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Dilemmas in planning diets using existing food nutrient content of foods across (FCTs).5 There is an urgent need to composition tables critically evaluate current FCTs. This will allow nutritionists to make an appropriate selection of foods when planning diets and counselling patients. In the interim, where large disparities exist, it Nutritionists use food composition tables (FCTs) to calculate the may be useful to use the mean of the nutritional values closest to each amount of nutrients while making dietary recommendations. A other for a particular food across the major FCTs available. Match- variety of FCTs including the National Institute of Nutrition (NIN) ing of foods is best done by using the scientific name (Genus; tables are widely used in India.1 Other tables that nutritionists use species). Although we specifically highlight the problems associ- include McCance and Widdowson’s composition of foods2 and the ated with estimation of potassium in the diet, similar problems exist United States Department of Agriculture (USDA) FCTs.3 While the to varying extents for other micronutrients. NIN tables were updated in 1989, and McCance and Widdowson’s tables in 1991, the USDA has regularly revised its tables in its online 25 August 2004 A. V. Bharathi database from 1995 to as recently as 2004. Mario Vaz Nutrient data across these tables are not always comparable for Division of Nutrition Department of Physiology similar foods and this has created problems for nutritionists while St John’s Medical College prescribing diets. In Table I, we compare the potassium content of Sarjapura Raod certain foods across these tables. The above FCTs largely use the Bangalore technique of flame photometry for potassium estimation. McCance Karnataka and Widdowson’s data, in addition, have been derived using other [email protected] techniques such as emission spectrometry and atomic absorption spectrophotometry. The values of potassium vary widely across the REFERENCES tables, and for some foods the difference is more then 20-fold. In 1 Gopalan C, Ramshastri BV, Balasubramanian SC. Nutritive value of Indian foods. certain renal conditions, potassium intake is restricted and nutri- Hyderabad:National Institute of Nutrition; 1989. tionists often need to prescribe diets with a specified potassium 2 Holland B, Welch AA, Unwin ID, Buss DH, Paul AA, Southgate DAT. McCance and Widdowson’s The Composition of foods, 5th ed. Cambridge:Royal Society of Chemistry; 4 content. The difficulty faced by nutritionists is the uncertainty 1995. while prescribing an accurate potassium content in the diet. Table I 3 United States Department of Agriculture. Nutrient data laboratory. http:// shows that some foods considered to have low levels of potassium in www.nal.usda.gov/fnic/foodcomp/ (accessed on 4 January 2004). one FCT are shown to have substantially higher levels of potassium 4 Alpers DH, Stenson WF, Bier DM. Dietary management of diabetes, renal disease, and hyperlipidemia. In: Alpers DH, Stenson WF, Bier DM (eds). Manual of nutritional in another. therapeutics. 3rd ed. Boston:Little Brown; 1995:435-75. Many factors are known to cause differences in nutrient compo- 5 Mugford DC. Nutrition labeling: Concern for precision of analysis. Food Australia sition such as the genetic make-up of foods, environmental condi- 1993;45:216-23. tions in which foods are grown, moisture content of foods and the stage of ripening of fruits, among others. Differences in the methods of biochemical estimation can also contribute to variations in the

TABLE I. Potassium content in foods according to different food composition tables (FCTs). Communication skills: Is there a need for training? Food NIN McCance and USDA USDA/ (mg/100 g) Widdowson’s (mg/100 g) NIN Good communication plays a pivotal role in the medical profession. (mg/100 g) It is especially important for doctors who need to communicate with Radish (pink) 10 240 233 * 23 patients regarding the disease, and with nurses and other members Orange 9.3 150 181 19 of the healthcare team to carry out the planned treatment. Good Beetroot 43 380 325 8 communication with patients is even more important today, when Banana 88 400 358 4 litigations against doctors are on the rise. It is generally believed that Papaya 69 200 257 4 good communication can decrease the number of litigations against Bitter gourd 152 330 608 4 doctors. There are three main settings where doctors need to utilize Peas (green) 79 330 244 3 their communication skills: (i) informing the patients of the diagno- Ladies finger 103 330 303 3 sis (especially of untreatable or terminal illnesses), (ii) explaining Cucumber 50 140 136 3 about the diagnostic or therapeutic procedures, and modes of treat- Plantain 193 500 499 3 Spinach 206 500 558 3 ment and their side-effects before obtaining informed consent, and Carrot 108 240 320 3 (iii) communicate to relatives about death. It is important to commu- Cauliflower 138 380 303 2 nicate in a language that the patient understands, bereft of technical French beans 120 230 209 2 terms. Extra care is required while dealing with untreatable condi- Beef (muscle) 214 350 297 * 1.5 tions. It is advisable to tell the truth about the diagnosis, as any Green gram (whole) 843 1250 * 1246 * 1.5 uncertainty regarding the diagnosis is bad for the patient. However, Celery leaves 210 320 260 1.2 one should not be ‘brutal’ while telling the truth. It is imperative to Yam (ordinary) 237 380 - - be gentle and give time to the patient to ask questions. It is generally NIN National Institute of Nutrition USDA United States Department of Agriculture useful to give all the information about the patient’s disease (as * Description of foods vary in detail across tables desired by her/him). However, the patient’s personality and premorbid

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mental condition might modify the manner in which it is done. For REFERENCES example, in a patient with obsessive–compulsive disorder, it is better 1 McCormack D, Evoy D, Mulcahy D, Walsh M. An evaluation of patients’ comprehension to concentrate on facts rather than on feelings while breaking bad of orthopaedic terminology: Implications for informed consent. J R Coll Surg Edinb news. 1997;42:33–5. 2 Sanwal AK, Kumar S, Sahni P, Nundy S. Informed consent in Indian patients. J R Soc Getting informed consent for a diagnostic procedure or therapeu- Med 1996;89:196–8. tic modality is another challenging area. The legal doctrine of 3 Chan D, Goh LG. The doctor–patient relationship: A survey of attitudes and practices informed consent requires that all patients must be informed of the of doctors in Singapore. Bioethics 2000;14:58–76. procedures, risks and benefits of any recommended treatment and 4 Schumacher JE, Ritchey FJ, Nelson LJ 3rd, Murray S, Martin J. Malpractice litigation available alternatives, and that patients’ decisions must be in- fear and risk management beliefs among teaching hospital physicians. South Med J 1995;88:1204–11. formed, voluntary and competent. This appears simple but in reality 5 Marco CA, Bessman ES, Schoenfeld CN, Kelen GD. Ethical issues of cardiopulmonary it is not so. As a rule, all patients are assumed to be competent. resuscitation: Current practice among emergency physicians. Acad Emerg Med However, certain groups of patients are not so, such as those with 1997;4:898–904. psychosis, mentally challenged individuals, minors, patients with severe/terminal illness and the elderly. Though we are expected to present all known information to patients, are all patients capable of understanding this information? In Ireland, it was found that most of the patients who had recently signed consent forms containing terms such as ‘fracture reduction’ or ‘internal fixation’ were unsure of their meaning.1 In India, with its high rates of illiteracy, it is commonly believed that patients need not be told about their ‘Rule of 80’ for coronary disease? operations as they are unable to understand the complexities and likely to forget the important facts quickly. In an Indian study by Recent studies in patients with coronary artery disease are changing 2 Sanwal et al., it was found that about 70% of patients could recall established perceptions regarding the goals for reduction of low- the relevant data regarding abdominal operations five days postop- density lipoprotein (LDL) cholesterol levels.1 The evidence for con- eratively; however, less educated, poorer and older patients per- tinuing benefit at levels below the recommended goal of 100 mg/dl formed badly. It was also interesting that 98% of the patients reiterates the broadly valid concept that variables, which vary appreciated being given the information as it reduced their anxiety continuously in the population, do not lend themselves to arbitrary regarding the operation. Patients are expected to make an autono- cut-offs. This is because the risk of coronary events varies continu- mous decision based on the information presented to them. But the ously with increasing levels, beginning from those that are consid- truth is often otherwise. This might be because doctors feel that their ered normal. Similar relationships are seen between adverse event 3 patients are incapable of making a rational choice. On the other rates, and blood sugar levels2 and blood pressure.3 It appears that hand, a number of patients would like their doctors to be involved soon a ‘rule of 80’ might begin to apply, at least in the treatment of in the decision-making. This is due to several reasons. First, patients patients after an acute coronary syndrome. Patients should receive are overloaded with information from a host of sources including 80 mg of atorvastatin with a goal to reduce the levels of LDL healthcare providers, journals, books and the internet, which are cholesterol to perhaps 80 mg/dl; blood pressure to (<130 mmHg often conflicting, confusing and complex. This necessitates pa- systolic and) <80 mmHg diastolic and4 in patients with diabetes, the tients’ dependence on doctors for decision-making. Second, many aim should be to achieve normal fasting plasma glucose levels (<80 patients trust their doctors to make the right decisions for them, mg/dl). A waist circumference of <80 cm would also help.3 They which poses an added responsibility. Our decision should be free will, of course, receive aspirin 80 mg or more. Perhaps then these from all bias (commercial, research potential, etc.), and should be high-risk patients will go on to live beyond 80, particularly if they taken as if the patient was one of our close relatives. This could help stay 80 metres away from cigarettees too! maintain the cordial doctor–patient relationship we enjoy, rather than practising medicine under the constant fear of litigation, as is 10 September 2004 Ganesan Karthikeyan the case in many western countries.4 In a survey in the USA, it was Balram Bhargava found that 94% of emergency physicians base their decisions K. Srinath Reddy regarding resuscitation on concerns of litigation and criticism, rather Department of Cardiology than their professional judgement of medical benefit or futility.5 Cardiothoracic Sciences Centre The ability to break bad news is a much-needed clinical skill. The All India Institute of Medical Sciences experience of informing close relatives about a patient’s death can be New Delhi [email protected] unnerving. Patients and families value direct, non-technical explana- tions given with compassion by a physician. They also value the time REFERENCES given to talk, express their feelings and ask questions. The creation of 1 Cannon CP, Braunwald E, McCabe CH, Rader DJ, Rouleau JL, Belder R, et al. an appropriate environment to do so is important. Intensive versus moderate lipid lowering with statins after acute coronary syndromes. Good quality, effective communication with patients and fami- N Engl J Med 2004;350:1495–504. lies is the key to success in clinical medicine. However, it is 2 American Diabetes Association. Standards of medical care in diabetes. Diabetes Care unfortunate that little emphasis is placed on this during undergradu- 2004;27(Suppl 1):S15–S35. 3 Hansson L, Zanchetti A, Carruthers SG, Dahlof B, Elmfeldt D, Julius S, et al. Effects ate medical training. There is a need to incorporate ‘training in of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: communication skills’ in our undergraduate curriculum. Principal results of the Hypertension Optimal Treatment (HOT) randomized trial. HOT Study Group. Lancet 1998;351:1755–62. 20 August 2004 Sudhir Kumar 4 Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, et al. The Department of Neurological Sciences Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, Christian Medical College and Treatment of High Blood Pressure. JAMA 2003;289:2560–72. Erratum in: JAMA Vellore 2003;290:197. Tamil Nadu [email protected]

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The mirage of polio eradication fever and other enteral infections along with polio. Together with measures for improvement in sanitation, the OPV programme should be continued in developing countries till the cost of IPV Another National Immunization Day, and are we any nearer to the decreases to that of OPV. eradication of polio? To control and eradicate polio, the ‘pulse We feel that it is necessary to abandon the immediate goal of strategy’ and oral polio vaccine (OPV) have been advocated since eradicating polio and aim at polio control as has been done in the past the early 1980s.1,2 There has been hardly any reference to OPV- for four other diseases for which eradication programmes were derived revertant polioviruses. Most doctors and policy-makers initially launched (hookworm, yellow fever, malaria and yaws). believed that, as in the case of smallpox, vaccination against polio Unless we abandon the goal of vaccine-induced polio eradica- would cease after the current pulse campaign of polio eradication. tion, we would continue to give good business to manufacturers of However, it has now been pointed out that ‘among strains of polio- either OPV or IPV. If we switch to IPV, it will be the turn of IPV viruses in the environment, 69% of type 1, 92% of type 2 and 55% manufacturers to make money indefinitely, as anyway we cannot of type 3 viruses were found to be neuro-virulent revertants. There stop polio vaccination in the foreseeable future! is clearly a signal for the hidden risk inherent in the continued use In the current year (2004), in India, Rs 1100 crore will be spent of OPV’.3 In the same article, it has now been proposed that on the eradication of polio; more than double the amount spent last inactivated polio vaccine (IPV) should be introduced from 2006, year! This is many times more than the expense on all the other OPV withdrawn from 2009, and IPV discontinued from 2015.4 vaccines in the universal immunization programme (UIP) put to- The cost of IPV today is Rs 450 per dose, i.e. about 100 times that gether! The additional money being spent on the polio eradication of OPV.5 Even if we assume that the cost would come down programme and the pulse polio strategy would not be required if we substantially when millions of doses are bought in bulk, the total cost move away from the goal of polio eradication to polio control. It will would still be too much to bear for a country such as India. Were the also stop further deterioration in the coverage of other vaccines policy-makers clearly told in the 1980s and 1990s that OPV would under the UIP.11–13 have to be necessarily followed by IPV? Smallpox virus was eradicated from the environment through 22 October 2004 Anant Phadke vaccination. This cannot be done for poliovirus for the following Centre for Enquiry into Health and Allied Themes reasons: Pune Maharashtra 1. Unlike in the case of smallpox, for every clinical case, there are [email protected] a thousand subclinical cases, which too allow the virus to replicate. Hence, even if there is no case of paralytic polio, the Ashok Kale wild virus will continue to circulate and replicate because of the Public Health Consultant pool of subclinical infection. Surveillance based on the follow up Pune of cases with acute flaccid paralysis (AFP) cannot monitor this Maharashtra spread. [email protected] 2. It is impossible to ensure 100% seroconversion even if we ensure 100% coverage which itself is highly impractical to achieve. REFERENCES Hence, there will always be a pool of subclinical infection even 1 John TJ. Towards a national policy on poliomyelitis. Indian J Pediatr 1981;18: 503–5. if overt paralysis does not occur. 2 John TJ, Steinhoff MC. Appropriate strategy for immunisation of children in India. 3. The majority of the Sabin viruses administered to children revert Community-based annual pulse (cluster) immunisation. Indian J Pediatr 1981;48: to the virulent form within a month.6,7 Such reversion was out of 677–83. question with the smallpox vaccine. Though OPV reduces the 3 John TJ. Polio eradication in India. What is the future? Indian Pediatr 2003;40: incidence of paralytic polio, it adds to the pool of virulent 455–62. 4 John TJ. A developing country perspective on vaccine-associated paralytic poliomyelitis. polioviruses. Hence, OPV cannot be stopped even if the inci- Bull World Health Organ 2004;82:53–7. dence of paralytic polio is reduced to zero. Also, it has been 5 Bhave S, Suresh K (eds). Together we make India polio free. Proceedings of IAP admitted that, ‘Discontinuation or declining immunization cov- National Workshop on Polio Eradication and Improvement of Routine Immunization erage of OPV will increase the risk of emergence of circulating in India: 20–21 May 2000. New Delhi:UNICEF; 2000: p. 7. 6 Dunn G, Begg NT, Cammack N, Minor PD. Virus excretion and mutation by infants vaccine-derived polioviruses (cVDPV) that re-acquire wild following primary vaccination with live oral polio vaccine from two sources. J Med virus-like properties and may cause outbreaks of polio.’4 Virol 1990;32:92–5. 4. It has been reported that immunocompromised individuals would 7 Abraham R, Minor P, Dunn G, Modlin JF, Ogra PL. Shedding of virulent poliovirus continue to excrete vaccine-derived revertant neurotropic viruses revertants during immunization with oral poliovirus vaccine after prior immunization 8–10 with inactivated polio vaccine. J Infect Dis 1993;168:1105–9. for years. With the HIV epidemic, this will be an important 8 Kew OM, Sutter RW, Nottay BK, McDonough MJ, Prevots DR, Quick L, et al. phenomenon. Prolonged replication of a type 1 vaccine-derived poliovirus in an immunodeficient 5. Polio vaccine production requires a pool of wild polio viruses and patient. J Clin Microbiol 1998;36:2893–9. this might cause an accidental release of the polio virus. 9 Dowdle WR, Birmingham ME. The biologic principles of poliovirus eradication. J Infect Dis 1997;175 (Suppl 1):286–92. If we switch to IPV, we will avoid vaccine-associated paralytic 10 World Health Organization. Primary immunodeficiency diseases: Report of a WHO polio (VAPP) but pathogenic polioviruses would continue to circu- scientific group. Clin Exp Immunol 1997;109 (Suppl 1):1–28. 11 Lessons learnt from pulse polio immunisation programme. AIIMS-India CLEN PPI late in the environment, though they would not cause paralytic polio. Program Evaluation 1997–98 Team. J Indian Med Assoc 2000;98:18–21. In the absence of measures to improve sanitary conditions, 12 Mathew JL, Gera T, Mittal SK. Eradication of poliomyelitis in India—future attempting to eradicate an enteric infection through vaccination is a perspectives. Pediatr Today 2000;3:647–60. mirage. Improved sewage management would also help to reduce 13 Kishore J, Pagare D, Malhotra R, Singh MM. Qualitative study of wild polio cases in high risk districts of Uttar Pradesh, India. Natl Med J India 2003;16:131–4. the thousands of deaths due to diarrhoea, hepatitis A and E, enteric

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