Autism: few facts to look at

Disclaimer: This article is for general medical information & health education purpose only. People without basic bachelor degree in medical science are requested not to use this information for diagnosis and treatment of the related condition as many signs & symptoms of various diseases can also be seen in normal people. Consult a good clinician for proper diagnosis and treatment. Thank you & enjoy reading

Autism or broadly speaking ASD (autism spectrum disorder) is one of the commonest childhood psychosocial disorder affecting around 1 in every 160 children worldwide & the prevalence is increasing. It begins in childhood and may persist into adolescence and adult hood. (1) ASD is characterized by three core symptoms (i) impaired social interaction and communication,(ii) a pattern of repetitive behavior and/or(iii) restricted interests in early childhood or first 3 years of life.(2) The distinctive social behaviors include an avoidance of eye contact, problems with emotional control or understanding the emotions of others, and a markedly restricted range of activities and interests.(3) Usually, children with autism have other health problems associated such as epilepsy, depression, anxiety and attention deficit hyperactivity disorder (ADHD). But intelligence level in such kids is extremely variable ranging from very low to even higher than other normal counterparts.(1)

            Available scientific data suggests both genetic and environmental factors as cause. Male children are more at risk with 2-3times more incidence rate than females.(4)  Hans Asperger who first described  "autistic psychopathy" now known as Asperger syndrome & Leo Kanner who first used autism in its modern sense introducing the term “early infantile autism”, have together designed the modern study of autism.(4) as genetic factors are hardly modifiable and need extensive research, we are going to focus more on environmental factors, possible preventive measures and treatment options.

Environmental causes of ASD:(5–7)

            Broadly speaking, definite cause of ASD is not yet known. Still strong scientific evidences exist for following factors

• advanced parental age
• preterm birth
• Birth complications like trauma or ischemia and hypoxia
• maternal obesity
• maternal diabetes
• maternal rubella infection
• use of drugs like valproate, serotonin reuptake inhibitors by mother
• maternal hypothyroxinemia
• caesarian section
• air pollution
• exposure to toxins like styrene, chromium, cyanide, methylene chloride, methanol, and arsenic during pregnancy
• short interpregnancy interval etc

Certain previously suspected factors such as vaccination, maternal smoking, and assisted reproductive technologies were not found to be related to ASD by various large level researches.(5) Also lack of warmth and affection in parents or any other emotional or psychological parental deficits also does not appear to be the cause.(7) Though the risk factors should be avoided, their avoidance does not guaranty a ASD free child to be borne. Hence the treatment remains the main stay of management which includes intensive behavioral, educational, and psychological training. As a cure is not available till date, Regular screening of infants and toddlers for symptoms and signs of autism & cooperation of parents/caregivers is crucial for an early intervention & better outcome.(1,7)

Management:(8)

•       Behavioral training and management:

opositive reinforcement, self-help, and social skills training to improve behavior and communication. many protocols have been developed such as

o  Applied Behavioral Analysis (ABA)(9)

o Treatment and Education of Autistic and Related Communication Handicapped Children (TEACCH)(10)

osensory integration

oincreased use of written and visual information

oadapted cognitive behavioral therapy (CBT)

•      Specialized therapies:

oSpeech therapy: to improve language & social skills,

oOccupational therapy: to learn to process information from the senses like sight, sound, hearing, touch, and smell,

oand physical therapy

•      Medicines: not much effective. Commonly used medications are, anxiolytics & antidepressants

•     Community support and parent training: a good psychiatrist or autism community should be consulted for learning this.

Some recent advances:

• multicomponent peer-mediated intervention (PMI)(11)
• social motivation hypothesis. (12)
• Social skills training(13)
• Pivotal Response Treatment (PRT)(14)

Autism or ASD is already a global pandemic with more than 1.5% of children being affected by this condition & the incidence rate is on a rise. The pity is there is no effective treatment yet and drugs do not help much. Major part of management targets at improving the overall psychosocial skills of affected kids as early as possible. For all these, the participation of parents or caregivers is a must. So it appears most logical to be well informed about this problem and its management for all of us. Take care, be healthy & keep smiling….

Refences:

1.         WHO | Autism spectrum disorders [Internet]. WHO. [cited 2018 Jan 25]. Available from: http://www.who.int/mediacentre/factsheets/autism-spectrum-disorders/en/

2.         Sener EF, Canatan H, Ozkul Y. Recent Advances in Autism Spectrum Disorders: Applications of Whole Exome Sequencing Technology. Psychiatry Investig. 2016 May;13(3):255–64.

3.         Park HR, Lee JM, Moon HE, Lee DS, Kim B-N, Kim J, et al. A Short Review on the Current Understanding of Autism Spectrum Disorders. Experimental Neurobiology. 2016 Feb;25(1):1.

4.         Park HR, Lee JM, Moon HE, Lee DS, Kim B-N, Kim J, et al. A Short Review on the Current Understanding of Autism Spectrum Disorders. Experimental Neurobiology. 2016 Feb;25(1):1.

5.         Modabbernia A, Velthorst E, Reichenberg A. Environmental risk factors for autism: an evidence-based review of systematic reviews and meta-analyses. Molecular Autism. 2017 Mar 17;8:13.

6.         Lyall K, Croen L, Daniels J, Fallin MD, Ladd-Acosta C, Lee BK, et al. The Changing Epidemiology of Autism Spectrum Disorders. Annual Review of Public Health. 2017;38(1):81–102.

7.         Autism: Practice Essentials, Background, Pathophysiology. 2017 Dec 6 [cited 2018 Jan 26]; Available from: https://emedicine.medscape.com/article/912781-overview

8.         Autism-Treatment Overview [Internet]. WebMD. [cited 2018 Jan 26]. Available from: https://www.webmd.com/brain/autism/autism-treatment-overview

9.         Fernandes FDM, Amato CA de la H. Applied behavior analysis and autism spectrum disorders: literature review. Codas. 2013;25(3):289–96.

10.       The TEACCH program for children and adults with autism: A meta-analysis of intervention studies. Clinical Psychology Review. 2013 Dec 1;33(8):940–53.

11.       Bambara LM, Cole CL, Chovanes J, Telesford A, Thomas A, Tsai S-C, et al. Improving the assertive conversational skills of adolescents with autism spectrum disorder in a natural context. Research in Autism Spectrum Disorders. 2018 Apr;48:1–16.

12.       Bottini S. Social reward processing in individuals with autism spectrum disorder: A systematic review of the social motivation hypothesis. Research in Autism Spectrum Disorders. 2018 Jan 1;45:9–26.

13.       Ashman R, Banks K, Philip RCM, Walley R, Stanfield AC. A pilot randomised controlled trial of a group based social skills intervention for adults with autism spectrum disorder. Research in Autism Spectrum Disorders. 2017 Nov 1;43–44:67–75.

14.       Lei J, Sukhodolsky DG, Abdullahi SM, Braconnier ML, Ventola P. Reduced anxiety following pivotal response treatment in young children with autism spectrum disorder. Research in Autism Spectrum Disorders. 2017 Nov 1;43–44:1–7.

12 unknown facts about ‘obesity’

            Obesity or high body mass index[BMI=weight(kg)/height(mt²)] continues to be a global menace accounting for 40 lakhs plus deaths globally in 2015 only representing 7.1% of all deaths from any cause.(1) Obesity is now considered to be a disease and not just a health issue and is a substantial economic burden on both developed and developing countries.(2) Fueled by economic growth, industrialization, mechanized transport, urbanization, an increasingly sedentary lifestyle, and a nutritional transition to processed foods and high calorie diets over the last 30 years, many countries have witnessed the prevalence of obesity in its citizens double, and even quadruple.(3) In 2016, more than 1.9 billion adults & 41 million children under the age of 5 were overweight or obese in 2016.(4)

            The matter to highlight here is, obesity is very much preventable(4) which will not only prevent weight problems but also various other diseases like cardiovascular diseases, diabetes, musculoskeletal disorders(osteoarthritis, degenerative disease of the joints), some cancers(endometrial, breast, ovarian, prostate, liver, gallbladder, kidney, and colon) and many more.(4) But, it is hardly a curable condition. The common consensus is, overweight is the result of imbalance between calories consumed and calories expended suggesting a eat less and move more strategy for a healthy life.(5) But this appears to be just the tip of the ice berg as recent scientific evidences point towards a much larger etiological profile and overeating along with lack of exercise are just a couple of symptoms rather than the root cause of this problem.(6) So let’s have a detailed discussion about the myths, facts & real problems associated with obesity.

            This concept perhaps started with an article ‘Myths, Presumptions, and Facts about Obesity’ by Krista Casazza et.al(7) and latter prompted a series of studies, reviews and analyses resulting in a brief yet productive data base to discuss here. I am going to summarize few of the interesting facts which can be utilized in day today life to be more fit and healthy.

1.    Small and sustained modifications in daily life style (e.g., walking for 20 minutes or eating two additional potato chips) may not affect body weight much in longer run.(8,9)

2.  Setting ambitious goals(e.g., 10kg reduction in 1 month) result in good outcomes as compared to realistic weight loss goals.(10)

3. A rapid loss of weight as good as slow and sustained weight loss, at least when the long term follow-up is done for weight results.(11)

4. Only physical education like specialized school based programs promoting physical activity, may not be enough to manage obesity (child obesity) indicating more importance of diet and a specific combination of frequency, intensity and duration of physical activity, which may not be achieved by just educating or motivating.(12)

5. Breast feeding does not appear to be protective against future obesity although having numerous other beneficial effects. (13,14)

6. Skipping major meals like breakfast, may not have any benefit in weight reduction. Rather taking regular breakfast may reduce the tendency of having extra snacks and help in weight reduction.(15)  

7. Consuming more fruits and vegetables are effective in weight reduction, only when associated with proper lifestyle modifications.(16)

8. Obese people are not necessarily lazy and less active than their normal weight counterparts, emphasizing again the fact that diet and genetics are more important than activity.(17)

9. Unnatural and unhealthy weight management methods like fasting, meal skipping, stimulants, diuretics, laxatives etc. may result not only in larger weight regain in long run but also may affect both mental and physical health of a person.(18,19)

10. Substantial body fat loss has got many adverse effects like complicating appetite control, decrease energy expenditure to a greater extent than predicted, increase in proneness to hypoglycemia and its related risk towards depressive symptoms, increase in plasma and tissue levels of persistent organic pollutants that promote hormone disruption and metabolic complications all of which increase the risk of weight regain. Hence maintenance is more important & difficult than attaining good health.(20)

11. Exercise alone may not result in significant weight reduction(21,22) but has got other advantages like reduction in belly fat & visceral fat, cardio metabolic risk factors, increase in skeletal muscle mass and improvement of cardiorespiratory fitness and overall health.(23) overall, dietary restriction accounts for 70-80% and physical activity for 20-30% importance for weight reduction.

12.  Same amount of effort may not result in similar weight loss in different individuals.(24) the proposed reason is differential compensatory adaptations to weight loss(adaptive thermogenesis) which may sometimes result in poor responder.(25) But weight reduction regimens should not be judged just by amount of weight loss only, as it has got numerous other benefits.(6)

   Obesity is a bigger problem than it is thought to be and it needs a broader approach as a complex multifactorial disease with genetic, behavioral, socioeconomic, and environmental risk factors increasing the overall morbidity, mortality and socioeconomic burden on the society. Take care, be healthy and keep smiling.

References:

1.         Kushner RF, Kahan S. Introduction: The State of Obesity in 2017. Med Clin North Am. 2018 Jan;102(1):1–11.

2.         PubMed Central Full Text PDF [Internet]. [cited 2018 Jan 18]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5409636/pdf/ijerph-14-00435.pdf

3.         Hruby A, Hu FB. The Epidemiology of Obesity: A Big Picture. PharmacoEconomics. 2015 Jul;33(7):673–89.

4.         WHO | Obesity and overweight [Internet]. WHO. [cited 2018 Jan 18]. Available from: http://www.who.int/mediacentre/factsheets/fs311/en/

5.         WHO | 10 facts on obesity [Internet]. WHO. [cited 2018 Jan 18]. Available from: http://www.who.int/features/factfiles/obesity/en/

6.         Chaput J-P, Ferraro ZM, Prud’homme D, Sharma AM. Widespread misconceptions about obesity. Can Fam Physician. 2014 Nov;60(11):973.

7.         Casazza K, Fontaine KR, Astrup A, Birch LL, Brown AW, Bohan Brown MM, et al. Myths, Presumptions, and Facts about Obesity. N Engl J Med. 2013 Jan 31;368(5):446–54.

8.         Hall KD. Predicting metabolic adaptation, body weight change, and energy intake in humans. Am J Physiol Endocrinol Metab. 2010 Mar;298(3):E449-466.

9.         Thomas DM, Schoeller DA, Redman LA, Martin CK, Levine JA, Heymsfield SB. A computational model to determine energy intake during weight loss. Am J Clin Nutr. 2010 Dec;92(6):1326–31.

10.       Linde JA, Jeffery RW, Levy RL, Pronk NP, Boyle RG. Weight loss goals and treatment outcomes among overweight men and women enrolled in a weight loss trial. Int J Obes 2005. 2005 Aug;29(8):1002–5.

11.       Nackers LM, Ross KM, Perri MG. The association between rate of initial weight loss and long-term success in obesity treatment: does slow and steady win the race? Int J Behav Med. 2010 Sep;17(3):161–7.

12.       Dobbins M, De Corby K, Robeson P, Husson H, Tirilis D. School-based physical activity programs for promoting physical activity and fitness in children and adolescents aged 6-18. Cochrane Database Syst Rev. 2009 Jan 21;(1):CD007651.

13.       Kramer MS, Fombonne E, Igumnov S, Vanilovich I, Matush L, Mironova E, et al. Effects of prolonged and exclusive breastfeeding on child behavior and maternal adjustment: evidence from a large, randomized trial. Pediatrics. 2008 Mar;121(3):e435-440.

14.       Gillman MW. Commentary: breastfeeding and obesity--the 2011 Scorecard. Int J Epidemiol. 2011 Jun;40(3):681–4.

15.       Schlundt DG, Hill JO, Sbrocco T, Pope-Cordle J, Sharp T. The role of breakfast in the treatment of obesity: a randomized clinical trial. Am J Clin Nutr. 1992 Mar;55(3):645–51.

16.       Rolls BJ, Ello-Martin JA, Tohill BC. What can intervention studies tell us about the relationship between fruit and vegetable consumption and weight management? Nutr Rev. 2004 Jan;62(1):1–17.

17.       DeLany JP, Kelley DE, Hames KC, Jakicic JM, Goodpaster BH. High energy expenditure masks low physical activity in obesity. Int J Obes 2005. 2013 Jul;37(7):1006–11.

18.       Utter J, Denny S, Robinson E, Ameratunga S, Crengle S. Identifying the “red flags” for unhealthy weight control among adolescents: findings from an item response theory analysis of a national survey. Int J Behav Nutr Phys Act. 2012 Aug 21;9:99.

19.       Hayes S, Napolitano MA. Examination of weight control practices in a non-clinical sample of college women. Eat Weight Disord EWD. 2012 Sep;17(3):e157-163.

20.       Chaput J-P, Doucet E, Tremblay A. Obesity: a disease or a biological adaptation? An update. Obes Rev Off J Int Assoc Study Obes. 2012 Aug;13(8):681–91.

21.       Thorogood A, Mottillo S, Shimony A, Filion KB, Joseph L, Genest J, et al. Isolated aerobic exercise and weight loss: a systematic review and meta-analysis of randomized controlled trials. Am J Med. 2011 Aug;124(8):747–55.

22.       Wing RR. Physical activity in the treatment of the adulthood overweight and obesity: current evidence and research issues. Med Sci Sports Exerc. 1999 Nov;31(11 Suppl):S547-552.

23.       Ross R, Bradshaw AJ. The future of obesity reduction: beyond weight loss. Nat Rev Endocrinol. 2009 Jun;5(6):319–25.

24.       Maclean PS, Bergouignan A, Cornier M-A, Jackman MR. Biology’s response to dieting: the impetus for weight regain. Am J Physiol Regul Integr Comp Physiol. 2011 Sep;301(3):R581-600.

25.       Tremblay A, Royer M-M, Chaput J-P, Doucet E. Adaptive thermogenesis can make a difference in the ability of obese individuals to lose body weight. Int J Obes 2005. 2013 Jun;37(6):759–64.