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The great Indian lady? Tired?
- Dr. Akhilesh Kumar Singh. MBBS, MD., Dr. Parul Kushwah. Dr. Rajesh Chauhan (6 May 2005)
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Surprising
- Sanjay Dalmia (12 May 2005)
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Is this study more relevant for health services in India?
- Smita Oswal (17 May 2005)
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Study design
- Luis F Dias (21 May 2005)
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Brought to light
- Arafat Mirza (21 May 2005)
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Is this article for BMJ?
- Kesavan Damodaran (21 May 2005)
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Nutritional Determinants of Fatigue and a Convergence of Treatments
- Suneel Bhat, Sanjay Bhat, and Dr. Timmanna T. Hegde (1 June 2005)
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Dr. Akhilesh Kumar Singh. MBBS, MD., Senior Resident Neurology. Institute of Human Behaviour & Allied Sciences. New Delhi, Dr. Parul Kushwah. Dr. Rajesh Chauhan
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Dear Editor, The classic Indian women is slightly different from the rest. She has the following transitions in her life- a daughter, wife and a mother. There is no system or desire of gaining independence by and large. Married off early in life, she starts looking after the extended household of her husband, that will now include the husband's parents, the siblings of her husband, tending to cattle, farms, do all the laundry, cooking, washing, feeding and then getting the children ready to go out to school with packed lunch, return to cleaning and brooming, fetching water for drinking and washing from a well/pond/river that may not be that close. Thereafter fetching wood for the kitchen and making cakes from the dung of the cattle. After this perhaps she finds time for herself and after ablutions and prayers, that are so essential, she may eat something or may decide to wait for the children to return and have meals together. By this time it is already 3 or 4 PM and it will be the time to start off with the next round of cleaning, cooking, laying beds, tending to cattle, milching, and after the children and in-laws are asleep, have a quick bite and be available for her husband as other facilities of entertainment are quite non-existent in the Indian villages. The next day will nearly be the same for her and she will try finishing off any pending or forgotten jobs. Then it may be some auspicious day and therefore she may like to keep a whole day's fast, or the fast may continue for a few more days depending on the occasion. A breast feeding mother will still have to feed her child though. 70 % of India lives in villages. Having seen the village life closely enough, having been born in villages, we know the life of a village lady. This is a very detailed and excellent study that the researchers have done from Nov 2001 to May 2003. However taking into context the above scenario of a lady from a village background, probably the need would not have been that urgent. What happens to one such "normal" lady enrolled for a study on chronic fatigue, when confronted with a direct question, as was asked by the research team, "Have you noticed that you have been getting tired during the past month". With regards. Dr. Akhilesh Kumar Singh
Competing interests: None declared |
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Sanjay Dalmia, SpR Royal Shrewsbury Hospital
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I am surprised that this "outside sainsbury type" survey with a few statistical jargons has found a place in prestigious British Medical Journal.It is understood that hunger, poor education, domestic violence,poor mental health,debt causes chronic fatigue.It is surprising that only 12% women reported chronic fatigue with these factors.It is though surprising that high body mass index was not associated with chronic fatigue. Competing interests: None declared |
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Smita Oswal, SHO Pinderfields General Hospital,WF1 4DG
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To conduct a study of this proportion over 18 months in a place like Goa where illiteracy and poverty are high is indeed a Herculean task. The authors must be commended for their effort. In addition to the factors described by the authors, temperature variations during the year, heavy Monsoon in the months of June to September and hormonal imbalances are other factors affecting fatigability in women from this part of the world. It would have been interesting to correlate the temperature variations with these findings over this 18 month period. I hope that these findings have been brought to the notice of local health authorities and the medical community in not only the state of Goa but also all around this vast country. Competing interests: None declared |
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Luis F Dias, GP HP11 1BP
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I am not sure how a general examination by a gynaecologist and a haemoglobin estimation sufficed to screen for other causes of chronic fatigue. Also, a sample size confined to a discrete area in North Goa is not necessarily representative enough to extrapolate these findings on a wider scale. Competing interests: None declared |
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Arafat Mirza, Junior Doctor from India 500013
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Easily, one in five of the women that present in the female outpatient in medicine department at my hospital (government hospital where patients are essentially from low socio economic background) complain of prolonged, generalized body aches, headache. And all the cases are attributed to poor nutrition and/ or anaemia. Never are they asked any history that relates to their domestic and psychological problems. As a matter of fact not a single case has ever been thought as being a chonic fatigue syndrome. All of them are prescribed NSAIDs (diclofenac) and B-Complex vitamins. These help the patients only as long as they are taken. So the patients come back to the outpatient every alternate week. And because a lot of such poor patients take the NSAID withouth food or any antacid they suffer from gastric erosions / ulcers for quite a number of patients. This study brings to light the need to attend to the psychological problems that patients might have and there by reduce the misuse of NSAIDS. Competing interests: None declared |
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Kesavan Damodaran, consultant physician private practise, Madras, India.
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I don't mean to discourage the authors, but is this study really relevant especially for a developing country where more people die everyday of curable diseases like TB, malaria and gastro-enteritis. Of course a typical Indian woman who has to shoulder the full domestic responsibility of running a large household in the sweltering heat of the tropics from around 5'o clock in the morning till late night will report fatigue......wwon't we too? This self reported fatigue can't be explained as a mental illness and it really is a combination of an unbalanced diet mixed with a cocktail of hot & humid weather,heavy workload and lack of holidays!!! Unfortunately these women don't have a EWTD for their work and they labor on and in most cases they manage to bring up wonderful children.And I think instead of the Indian doctors treating this FATIGUE, we will be doing more of a service if we treat the physical illnesses first. Competing interests: A doctor in India who has also worked in UK. |
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Suneel Bhat, Student Princeton University, Princeton, NJ 08544 USA, Sanjay Bhat, and Dr. Timmanna T. Hegde
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Patel et al. establish that chronic fatigue is prevalent among Indian women, and suggest that the discovered strong association with mental health factors may be indicative of psychological determinants for the disorder. First, it is interesting that the study deals solely with a more subjective “chronic fatigue,” which may also be termed as “idiopathic chronic fatigue,” [1] but does not go as far as to qualify cases of “chronic fatigue syndrome (CFS),” whose definition is more stringent. [2] Second, the study discounts the impact of nutritional influences on chronic fatigue in light of psychological factors, yet the only indicators of nutritional status used were body-mass index (BMI), hemoglobin concentration, and recent experience of hunger. While these may be indicative of overall caloric intake, no dietary analysis was conducted, which likely resulted in other critical nutritional, vitamin, or mineral deficiencies (aside from iron) being overlooked. It is therefore difficult to rule out the role of nutrition; in fact, the correlation of fatigue with common mental disorders may be due the unitary source of nutrient deficiency. [3] Furthermore, it is important to note, particularly in developing nations, treatment for both nutritional deficiency induced fatigue as well as psychosomatic or sociosomatic fatigue can actually be convergent in practice. In a case-by-case observational analysis of care delivered in a small town in Southern India, [unpublished data] nearly all presentations of fatigue were treated with vitamin supplementation. However, over 50% were identified as likely due to non-physiologic causes, and the treatment provided was explicitly given as a form of placebo. Although in developed nations placebo treatment has been suggested to be less effective in cases of CFS as compared with other medical conditions, [4] in the highly paternalistic delivery of health care in rural India, placebos may work at least as well and be more cost-effective than psychological therapy. [5, unpublished data] As vitamin, mineral, or nutritional supplementation for fatigue symptoms may be seen as a convergence of treatment for physiological and psychological/sociological manifestations of the disorder – i.e. either serving as a placebo or correcting nutritional deficiencies – addressing cases of fatigue in this manner in India may in fact be appropriate. [1] Afari N, Buchwald D. Chronic Fatigue Syndrome: A Review. Am J Psychiatry 2003; 160: 221-236. [2] Fukuda K, Straus SE, Hickie I, Sharpe MC, Dobbins JG, Komaroff A. The chronic fatigue syndrome: a comprehensive approach to its definition and study. Ann Intern Med 1994; 121: 953-959. [3] Coppen A, Bolander-Gouaille C. Treatment of depression: time to consider folic acid and vitamin B12. J Psychopharm 2005; 19: 59-65. [4] Cho HJ, Hotopf M, Wessely S. The Placebo Response in the Treatment of Chronic Fatigue Syndrome: A Systematic Review and Meta- analysis. Psychosom Med 2005; 67: 301-313. [5] Patel V, Chisholm D, Rabe-Hesketh S, Dias-Saxena F, Andrew G, Mann A. Efficacy and cost-effectiveness of drug and psychological treatments for common mental disorders in general health care in Goa, India: a randomised controlled trial. Lancet 2003; 361: 33-39. Competing interests: None declared |
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