrote this series while participating in the USC Center for Health Journalism‘s California Fellowship.

 

Sushant Singh Rajput Jolts Global Mental Health Dialogues

Trigger warning regarding mental health and suicide.

Sushant Singh Rajput, Disha Salian, Sudha Devi lost to mental health

Mental health has been exacerbated during the COVID-19 pandemic. Headlines relating to suicide have sent shock waves through the community. A successful tinsel star, Sushant Singh Rajput and his former manager, Disha Salian, succumbed to their mental health within one week of each other. And in a tragically poetic fashion, as Sushant Singh Rajput’s last rites were performed, his sister-in-law, Sudha Devi, passed away, who had allegedly stopped eating upon learning of his death. The rippling effect of mental health ran its course.

Popular for his acting in both TV and film, the 34-year-old actor, delivered a strong anti-suicide message in his last seen 2019 film ‘Chhichhore’. On June 14, 2020, the actor was found in his Mumbai home. He was reportedly suffering from depression. A week earlier, he had written a heartbroken Instagram story addressing the suicide of his 28-year-old former manager, Disha Salian.

Is it the lockdown and the resulting loneliness or is it the disease itself?

“It is both,” said Dr. Farida Sohrabji, Regents Professor and Interim Head, Department of Neuroscience and Experimental Therapeutics, Texas A&M College of Medicine, at a webinar organized by Ethnic Media Services, June 12, 2020. Both the molecular impacts of the virus and the pandemic-related isolation leads to depression,” she said.

The impact of social isolation can be quite devastating in many ways. Social isolation increases the risk of cardiovascular ailment, heightens the symptoms of autoimmune disease, and increases mental health issues. Not interacting with people increases the stress hormone cortisol and weakens the immune system. People who don’t have the virus but are being socially isolated slip into depression. The senior population, or those with comorbidities like diabetes, hypertension, etc., are isolated for their own good. They are entrapped by voluntary confinement and fall prey to depression.

And then there are those that are infected by the virus.“The virus enters the body through the nose,” says Dr. Sohrabji, “The nose is somewhat exposed to the brain and the virus can end up in the brain in the olfactory system (how we smell things). This area is strongly implicated with depression.”

Additionally, the full-blown inflammation caused by the virus has an effect on the brain and mood of the patient. “The proteins that fight the virus slash and burn cells in the war against the virus and the resulting inflammation can lead to depression,” she said. “ The medical community’s first thought was that the virus is akin to a respiratory disease but it has been noticed to be more than that. A broad basket of mental issues has been caused by it.”

Social distancing to prevent the spread of the virus can lead to depression and anxiety, while those infected with COVID-19 can experience mental health issues, including depression. Being cognizant of the dangers caused by the lockdown can help us help each other stay sane and safe. 

What can help?

A study by Harvard Medical School has a unique solution. Foster a pet. Pets have a calming effect. Dogs’ calming effect on humans appears to help people handle stress, the study says. Research suggests that people with dogs experience less cardiovascular reactivity during times of stress. That means that their heart rate and blood pressure go up less and return to normal more quickly, dampening the effects of stress on the body.

The power of touch appears to be an important part of this “pet effect.” Several studies show that blood pressure goes down when a person pets a dog. Having a dog is good for your heart too, says the study. Besides, dog owners tend to get more exercise as well. As coronavirus spreads across the US, Americans have stepped up to foster and adopt animals, keeping them out of shelters.

Contextualizing

”We come up with our sort-of explanations, even if they are not particularly persuasive, and then file the event away,” says Malcolm Gladwell on suicide. “I keep coming back to how important context is in understanding behavior.” 

The incontrovertible fact is that Sushant Singh Rajput, Sudha Devi, and Disha Salian were casualties of mental anguish during the lockdown. Rest in peace to all the lives that have been lost due to mental health.

Ritu Marwah is an award-winning author whose interest in history has led her to chronicle our life in times of COVID. How many more must we lose?

The Truth about Salt

Even if you think you eat a low salt diet, you’ll be surprised at how much added salt has entered our food chain, cautions Dr. Renu Lalwani, Assistant Clinical Professor of Medicine at Columbia University.

Salt, especially lowly table salt, is one of the most misunderstood foods. For many years now we’ve blamed salt for causing cardiovascular diseases – high blood pressure, heart disease and stroke. But even as health conscious humans avoid the lure of table salt, the real culprit sneaks past, entering our foodchain, disrupting our diets, damaging our health, because many of us fail to recognize the actual troublemaker – added salt in processed foods we love to consume.

How much salt do we need and how much do we actually eat?

Our body needs only 1/4 teaspoon of salt every day. Guidelines recommend less than 2000 (2.0grams) of salt a day. Each teaspoon of table salt contains almost 2300 milligrams of sodium and, on average, we eat five or more teaspoons of salt each day.

Five teaspoons of salt is 20 times more than our body needs for an entire day!

popcorn

We get most of our sodium from table salt, but cooked, packaged and processed foods contain added salt – the main source of sodium in our diet.

burgers

 

 

 

 

To put that in perspective – just one McDonald’s Quarter Pounder with Cheese = about 1190 mg of sodium. That’s one day’s worth of salt intake!

pretzels

In fact, the added salt we unwittingly consume eating out regularly or eating processed foods quickly adds up. The offenders are the most unlikely suspects -bread, pasta, cheese, chips, cereals, sauces, salad dressings, cake mixes, deli-meats, frozen foods, baking powder, canned food and even canned milk.

It’s really quite easy to exceed the recommended daily intake faster than using a saltshaker to enhance flavor.

 

The Benefits of Low Sodium

  • If you have high blood pressure, chronic kidney disease or heart failure – cut sodium intake to 1500 to 1800 mg per day to lower blood pressure
  • If you suffer from borderline hypertension – reduce sodium intake and try to lose weight to remove the need for medications and reduce the risk of heart disease
  • If you have chronic kidney disease and heart failure, it will help reduce or prevent fluid retention – swollen legs, or fluid congestion in the lungs
  • Lower sodium intake can help to reverse heart enlargement and dilatation in patients with heart disease and heart failure
  • Low sodium has been associated with lower risk of dying from a stroke, and can reduce the risk of kidney stones and osteoporosis.

Eat fresh – that’s the simple answer. Most fresh foods – unprocessed meats, fish, grains, lentils, beans, vegetables and fruit have a low sodium content and are better for you.

What do sodium labels actually mean?

  • Very low sodium means: 35 mg or less per serving
  • Low sodium means: 140 mg or less per serving
  • Reduced sodium: sodium is reduced by 25% of usual level
  • Light or lite in sodium: sodium is reduced by 50% of usual level

If you enjoy the taste of salt in your food, cutting down is a challenge, but do try to make healthier food choices.

Salt is an acquired taste and you can retrain your taste buds to enjoy low salt food very quickly. Once they do, most people find that they do not miss salt as much.

The information presented in this article is offered for educational and informational purposes only and should not be construed as personal medical advice. You should consult with your personal physician/care giver regarding your own medical care.

Meera Kymal is a contributing editor to India Currents

photo credit: spoony mushroom <a href=”http://www.flickr.com/photos/42875348@N00/3519933048″>shake me</a> via <a href=”http://photopin.com”>photopin</a> <a href=”https://creativecommons.org/licenses/by-nc-sa/2.0/”>(license)</a>

hypertension

Hypertension- The Silent Killer

Hypertension, or high blood pressure, is blood pressure greater than 140/90. It is critical to diagnose and treat this adequately because it can remain without symptoms and cause a stroke, heart failure, heart attack, aneurysm, kidney disease and vision loss. It is one of the most common conditions treated in a doctor’s office, yet it is under-diagnosed and uncontrolled in over half the patients with serious consequences. The goal is to treat it with a blood pressure (BP) of less than 140/90 or even 120/ 80 if the patient can tolerate it.

hypertensionIt is important to have an annual blood pressure check for adults, but if there is a strong family history of hypertension, or if the blood pressure is close to upper limits of normal, then more frequently. Pre-hypertension is a term given to BP that is 120-139 / 80-89 and indicates a possibility of progression to hypertension.

When I see a patient whose BP is mildly elevated for the first time in the office, I recheck the BP, and instruct the patient on life style changes for controlling it and ask him/her to return in 1-2 weeks for recheck. I also ask the patient to check their BP at home and bring the record to the office. For home use an aneroid or digital BP apparatus with the cuff that fits around the upper arm is best. Occasionally the home apparatus should be brought to the clinic to verify proper functioning.

Correct measurement of BP is key. Patient should be seated quietly for a few minutes. The correct cuff size must be used as a regular cuff can give higher readings on a large person. The inflatable bladder in the cuff should encircle 80% of the arm, so larger persons will need a larger cuff. The arm should be supported while checking the BP.

If high blood pressure is confirmed, I do a full physical exam focusing on target organs such as eye, kidney and heart to detect any damage, blood and urine tests to detect other risk factors like diabetes or high cholesterol, and an EKG. Both arms are checked, and if the BP difference between the two sides is greater than 15 mm, I look for vascular disease. In elderly patients and if someone complains of dizziness, I check a standing BP after 1-2 minutes to ensure the BP does not fall too much upon standing as this can lead to falls.

Blood pressure is not static and changes throughout the day with the highest readings in the early mornings, progressively declining in the afternoon and evening, and reaching the lowest readings during sleep. BP can be checked morning and evening at home and sometimes medication can be given in divided doses for optimal BP control.

There are a large variety of drugs to treat hypertension and they are effective and well tolerated by most people. The selection of a drug frequently depends on the presence of co-morbid conditions like diabetes, heart disease or kidney disease. Two or more medications may be needed to control BP. Diuretics or “water pills “ are common first line agents that are time tested and effective but they can exacerbate gout.

It is key to educate patients about their medicines. Patients should inform their doctor of all medications, so duplicate or outdated medicines can be weeded out and medications should be monitored on a regular basis.

Life style changes are key for controlling established hypertension. Obesity is a major risk factor and losing even 10 pounds can lower systolic pressure (the top number) by 5 mm. Reducing salt intake is vital for controlling hypertension. Total daily intake of salt in older individuals and in hypertensive people should be about two thirds of a level teaspoon of salt or 1500 mg of sodium. Canned and processed foods have a high salt content. It is important to read the label for sodium “per serving” in processed foods. Many of the packaged Indian foods sold in stores, although convenient, have very high sodium content and have up to half the day’s sodium allowance in a single small serving.

Wash canned products such as beans to reduce salt content. Other high salt foods in common use are soups, salad dressings, pickles, soy sauce, cheeses, bagels and breads. Even if a product says “low sodium” it may still contain too much sodium, so it is important to read and understand the nutrition labels.

Exercise improves cardiovascular fitness, reduces weight, reduces blood sugar, and improves blood pressure. Moderate exercise like brisk walking for 30 minutes a day can help reduce blood pressure independent of weight loss.
Meditation, relaxation and deep breathing can alleviate stress and help with BP control.

Alcohol consumption may best be avoided since it adds calories and makes losing weight more difficult. A can of beer or 5 ounces of wine daily can pack 12-15 pounds a year. Even light beer has over 100 calories in a can. Moderate or heavy drinking can lead to severe elevations in BP.  It is also important to control other cardiovascular risk factors such as diabetes, elevated lipids, and to quit smoking.

Isolated systolic hypertension is a condition which occurs in the elderly when only the top number or systolic BP is elevated due to stiffening of the large blood vessels, but it carries all the same cardiovascular risks, so has to be treated adequately.

Sometimes, BP may not be controlled even on multiple medications and is described as “Re-sistant Hypertension.” Frequently the cause is excess salt intake, missing medication doses, sleep apnea, obesity, decongestant use such as in cold medicine, pain medications called non- steroidal anti inflammatory drugs like ibuprofen or naproxen, too much alcohol consumption, and stress. If these causes of resistant blood pressure are ruled out, and BP remains high on multiple medications, referral to a specialist for further diagnosis and treatment is warranted.

Decades ago I used to see patients with massive cerebral hemorrhages, and many with bleeding and edema in their eyes from blood pressure crises. Fortunately they are less common now, but we still need to be vigorous in finding and treating this “silent killer.”

Padma Srinivasan is a physician practicing in the East Bay, and is Board certified in Internal Medicine and Nephrology. Besides medicine her other interests are Indian classical fine arts and traveling.