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Posted: 05 Nov 2011 08:04 PM PDT

Good nutrition takes on a different meaning as we progress through different stages of life, including the time when life nears the end.

WE can literally track the stages of our lives by noting the kinds of food we eat. At first, we don't really have a choice. From milk to oatmeal to solid food, we take what is given to us.

Then we graduated to different kinds of foods of our choice – some of which our parents wouldn't even put in their mouths.

After that, our choices may change, or be limited, due to our beliefs and health conditions.

And when our lives near the end, due to old age or illness, we are back to eating what we are given, again.

While parents and caregivers have a lot of guidance on the food that will help their children grow, relatively little is known about the kinds of food or the ways to feed one's ailing or ageing loved one.

To make things more complicated, it is difficult to come up with a rule of thumb that accommodates all individuals with different health conditions and food preferences.

As Dr Harold H. Sandstead, a now retired professor of preventive medicine and community health at the US University of Texas Medical Branch, wrote in his 1990 article, A point of view: nutrition and care of terminally ill patients, "It seems to me that there are no simple formulas for decisions, but there are useful guidelines: comfort the sick, cure if possible, do no harm, and above all, respect the person of the patient."

"Respect for the person of the patient," Sandstead continues, means placing the wishes of the patient first while at the same time meeting the patient's needs, which include preventing pain and suffering, comforting, maintaining a wholesome environment in the sick room, assisting with bodily functions in an unobtrusive way, providing spiritual support, and assisting with food and drink.

"It also includes truthfulness with regards to prognosis for those patients who wish and need to know, as well as clearly describing the benefits and risks of potential technical approaches for treatment of the patient's illness," he wrote.

"Finally, it involves discontinuing invasive or discomforting treatments when it becomes clear that recovery is highly unlikely and that life for practical purposes is at an end."

Food for the body and mind

To achieve all that Dr Sanstead proposes is a tall order, but they are what doctors and hospice volunteers like Yeo Puay Huei and Dr Siow Chih Peng from Kasih Hospice Care Society (KHCS) tries to do for those who are terminally ill. These are people who have conditions that limit life, is progressive, and no longer treatable, controllable or curable, by conventional medical treatment.

The goal, in the care of these patients, is to make the process of nearing death as comfortable as possible. In this regard, good nutrition plays a big role.

Besides providing the body with the nutrients and energy it needs to survive, good nutrition also allows a person's mind to function well. With a well-functioning mind, those nearing the end of their lives can, in turn, have the opportunity to sort out unfinished business and find peace within themselves with the support of their friends, family members or hospice organisations.

"(We notice that) when our patient's minds are peaceful, they respond better to medication. Even if they are beyond medication, the whole experience of dying becomes less fearful and less uncomfortable," says Yeo, who is the president of the KHCS.

Using common sense

It is not that difficult to understand why good nutrition is important for those who are terminally ill, but understanding their real nutritional needs might prove initially challenging to some caregivers.

One of the common worries caregivers have is that their loved ones are not eating enough.

"Some of them are already unable to do anything, and yet their families keep telling them that they must eat," says Dr Siow, who is deputy president of medical services at the KHCS.

There are also times when the patient requests for a particular food and is given a huge bowl or pack of it – an amount they cannot finish. This, instead, makes the patients feel guilty simply because they can't finish the food given to them.

"What (families) can do, is to provide food in small amounts, and with increased frequency," says Dr Siow.

The process that often needs a little explaining is that as their bodies gradually slow down, people who are terminally ill may not need as much food as they did before. While they may lose weight, they might not feel hungry, or have the appetite to eat.

This is shown in studies like the one published in the Journal of the American Medical Association in 1994, where US doctors Robert M. McCann, William J. Hall, and Annmarie Groth-Juncker, evaluated 32 mentally aware, competent patients with terminal illness in a comfort care unit.

They found that of the 32 patients monitored during the 12 months of study, 20 of them (63%) never experienced hunger, while the remaining ones had symptoms only initially. Similarly, 20 patients experienced either no thirst or thirst only initially during their terminal illness.

"In all patients, symptoms of hunger, thirst, and dry mouth could be alleviated, usually with small amounts of food, fluids, and/or by the application of ice chips and lubrication to the lips," read the results that are available on the journal's website.

While patients who are still on palliative therapy for cancer may be encouraged to eat and build their strength in between treatments when their appetite recovers so that they can withstand the next treatment, those who have only months to live may not require more than they can stomach. The same goes with oral medications as well.

"Sometimes we have to review the patients' medications and stop them one by one because they no longer serve their purpose," says Dr Siow.

Respecting wishes

"It is always advisable to get a professional opinion before deciding on any sort of management for a terminally ill patient," says Dr Jeyashree Jacob, the medical affairs manager of Wyeth Nutrition.

For patients who cannot swallow, tube feeding can help them get the nutrition they need. However, when they are in the terminal or palliative stage, any complications and discomfort resulting from this form of feeding should be taken into account.

In the end, the most important individuals are the patients themselves, says Dr Jeyashree. Even when the decisions on their care have to be discussed with their doctors, their wishes should be respected.

"It is not uncommon to hear an elderly lady who is dying saying all she wants is some ice cream. This is because it gives her comfort," says Dr Siow. Sometimes, cancer patients may feel very warm as a result of the disease and ask for cold drinks or ice cream just to cool their body down or quench their thirst.

"The body, in a way, knows what to ask for," Dr Siow adds.

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Enabling policies

Posted: 05 Nov 2011 08:03 PM PDT

New approaches and innovations in drug policies in Portugal, Switzerland, and Germany.

IN our first article, we wrote about punitive enforcement activities as being expensive ways of making a bad problem worse. Sixty years of punitive drug policy has not reduced drug demand or supply, and has had little or no impact on the spread of HIV/AIDS, increased comorbid psychiatric disorders in prisons, and increased acquisitive crimes, ie crimes committed to obtain drugs.

Across the globe, academics and policymakers alike have understood that medical treatment and reintegration techniques are the way to go to help persons who are chemically dependent on drugs.

In the following paragraphs, we will detail positive and negative aspects of innovations to drug policy in Portugal, Switzerland, and Germany.

Portugal

Portugal has had overwhelming success in reducing recidivism, addiction, HIV infection, and drug-related crime. Their approach is a holistic one, in that it involves assessment by qualified psychologists and social workers, cooperation with law enforcement entities, methadone maintenance therapy, needle-and-syringe exchange programmes, and socio-behavioural modalities to increase self-worth and motivation of the drug offender.

Portugal has enacted threshold quantities to determine which pathway the detained person will undergo. For example, the statutory amount is one gram for heroin and 25 grams for cannabis. If the person is caught with an amount of drugs below a statutory threshold quantity for consumption in 10 days, he will be diverted to a body called the Dissuasion Commission.

If the person is caught with an amount of drugs above the statutory threshold quantity for 10 days consumption, he will be sent to court for judicial deliberation on whether the person possessed that amount of drugs for consumption, or for trafficking.

If deemed to be trafficking, he or she faces the full application of the criminal law.

The Dissuasion Commission, consisting of lawyers, social workers, and psychologists, assesses the person and then directs him to treatment. Hence, although Portugal decriminalises consumption, it does not legalise it.

Drug use is still prohibited, but consumption is no longer labelled as a crime, but instead as a reason to direct the person to treatment.

Switzerland

Swiss drug policy applies the harm reduction approach in four pillars: Prevention, Treatment, Harm Reduction, and Enforcement.

The Prevention strategy encompasses, et al, to enhance early intervention, to make prevention part of everyday life, and to strengthen the individual's social network.

The Treatment strategy involves medically-prescribed methadone and other medicines, and psychiatric treatment for those with comorbidities.

The Harm Reduction strategy includes needle-and-syringe exchange programmes, consultation services for children of persons who consume drugs, and offers of employment so that persons who use drugs have no need to commit crime to finance their drug habits.

The Enforcement pillar has the primary goal of reducing supply, and hence concentrates on the trafficking of narcotics, illegal financial transactions related to such trafficking, and organised crime.

Hence, police do not waste valuable financial and human resources on drug users.

Germany

In Berlin, Germany, drug policy is intended to "balance" law enforcement and treatment options, and consists of outpatient counselling units, methadone maintenance, needle-and-syringe exchange programmes, and low threshold drop-in centres where drug users can have a meal, use a washing machine, shower, and have increased contact with health professionals, psychologists, and social workers.

However, newer approaches in Germany are less institutionalised, and have to compete with a predominant repression and abstinence model.

This is somewhat the situation in Malaysia, with NGOs, the National Anti-Drug Agency and the Health Ministry increasingly supporting harm reduction and treatment initiatives, whilst law enforcement agencies continue to arrest drug dependent persons, leading to them being caned and imprisoned.

So, while some parties are carrying out actions to reduce HIV spread, destigmatise and provide a stable enabling environment for drug users to return as productive members of society, there are several obstacles that prevent this, the most important being incarceration and caning of persons dependent on drugs.

It is worth looking at innovative drug policies overseas, and take from them modalities that Malaysia as a nation can benefit from.

> Fifa Rahman and Tan Sri Zaman Khan are from the Malaysian AIDS Council. For further information, e-mail starhealth@thestar.com.my. The views expressed are those of the writer and readers are advised to always consult expert advice before undertaking any changes to their lifestyles. The Star does not give any warranty on accuracy, completeness, functionality, usefulness or other assurances as to the content appearing in this column. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.

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Vaccine boon

Posted: 05 Nov 2011 08:01 PM PDT

Protect your child against the dangers of pneumococcal disease.

THE body has a natural defence system against harmful organisms such as bacteria and viruses. When these germs invade the body, your immune system makes antibodies that help destroy them. The next time you are exposed to the same infection, your body automatically recognises it and produces the same antibodies to destroy it.

Vaccinations work in pretty much the same way. A vaccination shot contains a very small and safe amount of the virus or bacteria, which has been either killed or weakened. This helps your body learn to recognise and attack the infection, if you contract it later on in life.

Thanks to vaccinations, diseases such as smallpox, which killed around one-third of all victims and scarred or blinded survivors, have been eradicated. Polio, caused by a virus that destroys nerve cells, once used to paralyse more than 1,000 children daily all over the world. It has now been virtually eliminated and Malaysia has been polio-free since 1985.

Pneumococcal disease

All children are given mandatory vaccinations that help protect against diseases such as tuberculosis, hepatitis B, diphtheria, tetanus, pertussis, polio, haemophilus influenza B, measles, mumps, as well as rubella.

On top of these, there are also recommended vaccinations, which are important to further help protect your child against other dangerous diseases, including pneumococcal disease.

Pneumococcal disease is caused by Streptococcus pneumoniae, commonly known as pneumococcus. It attacks various parts of the body, causing serious illnesses in both children and adults. There are generally two types of pneumococcal diseases: invasive diseases and non-invasive diseases.

Invasive diseases are more serious and occur within a major organ, or the blood, and include:

Pneumococcal pneumonia

·Most common disease caused by pneumococcus.

·May start off with high fever, cough, shortness of breath, rapid breathing, chest pains, nausea, vomiting, headache, tiredness and muscle aches.

·If not treated, pneumococcus can spread to other parts of the body, including the middle ear, nervous system, and even the blood. Blood infections can lead to serious complications.

Bacteraemia (blood infection)

·A serious complication that occurs when the bacteria spreads and infects the blood.

·Symptoms include fever, headache, as well as muscle aches and pains.

·If not treated, can lead to sepsis, which may affect the functions of major organs and eventually lead to septic shock.

·Septic shock is a sudden dysfunction in various vital organs and can be life-threatening.

Meningitis (inflammation of the brain covering and spinal cord)

·An extremely serious condition whereby the brain covering and spinal cord is inflamed.

·Persons affected often show symptoms such as severe headache, vomiting, high fever, stiff neck, sensitivity to light, confusion, and sleepiness.

·If untreated, more complications arise, such as seizures and permanent neurological damage, eg hearing/speech loss, learning disabilities, blindness, brain damage, and even paralysis.

Both bacteraemia and meningitis are complications that can kill within hours, and babies and toddlers fall into the high-risk groups of contracting these diseases. In fact, meningitis has one of the highest fatality rates, with most cases affecting children under the age of one year.

On the other hand, non-invasive diseases, occur outside major organs and the blood. These include:

Otitis media (infection of the middle ear)

·Symptoms include ear pain (especially when lying down), difficulty sleeping, difficulty hearing or responding to sounds, loss of balance, headache, fever, leaking of fluid from the ear, loss of appetite, vomiting, diarrhoea, or sore throat.

·Frequent or persistent infections or fluid build-up in the ears may result in serious complications such as permanent impaired hearing, speech or development delays in infants/toddlers, or even spread of the infection to nearby tissues such as the brain.

Sinusitis (sinus inflammation)

·A person may experience headache, facial tenderness, pain, fever, cloudy and discoloured nasal drainage, a feeling of nasal stuffiness, sore throat, or cough.

·Undiagnosed or untreated sinusitis may lead to eye socket infection – which may cause a person to lose the ability to move the eye, or permanent blindness, or infection of the frontal bone (usually occurs in children).

These diseases are less severe compared to bacteraemia and meningitis; however, they can still cause serious complications if not detected and treated early.

Prevent with vaccination

All cases of pneumococcus infection could once be treated effectively with antibiotics such as penicillin. In recent years however, some bacteria have become increasingly resistant to antibiotics, making it very difficult to treat such diseases.

There are more than 90 known pneumococcal serotypes, with 13 common ones that cause 80-92% of invasive diseases in young children all over the world. Pneumococcal vaccination is one of the best and most effective way of preventing invasive pneumococcal diseases in the first place.

Pneumococcal conjugate vaccines (PCV) protect infants and young children against pneumococcal disease.

Young children below two years old are at highest risk of being infected with the pneumococcus. The risk is higher if the child is in daycare or a nursery where the infection can pass easily from one child to another via air droplets from sneezing or coughing.

Immunisation can begin as early as six weeks of life. The added benefit of the vaccine is that it eradicates the bacteria from the nasopahrynx (back of the throat and nose), thus preventing its spread to other children and adults. This is acknowledged as an indirect benefit of the vaccine, also called herd immunity.

Other groups of individuals that should get vaccinated include:

·Adults aged 65 years and above.

·Children aged two months and above, especially those with chronic medical conditions such as diabetes, lung (except asthma), heart, kidney, or liver disease.

·Those with immune systems weakened by conditions such as cancer or HIV infection.

·Those without a spleen or who suffer from splenic dysfunction due to thalassaemia or sickle cell disease.

Weighing the risks

Some parents have been alarmed by reports of possible side effects associated with certain vaccines, which have been blown out of proportion by anti-vaccine groups. Notably, the alleged association of autism with the MMR vaccine, which has been proven to be false. The WHO has reaffirmed that none of the available vaccines is associated with autism.

The pneumococcal vaccine, like all other vaccines has been demonstrated to be safe, and causes only mild side effects such as redness or swelling at the injection site. Severe adverse reactions are extremely rare.

Pneumonia is the number one killer infection in children. Most of these are due to the pneumococcus, which kills about 750,000 children each year. Many countries have included the pneumococcal vaccine in their National Immunisation Program (NIP) to prevent these deaths and to reduce the disabilities associated with invasive pneumococcal disease.

The pneumococcal vaccine is currently not included in the Malaysian NIP. It is, however, readily available in private hospitals and from paediatricians and some general practitioners in private practice. You should consult your family doctor to obtain more information about this highly recommended vaccine.

> Datuk Dr Musa Mohd Nordin is a consultant paediatrician and neonatologist. This article is courtesy of the Malaysian Paediatric Association's Positive Parenting programme that is supported by an educational grant from Pfizer. The opinions expressed in the article are the view of the author. For further information, please visit www.mypositiveparenting.org.

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Kredit: www.thestar.com.my

Ahad, 6 November 2011

The Star Online: Lifestyle: Health

The Star Online: Lifestyle: Health

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