Editorial 1: The curious case of rising lactose intolerance
Introduction
- Lactose intolerance is caused by a lessened ability or inability to digest lactose, a sugar found in dairy products. Humans vary in the amount of lactose they can tolerate before symptoms develop. Symptoms may include abdominal pain, bloating, diarrhea, flatulence, and nausea. These symptoms typically start thirty minutes to two hours after eating or drinking something containing lactose, with the severity typically depending on the amount consumed. Lactose intolerance does not cause damage to the gastrointestinal tract.
A disorder or not!
- Doctors do not consider lactose intolerance to be a disorder. They describe it as the digestive system’s reaction to milk sugar (lactose) which it cannot digest.
- The body needs an enzyme called lactase which is produced by the cells lining the small intestine, to digest lactose.
- If one is deficient in lactase, the undigested lactose passes on to the colon, where it produces extra gas and water, resulting in bloating, cramps and diarrhoea.
- Lactose intolerance thus produces symptoms which can be uncomfortable, but it is never dangerous.
Extremely common
- Lactose intolerance is so common that except for the 1-2% people who might experience serious bloating and cramps and nausea immediately after consuming dairy, almost every adult has lactose intolerance in various degrees.
- As one ages, there is a normal decline in the amount of lactase that the small intestine produces.
- Lactose intolerance is a specific digestive issue associated with the consumption of dairy products and ceases to be a problem when the person totally avoids or restricts milk products in the diet.
- But its symptoms can easily overlap with another common and chronic gastric disorders such as IBS, the pathogenesis of which is quite different.
Varies by ethnicity
- According to literature, estimates for lactose intolerance vary by ethnicity.
- The prevalence rate is 75-95% in African American and Asian ethnicities while it is estimated to be 18-26% amongst Europeans.
- Though there are specific tests like the hydrogen breath test to determine lactose intolerance, these tests do not have much use in clinical practice.
- This is a condition that is generally self-diagnosed and self-managed. The usual tests for detecting lactose intolerance are not available here or are expensive but clinical diagnosis seems to suffice.
- It is possible to develop secondary lactose intolerance all of a sudden following surgery or chemotherapy or if one has an infection, ulcerative colitis or Crohn’s disease which affects the small intestine. But this usually goes away once the small intestine regains health.
Intolerance distinct from allergy
- The lactose intolerance is quite common among Asians — over 50% of the Indians are deficient in lactase — it is very easy to misdiagnose this condition, especially amongst the elderly.
- In the elderly, some malignancies like colon cancer can present themselves in the initial stages with atypical symptoms similar to that of the symptoms of lactose intolerance.
- The reaction is often immediate and severe in the case of milk allergy, while lactose intolerance will never lead to any serious disease or long-term complications.
Conclusion
- For persons with lactose intolerance who love to consume milk, there are options such as plant-based milk (soy/almond milk) or lactose-free milk. There are plenty of other food sources — yoghurt, tofu, nuts, spinach, broccoli, orange, lentils and legumes — that a lactose-intolerant person can depend on for calcium supplementation.
Editorial 2: India needs evidence-based, ethics-driven medicine
Context
- The recent push to integrate ‘AYUSH’ medicinal systems into mainstream health care to achieve universal health coverage and ‘decolonise medicine’ is a pluralistic approach that would require every participating system to meet basic safety and efficacy standards.
Efficacy and safety of homoeopathy
- Evidence on homoeopathy’s efficacy is weak.
- The first carefully conducted and well-reported double-blind randomised controlled trial (RCT), the Nuremberg Salt Test (1835), noted that “the symptoms or changes which the homeopaths claimed to observe as an effect of their medicines were the fruit of imagination, self-deception and preconceived opinion — if not fraud.”
- Multiple systematic reviews and meta-analyses have found that, across ailments, population groups (adults versus children), study types (placebo-controlled versus other trial types), and treatment regimes (individualised versus non-individualised), homoeopathic treatments lack clinically significant effects.
- Recently, researchers demonstrated that more than half of the 193 homoeopathic trials in the last two decades were not registered.
- Unregistered trials showed some evidence of efficacy but registered trials did not. There was reporting bias and other problematic practices, throwing the validity and reliability of evidence thus generated into doubt.
- Further, the World Health Organization (WHO) has warned against homoeopathic treatments for HIV, tuberculosis, and malaria, as well as flu and diarrhoea in infants, saying it has “no place” in their treatment.
- Evidence is accumulating that homoeopathy does not work for cancers and may not help to reduce the adverse effects of cancer treatments, contrary to lay belief.
- Instead, treatments have been linked to both non-fatal and fatal adverse events as well as their aggravation.
- Seeking homoeopathic care also delays the application of evidence-based clinical care. In several cases, it has caused injuries and sometimes death.
On standards
- Homoeopathy’s supporters argue that the standards commonly used in evidence-based medicine are not suitable for judging the “holistic effects” of homoeopathy. This claim can be debunked.
- First, the standards are not conveniently chosen by practitioners of allopathic medicine for themselves.
- Second, Homoeopathy advocates have failed to invent valid alternative evidence synthesis frameworks suited for testing its efficacy and safety, which are also acceptable to the critics.
- Third, the claim about homoeopathy being holistic is typically paired with evidence-based medicine being “reductionist”.
- Fourth, evidence-based medicine does not and should not stop at establishing empirical evidence. The quest is also to discover and explain the mechanisms underlying the evidence. In the last century, there has been no concrete evidence for proposed mechanisms of action for homoeopathy.
- No mechanistic ( molecular, physiological, biochemical, or otherwise) evidence to explain how concepts such as “like cures like”, “extreme dilution”, and “dematerialised spiritual force” result in better health.
- In the same period, several allopathic/modern medicine practices have updated themselves based on growing scientific evidence.
The right approach
- Adopting a pluralistic approach in medicine can decolonise medicine. In India, homoeopathy is at odds with this.
- Homoeopathy was introduced in 1839 in India by Austrian physician J.M. Honigberger.
- Of course, not all colonial-era practices need to be surrendered. Those with health and developmental benefits such as evidence-based elements of allopathic medicine and gender role and caste reforms should be retained.
Conclusion
- The argument to reject homoeopathy is not just based on its coloniality, but chiefly on the lack of evidence for efficacy, some evidence for lack of safety, no substantive progress on mechanisms of action in the last century, and homoeopathic practitioners’ escapist arguments. India’s path to universal health care must be grounded in evidence-based and ethics-driven medicine.
