In the first instance since the National Family Health Surveys began in the 1990s, there is no estimate of the number of anaemic women and children in India in the latest round of the exercise.

The sixth round of the National Family Health Survey was conducted between 2023-’24 and its findings were released in May.

Anaemia is a condition marked by low levels of haemoglobin in the blood. Iron is a key component of haemoglobin, and iron deficiency is among the leading causes of anaemia.

Anaemia is measured by analysing the haemoglobin count of a blood sample. According to the biomarker schedule of the sixth round of the National Family Health Survey, data was collected on height and weight, blood pressure and random blood glucose but not haemoglobin. Blood samples were collected by a finger prick but used to test for HIV, hepatitis-B, and hepatitis-C.

The government notes that anaemia is a “pressing public health challenge that demands urgent and sustained action”. Anaemia can impair the healthy growth and cognitive development of children. Among adults, anaemia causes fatigue and decreases their capacity to work.

Policies have focused on providing iron supplements, nutrient-fortified food in public health programmes and addressing non-nutritional causes.

There are also programmes like Anemia Mukt Bharat, under the National Health Mission and POSHAN Abhiyan. In June, the scheme was transitioned into the Anemia Mukt Bharat Abhiyaan with a broader strategy. But in the absence of reliable data, there is no way of assessing the impact of these interventions.

Data that shaped health policy

Between the third round of the survey in 2005-’06 and fourth round in 2015-’16, anaemia had decreased considerably.

In children aged six months to five years, it fell from 69.4% to 58.6%; for women between the ages of 15 to 49, it decreased slightly from 55.3% to 53.1%, and among pregnant women it declined from 57.9% to 50.4%. In men, anaemia decreased slightly from 24.2% to 22.7%.

This data formed the basis for a decade of policy. In 2018, the Centre launched the Anemia Mukt Bharat programme, the large-scale provision of iron and folic acid supplements, and the introduction of fortification mandates.

However, the fifth round of the survey saw a reversal of these gains: 57% of Indian women of reproductive age and two-thirds of children under five were found to be anaemic. Anaemia among children aged six-59 months increased from 58.4% to 67.1%, according to the survey’s own comparison table, a rise of nearly nine percentage points over four years.

For women between the ages of 15 to 49, the figure rose from about 53% to 57%, and among men, it rose from about 23% to 25.1%.

The findings of the fifth round of the survey contradicted nearly a decade of diet supplementation policies. One reading was that the programme was not working. The other was that the blood sample collection method was overstating the problem, contended experts like Harshpal Singh Sachdev, a former member of the World Health Organization’s guideline development group on anaemia, and Anura Kurpad of St John's Medical College in Bengaluru.

A different method

The National Family Health Survey has measured haemoglobin levels using capillary blood, drawn by a finger prick. There is substantial evidence that capillary sampling overestimates the prevalence of anaemia compared with venous blood, the clinical standard of taking a sample from a vein in the arm.

For instance, the Comprehensive National Nutrition Survey of 2016-’18, which drew venous blood, found anaemia in 30.7% of Indian children, less than half the 67.1% the National Family Health Survey reported using finger-prick samples. Only about a third of that was attributable to iron deficiency at all, which raises further questions about a policy response focusing on iron supplements.

The India Diet and Biomarkers Survey, now called SAMPADA, was launched in December 2022 for a more accurate estimate.

Covering about 260,000 people in 183 districts and drawing approximately 176,000 venous blood samples, the survey’s fieldwork was completed in 2025. But its data has not yet been released even though it was intended to replace the National Family Health Survey’s anaemia estimates.

Do you know?
ICMR completed SAMPADA—one of the world’s largest nutrition and biomarker surveys, covering 2.6 lakh individuals and generating nationally representative data on diet, physical activity, anemia, and nutritional status. #WeAreICMR pic.twitter.com/jvR5GQHvgU

— ICMR (@ICMRDELHI) November 19, 2025

Three problems

First, India for the moment has no updated national data on anaemia. Budgets, programme targets and state-level reviews continue in the absence of such data.

The second is coverage.

The National Family Health Survey provides district-level estimates across the country but the new SAMPADA covers 183 districts, whereas India has nearly 800 districts. This makes SAMPADA unsuitable for a district administration that needs to decide where to focus diet supplementation, or for a state that wants to compare its own blocks. The Centre’s Anemia Mukt Bharat scheme is also implemented at the local level guided by specific data.

The third issue is comparability and context.

The anaemia data from the 1990s to 2021 stops there. Findings from SAMPADA cannot be compared with the National Family Health Surveys since the methodology of blood sample and data collection is different.

Since anaemia was measured as part of the survey that also gathered information on contraception, childbirth, diet, menstrual practices, and domestic violence, it could be cross-tabulated with these topics.

A separate nutrition survey, no matter how well conducted, cannot show how anaemia varies with the number of children a woman has given birth to or whether she was married before the age of 18.

A data transition

Statistical systems that never alter their methods are worse, not better.. However, there must be a bridge when changing from one instrument to another, and in this case, there is no such bridge.

The simple solution would have been to overlap the two: keep the haemoglobin data in the sixth National Family Health Survey, release the SAMPADA data, and then use the difference between the two to adjust the earlier series to match the new one. This is standard procedure when a statistical agency alters its method, which is why revised series generally come with a back-cast rather than a gap.

If that was not possible, the new data could have been published first, and then the original withdrawn. Instead, there is now a data gap in an area in which the government invests significant time and energy.

A second omission

There is another omission that has attracted little attention. In the fourth round of the survey, women aged 30-49 were asked if they had ever had their cervix, breast, or their mouth examined. The findings showed that 22.3% had undergone a cervical examination, 9.8% a breast examination, and 12.4% an oral examination.

These questions were omitted in the sixth round of the survey at a time when India is expanding its vaccination programme against human papillomavirus, or HPV, which causes cervical cancer, one of the leading causes of cancer-related deaths among Indian women.

The vaccinations are currently aimed at adolescent girls whereas physical examinations can help protect the lives of older women, who were the subjects of these three questions. Unlike measuring anaemia, these questions do not require biomarkers which have to be obtained in a laboratory. The three questions, which were put to women in their 30s and 40s, asked whether anyone had ever examined them and took only a minute of interview time.

Without this information, there is no population level measure of whether cancer screening is reaching women at all, and no way to identify which states are lagging.

A survey that stands on its own

None of this takes away from the significance of the sixth round of the National Family Health Survey. It is the first in the series carried out by the International Institute for Population Sciences without any external technical or financial assistance.

But for the integrity of data crucial to its schemes and policies, the government must release the SAMPADA findings, clearly state how its estimates compare with those of the National Family Health Survey, explain whether the earlier figures can be adjusted to match them, and restore three screening questions for the following round.

Karan Babbar is an Assistant Professor of Economics at XLRI Jamshedpur.

There’s a new menace in town, thanks to an “innovation” by Big Tobacco.

A new study led by Indian Medical Research Council’s National Institute of Cancer Prevention and Research has found that oral nicotine pouches are reaching Indian cities through online platforms, hookah shops and gig delivery services even though it is not clear which Indian law – if any – governs these addictive, tobacco-free sachets are governed.

They are available in 445 flavours, at strengths of up to 120 mg.

The report warns that such pouches are an emerging public-health risk in India. They are rapidly penetrating urban markets and targeting youth through regulatory blind spots.

A nicotine pouch is a small, tobacco-free, tea-bag-like sack containing nicotine, flavorings, and plant-based fibres. Users tuck the pouch between their lip and gum for up to an hour, allowing nicotine to be absorbed directly into the bloodstream without smoke, vapour or spitting.

The Indian report followed a warning from the World Health Organization in May about the dangers posed by nicotine pouches. These products are already banned in several countries, including Singapore, France, Belgium and the Netherlands.

Unlike traditional smokeless tobacco like snuff or chewing tobacco, nicotine pouches do not contain tobacco leaf, dust or stem. The nicotine they use is extracted from tobacco plants or created synthetically in a lab.

Despite being tobacco-free, they contain harmful compounds including formaldehyde, chromium, nickel and ammonia. This exposure can easily exceed recommended reference doses for cardiovascular safety, heavily driving up heart rates and blood pressure.

These products are highly popular among younger people, particularly working men, who are attracted to their discreet, smoke-free usage.

These products are often marketed as “smokeless”, “tobacco-free” or as “clean nicotine”. But that does not make them harmless. Nicotine itself is a powerful chemical that can cause lasting damage.

“It is a matter of high alarm that manufacturers of nicotine pouches are actively targeting impressionable teenagers through calculated marketing strategies,” Dr Bhavna Barmi, a member of an organisation called Mothers Against Vaping told The Indian Express.

Companies make nicotine seem harmless by using colourful branding and offering consumers a range of flavours such as fruit and bubble gum. As a consequence, teenagers have come to view nicotine pouches as a lifestyle accessory, she said.

“Teenagers are drawn to using them without understanding the risk, and once hooked, many may experience long-term impacts on mood regulation, impulse control, and cognitive function,” Barmi said,

Anti-tobacco campaigners and health activists have been campaigning against these products and have petitioned the drug regulator against the applications by some companies to market them in India.

Here is what you need to know about this new product.

France is the latest country to ban the sale of #nicotine pouches, yet they remain unregulated at the EU level.

The Commission should include them & other alternatives in the promised revision of the Tobacco Products Directive without delay.

🔗 https://t.co/ho60Z8z7e0 pic.twitter.com/U7JoIkHULY

— European Cancer Leagues (@CancerLeagues) February 26, 2025

Are nicotine pouches regulated in the same manner as cigarettes and other tobacco products?Under the Directorate General of Foreign Trade schedule and the Central Board of Indirect Taxes and Customs rules, items with the India Harmonised Code 2404 91 30 (tobacco-free oral nicotine pouches) are categorised as “restricted”. The six-digit Harmonised Code is used around the world to classify products in international trade.

Unlike “free” items, such products cannot be cleared simply by paying duties. Unlike “prohibited” electronic cigarettes, they are not completely banned on paper, but they require a specific import licence or permission from the Directorate General of Foreign Trade.

How does the DGFT decide on granting a licence to import such products?
The Directorate General of Foreign Trade cross-references products with the health ministry and other authorities. If the Central Drugs Standard Control Organisation classifies recreational nicotine pouches as unapproved drugs, the DGFT will not issue an import licence unless the importer possesses a valid pharma-grade No Objection Certificate and manufacturing/import drug licence.

However, if nicotine pouches are considered to be food, there should be no reason for an import license to be denied.

Are duty-free stores exempt from import restrictions under the Customs Act?
This question is relevant since nicotine pouches are currently available in duty-free stores in some Indian airports. Duty-free stores are specifically licensed under section 58 of the Customs Act and cannot claim that they are not subject to jurisdiction of Indian law. Nothing in the licence issued under the Customs Act exempts them from being subject all other Indian laws.

Isn’t a duty free shop deemed to be outside the territory of India? Don’t passengers who purchase items from such shops “import” these into India when they cross the customs control at the airport?
In the case of Flemingo Duty Free Shop Pvt Ltd v. Shri Kaushik Bhattacharya decided on April 24, 2024, the Calcutta High Court was of the view that a duty-free store did not import goods into India because it was deemed to be located outside the country for the purposes of the Customs Act. As a result, the legal metrology act requiring goods sold there to be labelled in a particularly Indian manner would not apply.

That decision shouldn’t be read to support the view that no Indian law applies to duty free shops. If no Indian law applied to duty free shops, what happens if a murder occurred there or some group of passengers ransacked the shop? Could they claim that no crime has been committed because no Indian law applies to that space? Wouldn’t an Indian policeman have the power and duty to investigate and arrest the miscreants? Wouldn’t they be prosecuted in an Indian court?

They are exempt from the application of the Customs Act only in relation to payment to the Indian government of customs duties, levies and other taxes on the items that are sold. To claim that Indian law doesn’t apply to them is just absurd when they need an Indian licence to exist.

Adani issues statement on Reuters story on nicotine pouches at airport. Says characterisation of "the matter as a 'breach of law' is premature and legally unsustainable". “International passengers arriving in India may lawfully carry nicotine pouches purchased overseas for…

— Aditya Kalra (@adityakalra) July 9, 2026

What are the items that are permitted to be imported and sold in the duty-free stores?
Duty-free stores are also restricted in the items they can import and sell. Since only passengers entering or leaving the country can purchase items from these shops, they can only sell items that passengers are allowed to carry on the aircraft or into the country. These are listed in the baggage rules. If the duty-free shop had no restrictions on what it could sell, could it sell narcotics, arms and ammunition, all kinds of opioids? Surely no country would allow that.

If cigarettes can be imported and sold, why not nicotine pouches?
Cigarettes, along with alcohol, jewellery, watches, food and small electronic items, are specifically named in the list of items that are permitted to be sold in the duty-free shops. Nicotine pouches are not listed as items permitted to be sold in such shops. But could one argue that they are food? Given the specific classification under the Customs Act that categorises them as restricted, it is unlikely that a licence has been issued for them to be imported.

While it may seem that there are complex legal issues surrounding the import and sale of nicotine pouches it really is quite a straightforward issue for the government to resolve; it will take no more than a few minutes for a notification to be issued under the Customs Act, Foreign Trade Act and the Poisons Act banning, the import and sale of nicotine pouches in India on the basis of protecting health.

Under the Poisons Act, 1919, the Central government can ban the import of poisons into India, and individual state governments have issued rules to regulate the possession and sale of specific toxic substances within their borders. Indian states have formally added nicotine to the state poison schedules to crack down on unauthorised nicotine products.

So what are the central and state governments waiting for? If they don’t act quickly, like they did with vapes, nicotine pouches, with their targeted and aggressive marketing will become fashionable and that will create a permanent and growing demand for them.

Once that happens, notifying a ban, together with the usual poor enforcement, will only result in large-scale smuggling, as is currently happening with vapes.

Murali Neelakantan is the principal lawyer at Amicus.

More than 1.4 billion people worldwide live with high blood pressure (hypertension). It’s the single biggest metabolic risk factor for early death – driving diseases such as heart attacks, strokes, kidney failure and dementia.

Most of these cases of high blood pressure are shaped by how we live and what we eat. This means that making changes to your diet can have a big impact on your risk of developing high blood pressure.

Even small changes can help, as our latest research shows. We found that adding just one serving of nuts into your daily diet is linked with lower hypertension risk.

It’s well known that eating more plant foods is associated with a lower risk of hypertension – but research on the impact of nuts has been limited to date.

Fruits and vegetables are associated with a lower risk of hypertension, with consumption of 800g (ten portions) per day reducing the risk by 11%.

Whole grains – brown rice, oats, wholemeal bread – are similarly linked to lower risk of hypertension. Our research found that the people who consumed the highest amount of whole grains each day had a roughly 26% lower risk compared to people consuming the least.

We have also shown that legumes and soya are associated with a 16% and 19% lower risk of hypertension respectively.

Our latest analysis published in the British Journal of Nutrition, now shows the clear impact eating nuts can have on hypertension risk.

Our study pooled data from 143,000 people – including 20,665 people who had hypertension. We found that eating around a handful of nuts daily (between 30-35g) was linked with a 26% lower risk of hypertension compared to not eating any nuts.

Why plant foods work

Plant foods share a few key characteristics, which may explain why they’re beneficial for the heart.

They are an excellent source of potassium, which helps to lower blood pressure by shedding sodium and relaxing blood vessels.

Plant foods also provide fibre that feeds gut bacteria so they can produce short-chain fatty acids – compounds that are linked to lower blood pressure.

Many plant foods also contain L-arginine and nitrates, which the body converts into nitric oxide in order to widen blood vessels. Plant foods are rich in polyphenols, which have also been associated with lower blood pressure.

Despite nuts being energy-dense, they’re linked to lower obesity rates – thus helping to mitigate another risk factor for hypertension.

These overlapping mechanisms all nudge blood pressure down, and help explain the link between plant-rich diets and lower risk of cardiovascular diseases.

But as tempting as it might be to call nuts a heart health “superfood,” their real power lies within a broader pattern of healthy eating. While reductions in hypertension risk are observed with intake of even just one daily serving of nuts, a diet built around several whole plant foods may provide even further benefits.

This is exactly what Dash, Mediterranean and plant-based diets prove. They all work because they put these different plant-based foods on the same plate.

However, it’s worth noting that the studies included in our analysis are observational. This means they show that people who eat more nuts tend to have lower blood pressure, but they cannot fully prove that nuts are the cause.

People who consume more plant foods in their diet also tend to follow other healthy lifestyle habits such as regular physical activity. Although our analysis adjusted for many of these factors, we cannot fully rule their impact out.

But the randomised controlled Dash diet trials, where diet is actually changed to include more vegetables, whole grains and lean protein, are what give us confidence the link is real. Similarly, intervention trials, which compared the effects of multiple different plant-based diets, also show benefits for blood pressure reduction.

There are knowledge gaps to note, too. The nut studies we included in our review did not separate salted from unsalted. Since salt raises blood pressure, the true benefit of unsalted nuts may even be larger than reported.

Most of the data also came from Europe, the Americas and East Asia. Little evidence came from Africa and India. More large studies conducted in a variety of regions will help sharpen the evidence base.

The takeaway is practical and affordable. You don’t need supplements or fads. Fill half your plate with fruit and veg, choose whole grains, build meals around beans and tofu and add a handful of unsalted nuts. These are small habits that add up to a significant reduction in one of our biggest health risks.

Shireen Kassam is Visiting Professor, Health and Wellbeing Research Group, University of Winchester.

Dagfinn Aune is Research Fellow, School of Public Health, Imperial College London.

This article was first published on The Conversation.

For decades, Kenyans without health insurance have had one option when they fall sick, or a hospital bill arrives. Reach out to friends and family to gather what they can for their healthcare.

By 2023, official figures showed only about a quarter of Kenyans had any health cover. And most of these were people working in formal sector jobs. For the remaining 75%, who had no cover, falling sick meant paying out of their own pockets at health facilities. The few exceptions include maternity care and basic services in local clinics.

The World Health Organization estimates that half of all people worldwide impoverished by out-of-pocket health expenditures live in Africa.

In 2023, shortly after taking office, President William Ruto’s government pushed through a major health financing law, the Social Health Insurance Act. This new law scrapped the National Hospital Insurance Fund, the state insurer since 1966. The insurer had collected members’ contributions and paid their hospital bills, yet only managed to cover about a quarter of Kenyans. The new law replaced it with a new body, the Social Health Authority.

Every Kenyan, formally employed or not, is now expected to register with the authority and contribute 2.75% of their income. The law was immediately challenged in court. Petitioners argued that it had been rushed through without adequate public participation; that the executive bypassed parliament; the burden of 2.75% contribution was too heavy; and that tying healthcare access to registration and contributions violated constitutional rights.

In July 2024, the High Court agreed that public participation had been inadequate and struck down parts of the law. But an appeal court put the ruling on hold, allowing implementation to begin in October 2024.

That a reform was needed is not in doubt. The failures of the old system had been widely documented. But what almost no one remembers is that Kenya tried to pass health financing reform similar to the 2023 law nearly 20 years earlier. Championed by then health minister Charity Ngilu, this was vetoed by then president Mwai Kibaki.

In each case, the goal was the same: to increase health insurance coverage, to pool contributions, and move Kenya towards universal health coverage. So why did a reform built on the same basic model fail in 2004, yet pass in 2023, in just six weeks?

I set out to answer this in my PhD research. It struck me that most of the problems facing healthcare provision in Kenya hadn’t changed. We still had low health insurance coverage. Out-of-pocket expenditures remained high, as did the disease burden. And the national insurer was still dogged by corruption and inefficiency. So what had changed?

My paper concludes that three factors made the 2023 reform possible, where 2004 had failed: concentrating power in the presidency (which enabled the bypassing of institutions that might have opposed or slowed the reforms); co-opting opponents who had blocked the previous attempt; and framing the reform as a fight for the ordinary Kenyan.

This matters, because it changes how we think about reform. We often assume that big changes happen when the moment is finally right. But Kenya’s case suggests conditions for reform can be strategically built.

What I found

For my research I interviewed 48 people intimately involved in the formulation or review of one or both reforms. These executive-level respondents included presidential advisers, insurers, ministry of health officials, external aid agencies, a former health minister, and members of civil society. I also drew on parliamentary records, media reports and policy documents.

I wanted to know why a reform was needed, how each reform was designed, who drove it, who supported or opposed it and why, and how any resistance was overcome. I corroborated their accounts with archival records – especially relevant for the 2004 attempt. I compared a “successful” and a “failed” reform, to reach a conclusion.

One important caveat. The study focuses on the design and how the law passed, not whether it’s working.

I found that while the challenges affecting the health system were nearly identical in both periods, what had changed substantially was the politics, in three distinct ways.

First is executive dominance and institutional bypass. In 2023, the reform process was run from the president’s own office, rather than the health ministry. This top level leadership shielded it from opponents, but also enabled what I call institutional bypass – going around the bodies that would normally shape and check such processes, like the health ministry, the national insurer, and the parliamentary processes of scrutiny and public participation.

Parliamentary scrutiny was shortened (from 14 to three days), and the reform driven through before opposition could organise. Rather than reforming the old insurer, the government scrapped it altogether. By stripping away every point at which the law could be slowed, amended or blocked, the president was able to speedily pass the reform in weeks, with minimal changes.

In 2004, by contrast, the reform was led by the health minister, without strong presidential backing. Without this support, she couldn’t push the bill past the treasury, private sector, employers, and insurers who opposed it. The bill was eventually vetoed by the president.

Second is elite realignment. The powerful players who had blocked the 2004 reform shifted to supporting or not actively opposing the 2023 reform. These included the formal employers’ lobby, private insurers, unions, treasury, and even some external donors. This appeared to be part of a deliberate strategy. Employers, for instance, didn’t have to match their employees’ contributions. This is the very cost they fought against in 2004. And private insurers were left as second payers, topping up the public cover rather than being displaced by it, as they had feared in 2004.

Third is the populist framing applied. In 2023, the reform was sold not as a technical fix, but as a moral cause. The president framed the old system as one where the “poor subsidised the rich” and dismissed opponents as “cartels” profiting from a broken system. The reform itself was presented in a populist way as a fight for the ordinary Kenyans – the so-called “hustlers”.

Framed that way, opposing the reform – even for sound reasons – became difficult. And there were credible grounds to oppose it. The 2.75% contribution was too heavy; the legislative process was rushed; and public participation had been inadequate. But in that moral frame, raising any of these looked like defending the rich or status quo. The framing helped justify speed and sidelining of institutions.

Why this matters

The most striking implication is that a reform doesn’t just pass because the timing is right, or because there are real problems. At any moment, there are countless problems competing for policymakers’ attention. But reform can be strategically designed to pass, by concentrating power, bypassing institutions, co-opting opponents, and framing it as the people’s cause.

This isn’t just a Kenyan story. Many countries are trying to build universal health coverage, and they keep hitting the same walls: tight budgets, competing priorities, powerful opponents, hesitant leaders. Kenya shows how to get around those “walls”.

But this also raises important questions for democracies. The same tactics that pushed a much needed reform over the line also reduce scrutiny and public debate that give a law legitimacy. So whether this reform truly helps the ordinary Kenyan depends on whether the government keeps its financial promises once the political moment has passed.

And because it was rushed through, the reform is left vulnerable. Opposition leaders are already talking about undoing it, making it a contested issue heading into the 2027 elections.

Zil Audi-Poquillon is PhD Candidate - Health Policy and Health Economics, London School of Economics and Political Science.

This article was first published on The Conversation.

Aarti Rawal* is a 27-year-old resident of Delhi. In 2025 for the first time, Rawal took the flu vaccine on her doctor’s recommendation, “after a spell of long Covid in 2023 and 2024 messed up my health”, she said. “I’d get recurrent bronchial attacks exacerbated by winter pollution.”

When she repeated the shot in spring this year, she got her family to take it as well, even though they showed some reluctance. “They didn’t think it was necessary,” said Rawal.

Despite frequent travel within India and abroad, Rawal noticed that she was not falling sick as much as before, which, she said, “was a welcome relief”.

She has also been spared, so far, during Delhi’s present surge in influenza cases.

ISignal spoke with four doctors, all of whom affirmed Rawal’s experience in the context of the present surge of swine flu: People of all ages, including children, who have taken the flu shot have either not fallen sick, or experience milder symptoms.

Swine flu, also known as H1N1 flu based on the virus that causes it, is categorised as Influenza A, a serious form of the flu in terms of morbidity and mortality. India typically sees two influenza seasons, one from January to March and the other after the monsoon sets in.

“India’s swine flu mortality rate hovers between 2%-5%,” said Anupam Prakash, director professor and head, Department of Medicine at the Lady Hardinge Medical College & Associated Hospitals, Delhi.

Swine flu morbidity and mortality can largely be reduced by vaccination. But while the influenza vaccination is readily available in India, only 1.5% adults aged 45 or older had ever taken the vaccine, according to the Longitudinal Ageing Study in India 2017-’18.

India’s immunisation focus has so far been on infants, children and pregnant women. In the 12-23 month age group, the full immunisation coverage is 87.1%, although the National Immunisation Schedule excludes the influenza vaccine.

But with the country’s demographic profile poised to change – the above-60 age group is estimated to compose 15% of India’s population in 2036 as against 12% in 2021 – India’s health guidelines will need to adapt, Agam Vora, a chest physician based in Mumbai and joint secretary, Maharashtra state chapter of the Association of Physicians of India, told ISignal.

With a flu vaccine priced around Rs 2,000, pushing adoption among the masses would mean making it available for free at least to vulnerable categories among the less privileged, through government channels. For context, the poorest 20% households have a monthly expenditure of about Rs 12,000-18,000 for a family of five.

However, despite influenza causing around 125,000 deaths annually, about half of these in older adults and a fifth in children aged less than five, at present, the flu vaccine is neither available for free to adult beneficiaries of say, the National Food Security Act, nor to infants.

“We presently don’t have evidence to support the inclusion of the influenza vaccine in the free government vaccination programme,” said Raj Shankar Ghosh, a public health specialist. “While debility is high, the fatality rate is still too low to justify the investment.”

But the fatality rate depends on both testing and counting deaths.

For instance, doctors whom ISignal spoke with said that in the present influenza surge, they only sent cases for testing if they needed hospitalisation. If the testing were as widespread as during the Covid-19 pandemic, when even people recovering at home were tested, the case load would significantly increase, which means the fatality rate would be lower than the 2%-5% cited by experts.

But influenza may not be the direct cause of death in many cases. It is known to exacerbate comorbidities such as diabetes and heart conditions, leading to deaths. If such mortality were considered, the rate would be higher.

Vaccination key

Disease burden refers to the impact of sickness on a population, measured by death, permanent and temporary disability, and financial costs.

In the case of pneumonia, for instance, Ghosh explained that the available evidence – specifically, the current fatality rate and hospitalisation burden – support making the pneumococcal vaccine free for vulnerable people.

Vulnerable people include those with non-communicable diseases, or elderly outdoor workers, transport sector workers, manual workers, said Ghosh. “Simple lung function tests such as spirometry can be used to confirm beneficiaries.”

Still, the government administers the pneumococcal vaccine for no charge only to children, not to adults.

In the instance of influenza, Ghosh said, evidence that would justify the vaccine’s inclusion in the adult immunisation schedule is still missing.

India lacks a publicly-funded seasonal influenza immunisation, partly because cost-effectiveness is yet to be established.

Yet, a study published in the April 2026 edition of Influenza and Other Respiratory Viruses, and another study published in the July 2025 edition of the Journal of Medical Economics confirmed the efficacy of introducing the seasonal influenza vaccination in two separate cohorts – adults aged 60 and above, and healthy adults aged 18-65 and pregnant women respectively.

One study concluded that vaccination would “also likely reduce out-of-pocket spending for treatment, one of the focuses of the current Indian government”, and proposed private sector partnerships to make the influenza vaccination accessible.

Administering the quadrivalent flu shot to healthy adults aged 18-65 and pregnant women helped reduce the days they took leave from work because of sickness, and consequently, lower expenditure on health by about Rs 12,500 per person, as against unvaccinated people.

Flu shots need to be administered annually based on virus mutations, as we explain below. This needs sustained funding every year, unlike the Covid-19 vaccine which was a two-dose vaccine that was only needed once, or the pneumococcal vaccine that is administered twice at infancy and recommended as a booster for high-risk adults and elderly adults.

ISignal has reached out to the Ministry of Health & Family Welfare for a comment on what the government is doing to promote awareness of and the uptake of the flu vaccine. We will update this report when we receive a response.

H1N1 cases up, H3N2 cases down

The Indian Council of Medical Research influenza dashboard reports higher numbers of swine flu or H1N1 cases across India in 2026 as compared to the previous year. However, the overall number of flu cases is similar to previous years.

Specialists ISignal spoke to ratified this, saying the overall number of flu cases they were seeing in the clinical setting was similar to previous years. They attributed the higher swine flu test outcomes to greater awareness, readily available laboratory facilities and more testing.

Sub-clinical infection – with minimal or no outward symptoms – is widespread, explained Prakash, adding that “the more you test, the more positive cases you will identify”.

However, Prakash said the intensity of symptoms flu patients were presenting was definitely more severe this year. “Patients are experiencing severe body ache from the onset itself and high fever (103-104 degrees F), besides the usual flu symptoms,” he said.

The Ministry of Health and Family Welfare has listed fever, cough, sore throat, runny or stuffed nose, and breathing difficulties as the typical symptoms of swine flu.

Aakashneel Bhattacharya, an infectious diseases specialist practising in Gurgaon, spoke of seeing “patients in their 30s, so weak, that they needed support from their vehicle to his clinic”.

“Swine flu is debilitating irrespective of the patient’s age,” he said.

Bhattacharya has also seen a lingering dry cough in patients after the fever is resolved.

Among infants and children, patients have presented with the sudden onset of sore throat, cough, cold, myalgia (body ache), high fever (103-104 degrees F), and febrile seizures triggered by the fever, according to Supraja Chandrasekar, director of paediatric services at DHEE Hospital, Bengaluru.

“Prescription medicine such as an antiviral is used if the symptoms are severe, or don’t respond to the usual medications, like fever not responding to paracetamol or an NSAID, or if the child is unable to retain fluids (vomiting), or the coughing is severe especially through the night, or the child is looking dull,” she said. “And paediatric patients with breathing difficulties such as breathing too fast or wheezing or needing nebulisation or febrile seizures are best hospitalised.”

Specialists recommend the influenza vaccine

While scientific evidence for the inclusion of the influenza vaccine in the government adult immunisation schedule is missing, doctor associations have included it in their recommendations.

On August 24, the Association of Physicians of India presented to the Governor of Maharashtra a comprehensive framework for adult immunisation in India developed by the Indian Medical Association (IMA) in association with 23 societies representing different medical specialists, such as Cardiology Society of India, Chest Council of India, Federation of Obstetric & Gynaecological Societies of India, Geriatric Society of India, Indian Society of Nephrology, Indian Society of Oncology, Research Society for Study of Diabetes in India, Indian Academy of Geriatrics, etc.

“Usually, every specialist recommends vaccines based on their perspective, [so] we wanted to create a guideline that wouldn’t confuse patients with multiple health conditions,” said Vora, joint secretary of the Maharashtra state chapter of the Association of Physicians of India.

The framework, Unified Consensus on Adult Immunization 2026, recommends the flu vaccine for at-risk individuals such as those with non-communicable diseases, high-risk individuals with compromised immunity due to diseases like cancer or chronic kidney disease, those whose lifestyle compromises their immunity such as smokers or alcohol consumers, people who expect to travel or attend mass gatherings, and those above 50 years of age because that coincides with the setting in of immune senescence, the gradual age-related decline of the immune system.

A step further, Vora questioned the immunity of every person living in polluted cities. With research showing that pollution lowers immunity, and can even cause diabetes, he said residents of metros and large cities have compromised immunity. So, he recommends the influenza vaccine to adults across the board.

For children, the Indian Academy of Paediatrics guideline suggests that children from the age of six months to five years must take the flu shot annually.

The flu affects people of all ages, and children are especially vulnerable.

“After the age of five, the vaccine is optional, and recommended only to high-risk cases, such as children with asthma, or heart diseases, or on long term steroids, etc.,” explained Chandrasekhar.

Virus mutations

A decision about which flu vaccine to take is best left to a physician. Since 1973, the World Health Organization has been recommending the appropriate composition of the influenza vaccine based on the WHO Global Influenza Surveillance and Response System’s review of circulating strains, separately for the Northern Hemisphere and Southern Hemisphere, in February and September respectively.

Essentially, because viruses periodically mutate, the vaccine must cover the latest strains. Popular vaccines protect against the most prevalent three or four variants, and are consequently called trivalent or quadrivalent respectively.

Pharmaceutical majors in India offer both the intra-muscular vaccine made for the Northern Hemisphere and Southern Hemisphere. “Considering the pre-monsoon months are the best time of the year for Indians to get the flu shot, for the strongest protection during the humid monsoon when influenza peaks, we can opt for the latest Northern Hemisphere vaccine,” said Chandrasekhar.

A nasal spray variant is also available but Bhattacharya said the intra-muscular version is preferable.

The flu vaccine is manufactured every year, and those getting vaccinated must ensure the latest strain is used. “Avoid backlog vaccines of the previous year,” cautioned Chandrasekar.

This article first appeared on ISignal, a data-driven and public-interest journalism non-profit.

In June, one-year-old Sahil caught a fever and developed a rash all over his body. A month later, he was dead, mostly likely from a measles-malaria outbreak that ripped through Madhya Pradesh’s Balaghat district.

Sahil’s 12-year-old sister Lamnin fell ill with similar symptoms and died a day later at their home in Bondari village.

As Scroll reported in the first part of this series, at least 25 children from the Baiga and Gond tribes have died since May in this remote Adivasi habitation in Madhya Pradesh. For two months, the outbreak went undetected because of the complete absence of a healthcare system in the area.

Measles is a disease that can be prevented through vaccination. India added the measles vaccine to its universal immunisation programme in 1985.

But four decades later, in the villages of Balaghat, we found that immunisation drives against measles existed only on paper.

“Why should I lie?”

Sahil’s father Samaroo Dhurwey said that neither Sahil nor Lamlin had been vaccinated against measles.

Dhurwey told Scroll that none of his seven children had ever been immunised against any disease. His eldest daughter is married, and the youngest is five years old.

But the records maintained in the Kohnimod anganwadi in Bondari village show that Sahil last received one dose of the measles vaccine on April 21 this year, along with a Vitamin A injection and the pneumococcal vaccine.

After the death of two of his children, Dhurwey alleged that he was asked by a local health worker to say that both had been vaccinated. “Par mein jhoot kyu bolu,” he said. “But why should I lie?”

When we spoke to Lalita Dhurwey, the anganwadi worker, she said she had joined the post in May and did not know about the entry against Sahil’s name. However, she admitted the health department had not carried out any vaccination rounds since she began work.

Kapil Yadav, a teacher at a primary school that stands next to the anganwadi, told Scroll that for months he “kept insisting” that the health department vaccinate the schoolchildren”.

“But the anganwadi or health department did not carry out routine immunisation properly here,” he said.

Experts Scroll spoke to said the low levels of vaccination allowed the measles virus to spread like wildfire in the region. In the Birsa block of Balaghat, which saw many of the deaths, there has been no recorded measles outbreak in the last two decades.

That’s not all. As Scroll found out, the outbreak became deadlier for the children because many of them were malnourished. Moreover, the government’s take-home rations for children aged under six years had recently stopped, compounding the crisis.

Poor vaccination coverage

Three weeks after Sahil and Lamnin’s deaths, three-year-old Priti died in the neighbouring village of Kundekasa.

She had symptoms similar to the other deceased children – high fever, rashes on her body and whitish spots in the mouth, which were suggestive of a measles infection.

The register kept at the local anganwadi shows that Priti received her first dose of measles vaccine in December 2023.

The first dose of the vaccine is given to babies between the age of nine and twelve months and the second dose at 16-24 months.

She was one of the lucky few. The vaccination register listed 15 children – and 11 had missed their first measles shot.

Priti missed her second dose, which can affect a child’s long-term immunity against the virus.

She died on July 22. The cause of her death is “unknown”.

Soon after her death, the administration began mass surveillance in villages in the Birsa block. Until then, the health department was unaware of a measles outbreak.

In 2025, the health ministry set a target for elimination of measles by 2026 through 100% immunisation. India, however, has not met that deadline. We recorded 26,332 measles cases in the first half of 2026. Before this, India missed deadlines to eliminate measles in 2015, 2020 and 2023.

Data from the ministry shows that till 2025, 92.2% of children in India received both doses against the measles virus.

In Balaghat, the coverage is much lower. According to the latest round of National Family Health Survey, 81.3% children have received both the measles shots.

In Birsa, where the outbreak began, the Adivasi villages have even lower vaccination coverage. According to a team from the World Health Organisation that surveyed 177 children in the Birsa block this August, 80% had received their first measles vaccine and 70% their second.

But our investigation revealed that vaccination coverage was far worse than those figures suggest.

We visited families of seven deceased children to check their vaccination status. Parents of six children said they had never been inoculated against any disease. One parent said her child had been administered at least two vaccines, but was not sure for which disease.

Congress MLA Sanjay Uikey asserted that “none of the deceased children were fully vaccinated against measles”. Scroll could not verify this claim.

In Bondari village, Sukhwati bai, a helper at the local anganwadi, claimed parents refuse immunisation even if there is a camp held. Sukhwati herself did not get her eight children vaccinated. Her son Roop Lal, aged 16, died on August 10.

But Budhan Singh who lives in the same village said nobody from the health department held regular camps or visited them to explain the need for vaccines and their benefits. Singh’s four children have not received any vaccine, he claimed. “The health workers are coming now after all these deaths,” he said.

Data from the health department shows that officials conducted a ‘catch-up’ round of measles vaccination – administering 10,481 doses till August 28 – after the outbreak was discovered.

The vaccination officer, Dr Paresh Uplap, was removed from his post as the deaths were discovered. He was also removed from the post of the chief medical health officer in Balaghat.

Uplap admitted that “measles vaccination coverage could improve in Birsa” but maintained that measles alone did not kill at this scale. “The high number of deaths that happened here were because these children had other health issues,” he said.

‘On paper, malaria was under control’

Balaghat is a malaria-endemic zone.

In 2024, the containment zone of 40 villages where the outbreak took a toll recorded 697 malaria cases. In 2025, there were 492 cases.

Strikingly, this year in just one month, from July end to August end, the villages recorded 404 malaria cases.

Two senior officials from the Balaghat health department told Scroll they believe there has been “massive under-reporting in malaria cases” over the past few years. “As a result, several necessary measures under the malaria programme were not taken,” one official said.

“Until the outbreak began, on paper the malaria situation looked under control,” the official said.

Mosquito nets were not distributed by the government this year in four villages that Scroll visited. In several villages, spraying and fogging insecticides to kill mosquitoes was delayed.

Sunder Markam, a contractual worker, said he was appointed to conduct fogging in affected villages from August 12 after a jump in malaria cases.

In Kundekasa village, where four-year-old Arvind Dhurwey died of malaria, sarpanch Parshuram Dhurwey said the health department did not undertake any preventive measures to control the mosquito spread till July end. “All these fogging teams have come after the deaths began to increase,” he said.

The other factor

Experts say one more factor explains the fatalities in the area – malnutrition.

When the measles outbreak hit villages here, along with a sharp rise in malaria infections, malnourished children got seriously ill. Many caught both diseases.

Of the 150 children admitted in a primary health centre in Bithli village in Balaghat since July, medical officer Dr Saurabh Uikey counted over 50 as underweight. “Malnourishment makes recovery difficult,” he said. “Children are susceptible to even the smallest of infections and can die of preventable diseases.”

Virologist Shahid Jameel agreed. He told Scroll that malaria can “weaken the immunity system” and malnourishment can “compound the severity of the underlying health conditions”.

Every third child aged under five is underweight in Balaghat, data from the National Family Health Survey-6 shows.

But the data recorded by Balaghat’s Women and Child Development department officials appeared to be seriously undercounting the levels of malnourishment, Scroll found on the ground.

For example, in three anganwadis we visited, only five of 127 children were recorded as severely acute malnourished children – that is one in every 25 children. There was no record of moderate acute malnourished children even though several children were shockingly underweight.

Professor Vijay Nema, from the National Institute for Tribal Health Research, who visited Balaghat to investigate the outbreak, said that they found severely malnourished children during their field visits. “We do not need to measure their arm circumference to know that. They clearly looked undernourished,” he said.

He added: “A vaccine may not fully work on severely malnourished children.”

In Bondari village, three-year-old Priyanka Dhurwey had been vaccinated against measles, her father Sukhchand said.

She was one of the few children who had reached a hospital facility after falling sick with suspected measles symptoms.

But Priyanka died within two days of hospitalisation. In official records, her cause of death is “severe acute malnutrition, severe respiratory distress, severe anaemia, shock and respiratory failure”.

When Priyanka died on August 13, she weighed 4 kg. “That’s the weight of a two-month old baby,” said Rajaram Chandrawanshi, district early intervention officer. A child her age should ideally weigh between 11 kg and 15 kg.

Priyanka was not even listed as a malnourished child in the anganwadi’s register.

A failing ration programme

According to anganwadi workers in the villages, children’s nutrition was adversely affected recently when the government has stopped supplying take-home rations. Until March, children aged three or less received free food from the state government’s Women and Child Development department. The take-home-rations – rice, dal, soybean – were given to maintain a basic nutritional diet in children.The aid stopped five months ago after the Madhya Pradesh government failed to pay the agencies supplying the food.

“The last supply came in March. That stock lasted till April,” said Kundekasa’s anganwadi worker Mamta Yadav.

Sukhchand, Priyanka’s father, said in the last few months, after the rations stopped, “she had become very weak”.

“Anganwadi food helps many poor families in this region. We have been telling our supervisors to make some alternative arrangements,” said Suhadra Yadav, an anganwadi worker in Matla village.

Devendra Sundriyal, assistant director in the women and child development department, did not respond to Scroll’s calls and texts, asking about take-home rations not being delivered and the poor record-keeping at the anganwadi.

Local residents claim that malnourishment is a failure of multiple government departments, not just the Women and Child Development.

Mansaram Meravi, member of the local Zilla Parishad, said several tribal residents have not been able to avail forest resources and land rights under the Forest Rights Act, 2006, which affected their traditional source of nutrition.

The Baiga tribe traditionally relies on forest produce – they gather elephant foot yam, pihri or edible mushroom, and tubers from the forest to cook and eat. “Several are not allowed to gather forest produce,” said Meravi. “Their movement in the forest is now heavily controlled by the government.”

Two people spend an evening in the same garden and receive roughly the same number of mosquito bites. By morning, one barely notices them – while the other is covered in large, swollen, intensely itchy welts that linger for days.

Most of us have experienced this, or know someone who has. But why is it that mosquito bites affect some people so differently? The answer lies in the way a mosquito’s saliva interacts with our unique immune system.

When a mosquito bites you, they inject saliva into your skin. The immune system recognises the saliva as foreign and releases histamine – an immune cell chemical that causes allergy symptoms such as redness, swelling and itchiness.

But this only partly explains what’s going on. A mosquito’s saliva also contains a range of other biologically active compounds that interact with the immune system in more complex ways than once assumed.

For instance, a mosquito’s saliva also contains proteins that prevent blood clotting and keep blood flowing so they can feed undisturbed.

These same salivary proteins influence the immune response that occurs at the bite site. Rather than acting solely as a feeding aid, mosquito saliva can alter the local immune environment within minutes of a bite.

In plain terms, the saliva nudges the immune system toward a particular kind of response (called a “Th2” response) that’s more associated with allergy-type reactions than with fighting infection. This makes nearby blood vessels temporarily “leakier” which helps draw extra immune cells to the area.

For a simple bite, this mostly just means more redness, swelling and itching. But researchers think this same immune shift may also make it easier for viruses carried by the mosquito to get established in the skin and spread through the body.

Why some people react more strongly

One of the most striking features of mosquito bites is the enormous variation in how people respond.

A large genetic study of over 84,000 people backs this up. People reported experiencing everything from small, mild bumps to large, swollen ones. Even the same person’s reactions to mosquito bites changed over time.

Children often react more strongly than adults, and people exposed to unfamiliar mosquito species may also respond differently because saliva varies between species. The reason for this is largely due to exposure.

Reactions tend to be strongest the first few times someone is exposed to a particular mosquito species. They tend to settle down with repeated exposure as the immune system adjusts – a bit like gradually building tolerance.

Because children simply haven’t been bitten as many times yet, they’re more likely to still be in that stronger-reaction phase. The same logic explains the “unfamiliar species” effect: an adult who reacts mildly to their local mosquitoes can react strongly on a trip somewhere with different mosquito species, since their immune system hasn’t encountered those particular saliva proteins before.

Genetics probably contribute too, with inherited differences in immune regulation influencing how strongly a person responds.

But the key reason that people react so badly to mosquito bites comes down to having a mild hypersensitivity to mosquito saliva.

History of mosquito 🦟 nets in India
One of the earliest non-violent methods used by humans to prevent biting insects and thereby vector borne diseases, is the use of mosquito screens, nettings and curtains.
1/n pic.twitter.com/bB0Q3ChXSq

— Abhishek Avtans अभिषेक अवतंस 🌐 Public Linguist (@avtansa) May 6, 2023

A much smaller number of people develop exaggerated local reactions, sometimes called Skeeter syndrome, where swelling extends well beyond the bite itself and is often mistaken for bacterial cellulitis (a skin infection that causes redness and swelling).

There is no single known cause of hypersensitivity. However, Skeeter syndrome is thought to result from an unusually strong immune response to the proteins in mosquito saliva, involving mosquito-specific antibodies and other inflammatory immune responses.

Why some people develop this exaggerated response is not fully understood – although age, previous exposure to mosquitoes and individual susceptibility may all play a role. Fortunately, severe allergic reactions to mosquito bites are extremely uncommon.

If you’re someone that reacts badly to mosquito bites, applying a cold compress soon after a bite may help reduce swelling. Oral antihistamines and mild topical corticosteroid creams can also relieve itching and inflammation, particularly when used early.

Avoid scratching as this can prolong inflammation, damage the skin and increase the risk of infection. People who develop unusually large reactions, worsening pain or fever should seek medical advice.

Preventing bites remains the best strategy. Using insect repellents, covering exposed skin and sleeping under insecticide-treated bed nets where mosquito-borne diseases occur can all reduce the risk of being bitten.

Mosquito saliva and disease

The implications of mosquito saliva extends beyond the annoying, itchy bites they leave behind.

Researchers are increasingly recognising that these salivary proteins may influence what happens when pathogens are transmitted from mosquitoes to humans.

Specifically, the same immune changes that cause the itchy bites in the first place appear to help mosquito-born viruses such as dengue, Zika and West Nile virus establish a stronger initial infection and spread through the body faster than if the virus were injected without saliva alongside it.

Another intriguing discovery comes from malaria research. A landmark study found that children infected with Plasmodium falciparum, which is the parasite species responsible for the most severe form of human malaria, produced altered body odours compared with uninfected children. Several chemical compounds were present at higher levels, and mosquitoes were attracted to some of these odours.

These findings suggest malaria parasites may alter host odours in ways that could increase mosquito attraction, potentially improving their chances of transmission.

It’s for these reasons that scientists are currently exploring vaccines that target mosquito saliva itself, not just the pathogens it carries.

A mosquito bite may seem like a minor summer irritation, but it reflects a complex interaction between mosquito saliva and the immune system.

This article first appeared on The Conversation.

Going for much of the day without eating is often promoted as a way to improve health or lose weight. But a new study suggests that long gaps between meals may have different effects on older adults – especially those in the oldest age groups.

For the study, my colleagues and I followed nearly 3,000 people aged 60 and over in Sweden and found that those who usually went longest without eating developed chronic diseases faster than those who had shorter gaps between meals. The difference was clearest among people aged 78 and over.

This does not mean that fasting causes disease in old age, nor that every older person should avoid long intervals without food. But it does raise questions about whether advice based on studies of younger and middle-aged adults can be safely applied to older age groups.

Fasting helps the body switch from using readily available sugar to using stored energy, such as fat. Studies in younger adults have linked some forms of fasting to better control of blood sugar and other potentially beneficial changes in metabolism. A recent review found that intermittent fasting led to modest weight loss and some improvements in metabolic health compared with eating without restrictions.

Older bodies, however, work differently in important ways. Ageing changes how people digest food, absorb nutrients, control blood sugar and maintain muscle. Older adults are also more likely to live with several long-term health conditions and take multiple medications. All these factors could change how fasting affects health.

Our study used data from 2,981 adults aged 60 and over who took part in a long-running Swedish study of ageing. When the study began between 2001 and 2004, participants were 74 years old, on average.

Participants reported their usual times for eating meals, snacks and drinking. We calculated the longest gap between any two times they ate or drank during a typical 24-hour day. This gave us a measure of their usual fasting time, rather than whether they followed a particular fasting diet.

We did not know whether people deliberately limited the hours in which they ate or simply went for long periods without food because of their appetite, health, personal preferences or other circumstances. Our analysis, though, took several of these factors into account.

We then tracked diagnoses of 60 chronic diseases for up to 15 years. The diagnoses came from several sources, including in-person medical examinations, health histories, medication use, and patient registers. This allowed us to examine not only how many conditions people had, but how quickly that number increased.

Participants were divided into four groups, based on how long they typically went without eating each day. The shortest-fasting group went between six and 11.5 hours, while those in the longest-fasting group habitually did so for between 14 and 24 hours.

People who went 14 to 24 hours without eating developed chronic diseases faster than those with shorter fasting periods. This included cardiovascular diseases, such as heart failure and stroke, and neuropsychiatric conditions, such as depression and dementia. But it made no difference for musculoskeletal conditions like arthritis and osteoporosis.

Age appeared to matter. Among participants aged 78 and over, longer fasting was associated with faster accumulation of chronic diseases. We found no clear association among those aged 60 to 77.

Why age might change the picture

Several biological processes might explain why fasting has different effects at different ages. The digestive system can become less efficient in later life, reducing the absorption of essential nutrients such as vitamin B12, folate, calcium, and iron. Longer fasting compresses the time available for eating, potentially making it harder for older people to obtain and absorb enough nutrients.

Muscles also respond less effectively to protein with age. Eating protein regularly throughout the day provides repeated signals that help the body maintain muscle. Long gaps between meals may reduce these opportunities. Previous studies have linked muscle loss in older adults to ill health, including cardiovascular and neuropsychiatric diseases.

Medication use may also be important. Some medicines need to be taken with food to improve absorption or reduce side-effects, while others can affect blood sugar if taken far from meals. These explanations are plausible, but our study was not designed to identify the biological mechanisms behind the association of fasting with chronic conditions.

People who usually went longest without eating also tended to be older, eat fewer meals, consume less energy and protein, exercise less, and have more diseases when the study began. We took these and many other differences into account, including diet quality, smoking, sleep, education, living arrangements, social connections and care needs. The results were also similar when we repeated the analysis using different assumptions.

Even so, this was an observational study, so we cannot say that long fasting periods caused people to develop diseases faster. Poor health could instead lead people to skip meals, lose their appetite or change their eating habits. We took frailty and difficulties with everyday activities into account and still found similar results, but we cannot completely rule out the possibility that poor health caused the longer fasting periods rather than the other way around.

Participants were mainly highly educated, urban, community-dwelling older adults in Sweden. Eating patterns may differ in other countries, rural or disadvantaged communities, and among older people living in institutions. The meal-timing data were also collected more than two decades ago, and dietary habits may since have changed.

Taken together, these findings do not point to one ideal number of hours between meals. Instead, they suggest that fasting advice may need to account for age, nutritional vulnerability, medication use, and existing health problems.

An eating pattern that offers some metabolic benefit earlier in adulthood may carry additional risks later in life, when getting enough nutrients, maintaining muscle and staying physically independent can become harder.

Adrián Carballo Casla is Postdoctoral Researcher in Geriatric Epidemiology, Karolinska Institutet.

This article was first published on The Conversation.

Mahasingh Parte lives in the last hut in a village on the border of Madhya Pradesh and Chhattisgarh.

To reach the village, Matla, one has to trek a kilometre up a hill, on muddy trails and slippery slopes.

The village in Balaghat district in eastern Madhya Pradesh is surrounded by rolling hills and forests, a picture of tranquility for tourists visiting the nearby Kanha National Park.

But for Parte and other members of the Baiga tribe, who live in this remote region, life is a daily struggle – with little help forthcoming from the government.

Parte earns a living by collecting and selling tendu leaves and forest produce or labouring on other farms. The hut itself is bare except for a few steel utensils stacked in one dark corner. He grows millet and forages for seeds, other than depending on government ration.

“If we can manage, we eat two meals a day,” he told Scroll. “On many days, my children eat just once.”

In May, Parte’s four-year-old son Samlu caught a high fever. Soon, his six-year-old daughter Shamku’s body also felt warm.

One by one, all his five children fell ill.

But Samlu and Shamku were the worst off. Both had a rash-like eruption on their bodies. They developed a cough and a cold, and their eyes swelled up. They could not keep their food down and kept vomiting.

Parte approached a ‘panda pujari’, or faith healer, in the village who chanted a few mantras, gave them water to keep near the children, and assured them they will be alright.

The Baigas trust faith healers and are often reluctant to rely on the ramshackle and near-absent state healthcare system.

Parte had never been to a hospital, not even for his wife’s five deliveries. “We don’t trust them,” he said. The nearest health sub-centre in Machhurda village is 5 km away but has no doctor.

But, this time, the mantras did not cure the children.

On the morning of May 18, four days after he fell ill, Samlu died. The next evening, Shamku passed away.

No one from the health department visited their home or were even aware of the deaths for at least two months. The village has no accredited social health activist or ASHA worker – a government health worker who monitors the health of the rural population.

A week ago, Sadesh, a 10-year-old in the same village, had died of similar symptoms – fever, whitish spots in the mouth and tongue, rashes on body and vomiting.

Sadesh’s uncle Hansu Dhurwey told Scroll that he, too, was taken to a panda pujari. “When his condition did not improve, we took him to a private doctor in Khadi (a nearby town in Chhattisgarh). But the doctor said Sadesh was already critical. So we brought him home.”

The village residents climbed up a hill with the bodies of the three children in their arms and buried them in a forest. Large stones were placed to mark their resting places.

Unknown to the government, the buried children were possibly the first casualties in a mysterious measles and malaria outbreak in this remote Madhya Pradesh region that went undetected for at least two months – and led to the deaths of at least 25 children from the Baiga and Gond tribes.

Scroll travelled to Balaghat to trace the outbreak’s path– starting from Matla village where the first deaths possibly occurred to Bondari, which officially became the ground zero of the outbreak, and villages beyond where the infection has now spread.

Many children were ill for weeks before succumbing, indicating that timely treatment could have saved lives. “We are seeing so many cases and deaths because there is no health system here,” Congress MLA Sanjay Uikey said.

‘Health teams are coming now, after my children have died’

Uikey’s observation matched what Scroll saw on the ground. We found only a small minority of children in the tribal villages had been vaccinated against measles. Parte told us that none of his five children had been immunised against any disease.

Three children died in Matla in May, followed by four more in June, and three more in July in other villages of the Birsa block. A local anganwadi worker in Matla told Scroll that she knew of the deaths in the village but had failed to report them.

It was after the ninth death on July 22 that the health department swung into action.

The Madhya Pradesh health department’s own records on the 25 deceased children, which Scroll has accessed, showed that only nine of them managed to get some medical attention in government or private hospitals. The local legislator and health officials say the number of children who died of the disease is 29.

On August 29, chief minister Mohan Yadav travelled to the affected villages and announced a compensation of Rs 2 lakh for 22 children who died during the outbreak.

In the first seven deaths, Scroll found that the children, aged one to 12, died at home without any medical care. None had been vaccinated against measles.

Auxiliary nurse midwives and ASHA workers, the first point of contact in the government healthcare system, were absent in the villages we visited. Health officials said that many of the children were malnourished and had contracted malaria, which made the measles infection worse.

The Baigas are a particularly vulnerable tribal group who live close to forests, and the Gonds are one of the largest indigenous tribal groups in central India. They shy away from government hospitals due to a lack of trust, officials said.

The Indian state is barely present in this remote region. “There is no road in our village, an ambulance can’t reach us. We have to carry sick people on bamboo sticks,” said Samaroo Dhurwey, who lost two children to the suspected measles and malaria infection.

In late August, as he watched health workers arriving in his village with a fogging machine, he said: “The health teams are coming to spray now, after my children have died.”

The disease is discovered

In May, Samaroo Dhurwey travelled from Bondari village to Matla, a distance of 10 km – around the time when Parte’s children had fallen ill in the same village.

“After I returned, my seven children, wife and I all fell ill,” Dhurwey, aged 56, told Scroll. A few days later, his brother’s family, who live in a nearby hut, also fell ill.

The condition of Dhurwey’s two children – one-year-old Sahil and 12-year-old Lamnin – worsened. They had rashes on their body, whitish spots in the mouth, difficulty in eating, high fever, cold, and eventually “altered sensorium” or a confused mental state. These are classic measles and malaria symptoms, two experts told Scroll.

From May till June, they remained ill for almost a month but were not taken to a hospital. Bondari village has no accredited social health activist and the nearest primary health center in Songudda had no medical officer.

Lamnin died on June 26, Sahil the next day. Three weeks later, a third child died in the village.

Except for the villagers, nobody in the government knew of the deaths.

In July, Parshuram Dhurwey, the sarpanch of the Adori panchayat, heard about the three deaths in the Bondari village. “Something was not right,” Dhurwey said.

On July 22, Dhurwey informed the then sub-district magistrate, Arpit Gupta, who sent a team to the village the next day. “We initially thought it was a seasonal flu. But when we went door to door, we found sick children in every house,” Gupta said.

By July end, Gupta had an inkling that the spread of infection was much larger.

Bondari became the ground zero of the “mysterious outbreak”, with at least one sick child in each of the 103 homes. Tribals from the Baiga community were the worst affected.

“Every year there are few deaths during the monsoons. But we have never seen this before. Children were ill everywhere,” Dhurwey told Scroll.

Health teams poured into the hills in early August, with workers from as far as 100 km transferred here to carry out surveys. They began to report measles-like symptoms in children in other villages.

Till mid-August, the outbreak was largely contained to 18 villages in four gram panchayats. But by late August, ill children were being found even beyond those villages.

“Since the measles outbreak has occurred for the first time here, many health workers were untrained in identifying the symptoms. That led to a delay,” said Arpit Gupta, the sub-district magistrate who was later transferred out.

Health workers began the difficult task of counselling families to admit their children in hospitals. Many tribal residents chose to hide in the forest when health teams came. They called the unknown infection ‘mata’ and chose to seek panda pujaris for cure. This further delayed timely treatment.

“Even hospitalising the children was tough,” said Dr Paresh Uplap, former chief medical health officer in Balaghat. Uplap was removed from the post earlier this week. “Parents were running away from hospital wards with their kids.” Eventually, the collector ordered police constables to be stationed outside wards.

Measles and malaria

On July 27, members of the National Institute for Tribal Health Research visited Balaghat to advise the district health department.

It put out a report, accessed by Scroll, which found a high incidence of measles in these villages – in 21 out of 47 samples it tested. Malaria was found in eight out of 16 samples.

In the last week of July, the health department also sent blood samples of the sick children to Jabalpur Medical College and the National Institute of Virology in Pune.

The Jabalpur Medical College’s microbiology department stated that it found measles virus in 17 of 64 serum samples and malaria parasite in 50 of the 96 samples. In some cases, children were infected by both.

As the deceased children had been buried, the reason for their death could not be confirmed. But a detailed history of their symptoms pointed to a measles-like illness, a senior health officer in Balaghat told Scroll.

Researchers with the ICMR said they were investigating the entry of the measles virus into Birsa, a region with no recorded outbreaks for at least two decades. “It is a big question for us,” said Professor Vijay Nema, scientist at National Institute for Tribal Health Research, who visited Balaghat.

Several residents migrate to Telangana to harvest chillies. Officials suspect the virus could have also travelled back on an asymptomatic carrier.

Even if not usually fatal, the measles virus is highly contagious. An infected person can transmit the virus by coughing, sneezing, or even talking five days before the initial symptoms emerge. “At the peak of the Covid-19 pandemic, the R naught value for coronavirus was 2.5,” virologist Shahid Jameel pointed out.

R naught is the average number of people that a single infected person can infect in a population with no previous immunity. “For measles, the value is 18, making it one of the most contagious diseases,” Jameel explained.

The lack of vaccination allowed the virus to spread silently until it snowballed into a localised outbreak.

Nema said they suspect the virus may have spread through “super spreader events” – weekly markets where parents brought their children, gatherings in residential schools for tribal students, and an August 9 public meeting in the district to observe World Tribal Day.

An absent state

The outbreak has exposed the abysmal health infrastructure in the Birsa block of Balaghat, where the deaths occurred.

In fact, of the 72 vacancies of ASHA workers across Balaghat, 48 are in the Birsa block.

The local anganwadi worker in Matla, Suhadra Yadav, where the first deaths occurred, failed to report the infection to health authorities even when she got to know of them, she admitted to Scroll.

An anganwadi worker is supposed to report deaths in her monthly progress reports to her supervisor and child development project officers.

In Yadav’s register, Parte’s children, Samlu and Shamku, have been named as Ram and Ruhi.

Scroll found that under-reporting of deaths in the community by government officials is common. “There is a limited outreach of the health department and women and child development department here,” said Dinesh Dhurwey, district president of the Adivasi Vikas Parishad.

‘They say these are Baigas, they know nothing’

The Birsa block in Balaghat, which includes Bondari and other affected villages, was declared Naxal-free in December 2025.

Uplap, former district chief medical health officer, admitted that government officials have only recently begun to reach out to villages in the Birsa block. “Naxal activities made our work difficult,” he said.

However, Shubham Uikey, a Balaghat-based social activist, pointed out that the district had reported no active violence by Naxals for many years.

Uplap said that the village residents often resist medical intervention. He cited the example of Samaroo Dhurwey’s brother Dashrath who also lost his 13-year-old son to “measles-like symptoms” on August 13. When his second son fell sick, Dashrath refused to admit him to the hospital.

His brother Samaroo said they “follow what the panda pujari says”. “The panda told us that our children will die in hospital,” he said.

The lack of trust in government healthcare goes beyond a panda pujari’s advice.

Members of the Baiga community complained that even when they visited clinics and hospitals, they were treated with condescension and disrespect.

“They say these are Baigas, they know nothing. Give them any medicine,” said Budhan Singh, who lost his brother Rooplal in August to the disease. “They will have it like cattle.”

The presence of the health teams in the area following the outbreak may have inspired some confidence.

Sarpanch Parshuram Dhurwey said after a few children recovered and returned from the hospital, local residents will begin to trust government healthcare. “More people are willing to send their children to hospitals now,” he said. “The government never made such efforts before.”

This is the first story of a two-part series.

Lentils, beans and chickpeas have been feeding people for thousands of years. Lentils are among the world’s earliest cultivated crops, with archaeological evidence tracing them back to the beginnings of agriculture. Yet scientists are still learning what happens inside our bodies when we eat them.

A 2026 review of the research examined the evidence on pulses and their effects on the gut and metabolism. Pulses are the dried edible seeds of legume plants, including lentils, chickpeas, dried beans and dried peas. Legumes are the wider plant family and also include foods such as soya and fresh peas.

The researchers brought together evidence from human studies with laboratory and animal research. So what does the science suggest pulses actually do once we eat them?

1. They feed microbes in your gut

Pulses provide plant protein and fibre, along with carbohydrates that are not always completely broken down before they reach the large intestine.

There, gut microbes get involved. When some bacteria break down fibre and other carbohydrates, they produce substances called short-chain fatty acids. These help support the lining of the gut and are involved in how the immune system and metabolism work.

Because pulses provide some of the carbohydrates these microbes feed on, researchers are interested in whether regularly eating them changes which microbes thrive in the gut and what they produce.

The recent review found promising evidence that pulses can affect the gut microbiome, the community of microbes living in our digestive system. But much of this research still comes from laboratory and animal studies. Longer human trials are needed before we know how important these changes are for health.

2. They can change what happens to your blood sugar after a meal

Blood sugar normally rises after we eat carbohydrates. Pulses appear to reduce the size of that rise.

A review that combined the results of 65 clinical trials, involving 2,102 adults with and without type 2 diabetes, found that eating pulses reduced rises in blood sugar after meals.

One possible explanation lies in their structure. Pulses contain fibre and starch that can be digested relatively slowly, and intact cell walls can make some of the starch harder for digestive enzymes to reach.

The evidence for longer-term changes is less certain. The same review found some improvements in measures of blood-sugar control, particularly among people with type 2 diabetes, but researchers rated much of this evidence as low or very low certainty.

3. They may modestly lower cholesterol

There is also evidence from human trials that eating legumes can produce small improvements in cholesterol.

A 2024 review of 24 trials involving 1,938 people found modest reductions in both total cholesterol and LDL cholesterol.

LDL stands for low-density lipoprotein. These particles carry cholesterol through the blood, and extensive genetic and clinical evidence shows that higher exposure to LDL contributes to the build-up of fatty plaques in arteries, increasing the risk of cardiovascular disease.

The changes seen in the legume trials were relatively small, so eating beans or lentils should not be thought of as a treatment for high cholesterol. They can, however, form part of a diet that supports cardiovascular health.

4. They may help you feel fuller

Pulses may also affect how hungry you feel after eating.

A systematic review and meta-analysis of short-term feeding trials found that people reported feeling fuller after meals containing pulses than after comparison meals. However, this did not reliably translate into eating less at the next meal.

This means the evidence supports a short-term effect on feelings of fullness more clearly than it supports claims that pulses automatically reduce how much we eat.

5. How you prepare them can change what your body absorbs

Pulses contain minerals such as iron and zinc, but they also naturally contain phytate. Phytate can bind to minerals and make some of them less available for the body to absorb. broken link

Preparation can change this. Research has found that techniques including soaking and sprouting can reduce phytate and improve the availability of iron and zinc, although the effects vary between foods and preparation methods.

So the amount of a mineral present in a food tells only part of the nutritional story. How that food is prepared can influence how much becomes available for our bodies to use.

There is an environmental advantage too

Pulses also have an unusual ability before they ever reach our plates.

Legume plants form partnerships with bacteria around their roots that convert nitrogen from the atmosphere into forms plants can use. This relationship is one reason legumes are important in farming systems and can help reduce reliance on synthetic nitrogen fertilisers.

So, should we eat more pulses? The evidence is strongest for some effects and still developing for others. Human trials suggest pulses can reduce blood-sugar rises after meals, modestly improve cholesterol and increase feelings of fullness. Research into their effects on our gut microbes is particularly interesting, but better long-term studies in people are still needed.

Fortunately, adding pulses to meals does not require much reinvention. Lentils can be added to soups, curries and salads. Chickpeas can become hummus or be roasted, while beans work in stews, wraps and pasta dishes.

After thousands of years on our plates, pulses are hardly a new discovery. What is changing is our ability to follow what happens after we eat them, from the bacteria in our gut to changes in our blood. And scientists are still filling in parts of that picture.

Lewis CE Mason is Lecturer in Microbiology, Kingston University.

This article was first published on The Conversation.

Cottage cheese is having a moment. It’s being added to dips, mixed into batters and even used in pizza and brownies. It’s touted as a high-protein food that can help build muscle and lose fat. But the research supporting these benefits is not quite as abundant as the number of viral cottage cheese recipes that are out there.

My colleagues and I published a review last year which provided a full breakdown of the available evidence.

Interestingly, our review did not identify any published studies which directly examined the effects of cottage cheese on muscle mass, growth and function. There were also no studies investigating whether eating cottage cheese leads to meaningful changes in body weight or body composition.

This means that much of the current hype around cottage cheese and its benefits is really only based on what we know about protein in general. There is actually relatively little research on the impact that cottage cheese has on muscle gain and weight loss.

What the research says

Cottage cheese is relatively low in fat compared with many other cheese varieties, making it high in protein relative to its fat and calorie content. This means you can consume a high amount of protein without necessarily consuming as much fat or calories as you might with other types of cheese.

The protein in cottage cheese also comes predominantly from casein. This is a slower-digesting protein that causes a more prolonged release of amino acids (the building blocks of proteins, including those needed to maintain and build muscle) compared with proteins such as whey, which are rapidly digested and absorbed. Because casein is digested more slowly, it has been suggested it could help people feel fuller for longer.

Cottage cheese’s enduring popularity among fitness enthusiasts perhaps stems from suggestions that its high-quality protein can support muscle growth when combined with resistance training (such as weight lifting).

Its high protein-to-fat ratio and potential to promote fullness have also led to suggestions that cottage cheese could make it easier to maintain a calorie deficit, which can support fat loss.

But there is an important distinction here: the purported benefits of cottage cheese are based on what we know about protein generally.

So to understand what the research actually says about cottage cheese’s impact on health, my colleagues and I conducted a review, providing a full breakdown of the available evidence. High-quality human randomised controlled trials, the gold standard for establishing causal effects, are lacking. This makes firm conclusions difficult.

A study in healthy women found that cottage cheese caused more insulin to be released into the blood stream than a cod fillet or soy protein did. Insulin is a hormone that helps regulate blood sugar. It does this by promoting the uptake of glucose (a type of sugar) from the bloodstream into cells, where it can be used for energy or stored for later use.

Studies in both healthy and diabetic participants similarly found that cottage cheese stimulated a greater insulin response than several other protein sources, including egg white, lean beef, turkey, fish and soy.

These findings suggest that cottage cheese causes greater amounts of insulin to be released compared with some other protein sources. The reason for this is not entirely clear, although differences in protein composition, amino acid availability and how easily the protein source is digested may play a role.

There have also been individual studies examining cottage cheese’s effects on energy expenditure (the number of calories a person burns) and appetite. These studies suggest that cottage cheese does not appear to affect energy expenditure, satiety or appetite differently from other protein sources when matched for calories, protein and other macronutrients.

Overall, our review did not find any studies that directly examined the effects of cottage cheese on muscle mass, growth and function. Nor did we find any studies showing cottage cheese leads to meaningful changes in body weight and composition.

So, while the nutritional characteristics of cottage cheese make some of the claims surrounding it biologically plausible, we should be careful not to confuse plausibility with evidence.

Our research team is currently investigating various aspects of cottage cheese in the hopes of understanding its effects on the gut, muscle health and ageing. We hope that the results of our work will provide much-needed evidence showing how cottage cheese impacts our health.

What does this mean for you?

The proposed benefits of cottage cheese are largely grounded in plausible mechanisms and evidence relating to its nutritional characteristics – rather than evidence demonstrating that cottage cheese itself produces these benefits.

But despite the lack of direct scientific evidence, cottage cheese remains a versatile, protein-rich food which can be included as part of a healthy diet. It provides a convenient and nutritious way of increasing protein intake.

Still, it’s important that when health claims are made, we’re clear about where the evidence ends and the speculation begins. For now, the science behind cottage cheese is promising in places, but the trend is ahead of the research.

Dominic Farsi is Visiting Postdoctoral Research Associate, King's College London; Teagasc; Queen's University Belfast.

This article was first published on The Conversation.

I’ve spent more than three decades studying how exercise and diet keep us healthy. But one thing keeps showing up in the data: living longer and living well are not in sync. While we’ve partly solved the first one, we are lagging behind at the second.

Over the past century, the average Canadian’s life expectancy has increased by 22 years, to roughly 80 for men and 84 for women. Medical and scientific research may push those numbers higher. However, the number of years we can expect to live in good health has been declining, and in Canada it now stands at about 67, down from a peak of about 70 years.

That means a lot of us are on track to spend close to two decades, sometimes longer, living with chronic illness, cognitive decline or lost mobility. That gap, not lifespan itself, is the real crisis. And almost nobody treats it like one.

Longevity is the wrong score

Longevity is the word on everyone’s lips, with influencers discussing the possibility of three-digit lifespans. One wealthy biohacker was investing millions into his goal of 160 years of life, and inviting others to spend as much as US$1 million a year to join him. He recently announced he has developed an autoimmune condition.

Life has become an endurance event, and we need to push through to the bitter end.

In contrast, picture the 80-year-old down the street who carries their own groceries, climbs their own stairs, drives their car and gets down on the floor to play with their grandchild. That’s the target worth chasing.

Ideally, good health and health-related quality of life would last our whole lives. The balance between the quality and quantity of our years is the idea behind healthspan: the period of our lives we spend in good health. Admittedly, good health is subjective, and it has been argued that healthspan may not be definable at a single age and is more accurately represented by an index.

However we measure it, it’s clear that closing the gap between healthspan and lifespan is both painfully necessary and maddeningly hard to pull off, which may explain the mismatch between how big the problem is and how little has been invested in fixing it: estimates put the ratio of treatment to prevention health spending at almost 12:1 in Canada.

Betting on healthspan

At McMaster University, the new McCall MacBain Kinesiology and Healthspan Institute aims to close the healthspan gap.

Kinesiology is the science of how the body moves, performs and functions. When paired with preventive medicine’s approach to disease, it can help keep people out of the clinic in the first place, not just treat them once they arrive.

The institute’s mandate prioritises cross-disciplinary collaboration to advance research and teaching and to turn the results into meaningful action that materially benefits communities. Research alone doesn’t change lives; people armed with good evidence do.

We want to help Canadians and people well beyond our borders to spend more of their years in good health by delaying disease onset, preserving physical and cognitive function and building resilience before it’s needed.

Achieving this would improve quality of life while lowering the cost of treating cancer, stroke, heart disease, dementia, chronic pain and impaired mobility down the road.

The institute is the first of its kind, enabled by a $50 million donation from philanthropists Marcy and John McCall MacBain and their foundation. The investment backs a specific bet: that the broadest, most affordable, evidence-based interventions for healthspan are still there to be found and put into practice.

We aim to show exactly how committing time and resources across an entire life, starting in childhood, builds a reserve of health that can hold off the chronic problems that tend to compromise our final decades.

The wrong face of the wellness and longevity industries

The wellness and longevity industries and online biohackers have followers convinced that the ultimate goal is “maxxing” your life through pills, protocols and potions.

Not surprisingly, the major components of healthspan are already well known: regular exercise, better sleep, a healthy diet, real social connection, not smoking and going easy on alcohol.

By addressing these factors, you can put yourself in a much better position to fend off the diseases that dominate older age. The best way to treat chronic illness is still to delay it, or in the case of dementia and cognitive decline, avoid it altogether.

Canada spends close to $144 billion a year on wellness-related products, only to watch people slide into declining health at increasingly younger ages.

Here’s what the research actually tells us: there is no evidence that the supplements, peptides and “treatments” the longevity and wellness industries sell contribute anything to your healthspan.

Influential factors are widespread

Discussing this issue requires perspective. The factors with the greatest influence on healthspan are not a supplement stack or a peptide cocktail. These factors are complex, difficult to fix and aren’t evenly available across all sectors of society.

Safe streets and parks. Affordable food. A place to sleep. A neighbour to walk with. Predictable working hours. Access to childcare. None of these are luxuries, but they are a core foundational infrastructure of a longer healthspan, which for far too many Canadians is simply out of reach.

Income, education, housing, working conditions, neighbourhood safety, social isolation and discrimination weigh at least as heavily in who ages well as anything found in a missive on longevity.

Health research has moved beyond the question of whether we can live longer. We already do. The new question is whether we’re willing to invest seriously, equitably and early in living better. We may discover that pursuing a longer healthspan also leads to even greater longevity, for all. That’s definitely a goal worth pursuing.

Stuart Phillips is Professor, Kinesiology, Tier 1 Canada Research Chair in Skeletal Muscle Health, McMaster University.

From the first hint of cold winter mornings, supermarkets and pharmacies begin heavy marketing to coax us to stock up on vitamin C to get through the cold and flu season.

But where did that idea come from?

As we’ll see, it’s a story including a Nobel Prize winner, a book and some claims that don’t quite stack up.

Nobel Prize winner writes a book

Linus Pauling was a chemist from the United States who won two Nobel Prizes. One was in 1954 for chemistry, for his research into chemical bonds. The other was in 1962 for peace, for his activism against nuclear weapons testing.

He was not a dietitian or an infectious disease physician. But that didn’t stop him publishing a book on vitamin C and colds in 1970. This book is widely credited with the skyrocketing sales of vitamin C at the time, a trend that continues today.

In this book, Pauling said we should consume high doses of vitamin C, around 1,000-2,000 milligrams a day for good health, and even more to prevent a cold.

His recommendations were said to be initially from one placebo-controlled trial in children on a ski camp in the Swiss Alps. He then analysed a further four studies conducted after his claims.

But his interpretation of these studies has been widely criticised. There were incorrect mathematical analyses, reliance on four poor-quality trials and the overemphasis of the study in children.

So, do mega-doses of vitamin C work?

The short answer is not really. Multiple studies conducted since the ones Pauling analysed show that if there is an effect on vitamin C and colds, it’s minimal. Even then, any marginal benefits are only under certain circumstances, such as if you’re an athlete or in the army.

One study, published in 2023, was a meta-analysis that combined the results of ten placebo-controlled trials. These looked at the effect of vitamin C on the severity and duration of colds. In total, these trials involved 2,736 healthy people (adults, children and athletes) who regularly took at least 1,000mg of vitamin C a day, not just when they had a cold.

Overall, the researchers found people who took vitamin C had a 15% reduction in severe cold symptoms compared to those who didn’t take it. This was expressed as the number of days “confined indoors”, which the authors acknowledged as a limitation. Vitamin C did not affect how long mild symptoms lasted.

A meta-analysis in 2013 found taking lower doses (at around 200mg a day) did not decrease the number of colds in the general population. However, there were fewer colds for athletes and army personnel.

Similar to the other study, regular vitamin C supplements showed a reduction in severity of symptoms in children and adults by 8%-14%. However, taking vitamin C at the start of the cold had no benefit.

So, from these two meta-analyses, Pauling’s original advice is over-stated. There is no evidence vitamin C will reduce your risk of catching a cold.

There is some evidence it will reduce how long severe symptoms last, but on average only by about 10%. So if severe symptoms from a cold last for five days, it will reduce severe symptoms by about 12 hours. If the severe symptoms last for 24 hours, they will reduce by about two-and-a-half hours.

Taking vitamin C when symptoms start will have no effect. You need to be taking it regularly, even before you get sick.

So how much vitamin C is too much?

Pauling’s recommendation for good health, at around 1,000–2,000mg a day, is around the upper limit of what’s now considered safe to consume.

Australia has not set an upper limit for vitamin C, due to inconclusive evidence. But guidelines refer to other expert recommendations for adults to not consume more than 1,000mg a day. In the United States, the upper limit for adults is 2,000mg a day.

Pauling’s recommendation is also much higher than the recommended daily intake in Australia and other countries. For adults over 19 in Australia, this is 45mg.

This is what you would find in half an orange, three to four florets of cooked broccoli or one-third of a glass of orange juice.

So what should I do?

Taking high doses of vitamin C (over 1,000mg a day) continually can increase your risk of adverse events such as:

• gastrointestinal effects, such as diarrhoea, nausea, stomach cramps and bloating

• more oxalate excretion, which may lead to kidney stones

• an increase in iron absorption, which may lead to tissue damage in people with undiagnosed haemochromatosis (an inherited disorder where you absorb too much iron from your food)

• interactions with radiation therapy, chemotherapy and the cholesterol-lowering drugs statins.

If you feel you would benefit from vitamin C supplements, discuss this with your GP. You should limit the dose to below 1,000mg a day and be mindful of the side effects.

Remember less than 4% of Australians are deficient in vitamin C.

Evangeline Mantzioris is Program Director of Nutrition and Food Sciences, Accredited Practising Dietitian, Adelaide University.

This article was first published on The Conversation.

On August 8, a packed auditorium in Pune rose to applaud Tukaram Mundhe. Some took videos of the bureaucrat walking up to the stage. Others shouted out compliments. The event itself was titled “Unstoppable Tukaram”.

Rarely has any bureaucrat appointed Maharashtra’s food and drug administration commissioner met with such public adulation.

Since Mundhe took over in May, his crackdown on unhygienic practices in the food industry in the state has won him truckloads of admirers – and inspired social media memes.

“He is going viral on social media,” said B Shami, who owns Crown Bakery in Mumbai. “And it has caused panic in our industry.”

Under the bureaucrat’s instructions, food inspectors have scaled up surprise inspections. Not just that, they are handing out immediate suspension notices for serious violations, a departure from previous practices, officials told Scroll. “He is not afraid to go after big influential players,” said Omprakash Sadhwani, a retired joint commissioner of drugs in the food and drug administration.

In the last three months, Domino’s and Pizza Hut outlets have been temporarily shut down after inspectors found cockroaches and expired products in their kitchens. Many of Mumbai’s legacy food businesses, from the K Rustom ice-cream parlour to Parsi Dairy and restaurants like Shalimar and Rehmania had their licences suspended for a few days for a range of violations – fungal growth on walls, presence of rats and cockroaches, food not covered by insect-proof meshes and failure to test drinking water for pathogens.

All four businesses had their licences restored after they met hygiene standards.

The FDA, under Mundhe, has not shied away from turning the scrutiny on dark stores of quick commerce giants like Blinkit, Zepto and Instamart. Several were suspended after lizards, cockroaches and expired products were found on their racks.

The series of crackdowns have made Mundhe a household name, so much so that actor Paresh Rawal took to social media platform X to urge Chief Minister Devendra Fadnavis to ensure that the bureaucrat is not shunted out of his department.

The 2005-batch IAS officer has a reputation for being an honest bureaucrat, unafraid to ruffle feathers. He has been transferred 25 times in over two decades. In some posts, he has spent only a few months.

The Maharashtra FDA’s drive appears to have prodded similar action in neighbouring Karnataka, where inspection of five-star hotel kitchens and high-end restaurants also revealed shocking sanitary standards.

While Mundhe has found a huge fan following, the food industry is unnerved. Several business owners have approached courts asking for relief. Many say that by handing out immediate suspension notices, he is skipping standard procedures.

On August 18, the Bombay High Court said the food and drug administration was going “overboard” and directed it to pay Rs 5 lakh fine to a Pune sweet shop for not reinstating its licence despite a 98% adherence to hygiene.

But former joint commissioner for food in Maharashtra, CB Pawar, told Scroll that the slew of strict measures were “not harsh”.

Pawar added, defending Mundhe’s style of functioning, “The provisions under the Act allow FDA to suspend outlets. If a restaurant is unhygienic and not shut down, who will be responsible if people get food poisoning?”

In the Pune outlet particularly, a complaint of food poisoning had been filed with the FDA and its food samples were found unsafe.

At a press conference on Thursday, Mundhe said, “If there are observations made by the HC, we take it seriously. At the same time we make sure to follow the law. We are not exceeding our jurisdiction, we are following due process.”

From people buying breakfast on the street to those ordering groceries on quick commerce apps, consumers are cheering Mundhe.

In Sion, Vilas Singh, aged 24, first read about Mundhe on Instagram when the bureaucrat began suspending a few famous restaurants. Over the last few weeks, he has begun to see changes in local food stalls.

“I usually have breakfast outside,” Singh said. “Earlier I would get vada pav or idli in a newspaper. Sometimes the newspaper ink would stain the food if it was too hot. Now they wrap it in butter paper.”

‘No hesitation’

Mundhe began his career in 2005 as an assistant collector in Solapur, and was later posted as the collector of the district in 2014. He is remembered for initiating multiple water conservation projects in Solapur to remove the dependence of several villages on water tankers.

In 2016, Mundhe was given charge of the Navi Mumbai Municipal Corporation, where he cracked down on illegal construction and unauthorised hawkers. While his work was appreciated by local residents, several politicians campaigned for his transfer and a no-confidence motion was passed by corporators against him. He was eventually moved out in less than a year without being assigned another posting.

In 2020, the Uddhav Thackeray-led government posted Mundhe as Nagpur commissioner, where he cancelled several major tenders awarded by the previous commissioner. His method of working irked union minister Nitin Gadkari who complained to the Prime Minister’s Office against him.

In an interview to The Hindu, Mundhe maintained that he followed three principles before he took any action – legality, public interest and whether his decision is morally correct. “If any two conditions are met – including legality – I act. There is no hesitation, no gradual approach, no negotiation with what is wrong simply because it is powerful,” he said.

A new regime

The food industry in Maharashtra has been taken aback by the new-found aggression in the food and drug administration’s methods.

A food inspector told Scroll that before Mundhe took over, inspections were less frequent due to staff shortage. “We are working overtime now,” he said.

The official said that Mundhe has instructed them to adhere to “zero-tolerance” for unsanitary conditions.

On June 29, a food inspector conducted a surprise inspection in Pawan Bar and Restaurant in Navi Mumbai.

According to the Indian Hotel and Restaurant Association, earlier food inspectors would “usually notify a restaurant before an inspection”. Now, most inspections are conducted without intimation.

The inspection in Pawan Bar and Restaurant found hygiene-related lapses. The restaurant had a63% compliance with requirements under the Food Safety and Standards Act, 2006. The next day the FDA issued a suspension notice to the restaurant.

Two weeks later, in a re-inspection the restaurant had 100% compliance with all requirements. Even then, the FDA did not revoke its suspension.

The restaurant finally approached the Bombay High Court, which revoked the suspension. The hotel’s kitchen remained shut for over 25 days. The lawyer representing the restaurant owner, Sagar Shetty, told Scroll that their main grievance was that the officials did not issue an improvement notice. Instead, they chose to immediately suspend the license.

Under the Food Safety and Standards Act, 2006, a food inspector can inspect a food outlet and issue an ‘improvement notice’. The notice points out violations and gives a period of two weeks to comply. In cases where a food operator fails to comply, the inspector can suspend their license after a showcause notice.

The Act also gives the FDA power to immediately suspend a licence “in the interest of public health”.

It is this provision that Mundhe’s team has opted for in several cases.

Across Maharashtra, the licences of at least 10 hotels have been suspended in the last three months immediately after inspection, said Vijay Shetty, president of Indian Hotel and Restaurant Association, or AHAR.

Ashwini Ranjane, assistant commissioner for food, said it was well within the rights of the food inspector to suspend licences. “A food inspector can immediately make out if a place is unsanitary by just looking at a restaurant’s kitchen,” she said.

Ranjane added that the FDA gives improvement notices in 70% to 80% cases of minor violations – if record keeping is poor, if employees’ medical records are not maintained, or if minor hygiene lapses are seen.

“Immediate suspension is issued when during our visits, we see dirt everywhere,” she said. “If there are major issues and multiple violations that the operator needs to work on and that is not possible to achieve in a few days, we have to suspend them.”

In July, food inspectors found expired flavouring agents and essence, rats and houseflies in K Rustom’s ice-cream parlour. In the century-old Parsi Dairy, fungus was found on the walls and raw materials found lying on the floor. Despite the presence of rats and flies, the food was left uncovered.

The licences of both outlets were suspended temporarily. Parsi Dairy was able to reopen after about 10 days after a re-inspection was undertaken. K Rustom decided to renovate its over 70-year-old store. An FDA officer said their licence has also been reinstated.

“If the food can directly harm the health of customers, then we can suspend the licence immediately,” a retired joint commissioner of food from Maharashtra told Scroll.

Several bakery owners protested against a blanket suspension of licence following “minor violations” during inspections. In July, the FDA issued stop-business notices to four bakeries after finding “hygiene related lapses”, expired raw materials and unsanitary cooking conditions. In videos that FDA shared, the New Maharashtra bakery in Chembur had fungus on baking trays and its walls.

An owner of a well-known brand of bread in Mumbai told Scroll that several small players use artificial flavours in khari, or do not label their loaves with an expiry date or display the nutritional content. “We welcome action in such cases,” he said, requesting anonymity.

“But the problem is pests,” he said. “It is difficult to totally prevent it.”

B Shami, who owns Crown Bakery, agreed. “Mumbai city’s hygiene levels are questionable,” he said. “We have open drains that allow rats everywhere. No baker wants to have a filthy kitchen.”

Responding to the allegation that FDA has gone overboard, Mundhe said that when FDA suspends any licence, “it is after multiple violations”.

He added, “In some cases, improvement notices and enough time was given. If these outlets have grievance they can appeal to me.”

Dark stores

Maharashtra has amongst the highest number of so-called dark stores run by quick commerce services, with Mumbai and Pune leading the list. For a city starved for time, the delivery services have become a lifeline for many users.

But Mundhe’s drive has made consumers think twice.

On August 14, the FDA released details of a month-long inspection of 86 dark stores. According to Ranjane, assistant food commissioner, they found minor to major violations in almost all stores.

The FDA issued improvement notices to 60 stores and suspended 14 others, including five operated by Blinkit, five by Zepto and two by Swiggy Instamart.

In the video shared by FDA, cockroaches could be seen moving amongst packaged items in a Bandra West store of Instamart. The same store had rodent droppings and lizard infestation. In another video, chocolate was infested by worms, and stale lettuce was stored in a Blinkit store in Ghatkopar. Both these outlets’ licences were suspended.

“On our visits, we found racks full of cockroaches,” Ranjane said, pointing out that faulty cold storage and hygiene lapses in dark stores were rampant.

‘Good practices’

Food business owners, too, admit that Mundhe has forced the industry to shape up.

“Hygiene is important, and he is bringing in good practices,” Shami added.

An employee from a Chembur-based self-help group, which sells chapatis and vegetarian dishes, said small outlets like theirs have switched from wrapping chapatis in newspapers to food-grade butter paper after the FDA began to inspect the area. “That has slightly increased our cost, but food operators are willing to comply,” the employee said. “Otherwise we will have to shut too.”

Ordinary customers are even more grateful. Ganesh Sonawale, who drives an autorickshaw, eats his lunch outside every day. “Roadside dhabas have become cleaner,” he said. “Food is now wrapped in brown paper. These two changes I am seeing everywhere.”

Sonawale said he hoped the drives would not stop in a few months. “It feels nice to eat food in a clean place now,” he added.

In January, Rushikesh Dhore visited a doctor in Maharashtra’s Akola district with a range of problems – insomnia, irritability, twitching and pain in his leg muscles.

But most striking for the 25-year-old was a feeling of “tremors” running through his legs.

The doctor was perplexed and advised Dhore, a resident of Goregaon village in Murtijapur, to visit a neurologist in Akola city, 50 km away.

Neurologist Dr Nitin Virwani immediately knew what the problem was. He had treated similar patients a few weeks before Dhore showed up.

As he had suspected, Dhore had recently started using a skin brightening cream he bought from a store in his village. “Within days of using the cream, I couldn’t sleep at night. Because I was awake all night, I became irritable. Then a burning sensation began in my legs,” he said.

Like him, a 30-year-old woman in Akola had started using a fairness cream on a friend’s recommendation in April. In the initial days, she felt her skin “considerably brighten and blemishes lighten”. “I even told a few other friends to use it. It is easily available in grocery stores,” she said, requesting anonymity.

In a few weeks, however, her face became dry and itchy. Then, a constant tingling sensation began in her feet.

When Virwani asked for a few blood tests, it turned out that her mercury serum level was 10 times the normal range.

Her blood also tested positive for CASPR 2 antibodies. Both tests are a sign that the body has been exposed to heavy metals, which leads to involuntary muscle twitching and leg pain, a symptom Virwani saw in both patients.

‘Over a 100 cases’

In Akola, Virwani has treated 40 such patients in the last year.

He is not the only doctor to do so. Indeed, neurologists across Maharashtra have been sharing stories of mercury poisoning in young people over the last year on a common WhatsApp group.

“In most cases, it is mercury poisoning caused by skin brightening creams,” said Dr Bhushan Joshi, a neurologist in Pune’s Manipal hospital. In some cases, he added, patients suffered nephrotoxicity, or kidney damage.

“I am a part of a group of neurologists from the state. Together, we have seen over 100 cases in the last few months,” he said.

The doctors also privately tested some samples of the creams and found high mercury levels in them.

In most cases, the fairness creams had no details about ingredients, manufacturer or the batch of production. The Maharashtra government has now begun a crackdown on stores and distributors stocking the creams, but there is very little information about how they were being sold in the first place.

Unlike drugs, selling cosmetic products needs no licence, although manufacturers need a licence to make them. This has posed the biggest challenge in this case, an official of the food and drug administration department told Scroll. “We can’t track the retailers, or the several rural grocery shops that stock these products and there are no licensed distributors. We are unable to pin down the distribution chain,” a Mumbai-based drug inspector said.

The cream that both Dhore and the 30-year-old used was purportedly made by Goree Cosmetics, a Pakistani brand. “But the packaging had no label or batch details which is why we suspect it could also be counterfeit,” said Ganesh Rokade, Maharashtra FDA’s joint commissioner for drugs.

Six first information reports have been filed under various provisions of the Drugs and Cosmetics Act, 1940, in Parbhani, Sambhajinagar, Nanded, Mumbai and Nashik against owners of grocery stores and cosmetic stores for selling such products and against unknown persons for manufacturing and distribution.

The primary charge is under Section 27 of the act, which provides three years of imprisonment for manufacture or sale of adulterated or unsafe cosmetics.

The Maharashtra FDA has issued an alert for three Pakistani brands – a cream, whitening body lotion and whitening soap manufactured by Goree Cosmetics, a beauty cream made by Golden Star Cosmetics, and a cream called Face Fresh Gold Plus made by Shaheen Cosmetics.

Scroll has emailed the three Pakistani manufacturers, asking for a response to the revelations. The story will be updated if they respond.

According to Viraj Paunikar, joint commissioner of drugs in Sambhajinagar, the products of Goree Cosmetics were tested and found to have high levels of mercury.

In one raid in Sambhajinagar, “the mercury level was found to be 18 to 40 times higher than the permissible level in the seized products”, said Rokade.

“We have requested the Maharashtra DGP to initiate an inquiry under the anti-terrorism squad,” said Rokade. “Some product labels mention ‘made in Pakistan’. We want to see if these not-of-standard-quality products are being forced into India or if they are domestically manufactured and distributed as part of some nexus.”

However, neurologists Scroll spoke to said they also came across domestic brands that had high levels of mercury. Drug officials told Scroll that the department has written to officials in Karnataka to investigate one manufacturer of cosmetics based on complaints about their skin brightening cream.

Surge in patients

Neurologist Dr Rahul Baviskar saw the first trickle of cases in his Nashik clinic about six months ago.

“Young patients between 20 and 40 years of age came in with similar symptoms – a burning sensation in their feet, pain in legs and thighs, and a rippling movement as if worms were crawling under their skin,” he said. Some patients complained of insomnia for a month.

“We could not correlate this with mercury initially,” he said. The breakthrough came when a patient told him that he observed these symptoms after he began to use a new skin brightening cream.

Mercury blocks the production of an enzyme called tyrosinase, which produces melanin that gives skin its dark colour. The metal is often illegally added to skin brightening cream for that reason. It is low-cost and gives rapid results compared to other skin brightening agents like niacinamide or kojic acid.

Under Drugs and Cosmetics Act, 1940, mercury is only permitted up to 1ppm in all cosmetics except for eye shadows where higher levels are permitted.

However, mercury can confuse the immune system and lead to higher production of antibodies. Baviskar said 17 patients he treated had signs that the presence of mercury had confused the immune system, and made it generate more anti-CASPR2 antibodies. This is called a CASPR2 antibody response in which healthy nerve cells are attacked causing twitching in muscles, memory loss and seizures.

“In other districts, my colleagues had sent samples of locally manufactured face cream for testing and found it had high levels of mercury,” Baviskar said.

In Sambhajinagar, neurologist Dr Anand Soni saw many patients with CASPR2 antibody response. Three of his patients developed kidney problems. In all cases, doctors said patients recovered after being administered steroids. “Since the exposure was short term, once the cream is stopped, the symptoms eventually reduce,” said Soni.

Satish Sinha, associate director at Toxic Link, a non profit that works on toxicity and waste related issues, said their organisation has been flagging the issue of high levels of mercury in beauty creams for several years. “In our two previous reports, we found high mercury content in cosmetics. The regulation needs to be stronger. In our tests, several products imported from Pakistan and Thailand had mercury beyond permissible limits,” Sinha said.

The supply chain

Since March, the Maharashtra food and drug administration has raided stores selling the creams and seized stock worth over Rs 70 lakh.

On March 29, police in Sambhajinagar and officials of the food and drug administration department raided three stores and seized products of Goree Cosmetics. “The owners of the store could only tell us that they purchased the cream from Crawford market in Mumbai. They had no bills or purchase order,” Paunikar said.

The problem in all the cases, Paunikar said, is in establishing the supply chain. “The shopkeepers have not been able to lead us to those who supply the products or the distributor,” he said. “We have asked the police to investigate further. We don’t know if an import license has been approved for this product.”

Paunikar said since cosmetics can be sold without a licence, it makes it easy for counterfeit products or illegal products to enter the market. Manufacturers of cosmetics are monitored through regular inspections. “But if there are illegal manufacturers, finding them is not easy,” Paunikar pointed.

Companies selling packaged food products in India often claim that they are healthy, natural, pure, sugar-free – but are they actually so?

In 2024, a committee of the Food Safety and Standards Authority of India reviewed more than 160 food products that had been flagged for making misleading claims. Two years later, our investigation found a majority of those claims were still in circulation.

In this episode of True Story, Scroll’s Executive Editor Supriya Sharma speaks to Shreegireesh Jalihal who spent months investigating how the Indian government’s efforts to regulate the industry are falling short.

Also read: India’s food regulator flagged over 160 misleading claims. Years later, 120 are still around

How India’s ambitious plan to curb unhealthy food failed

It is easy to assume that harder training always produces better results. In resistance training, which includes lifting weights or using resistance machines, taking every set to the point where you cannot complete another repetition may create more fatigue without producing better results.

A repetition, or rep, is one complete movement of an exercise. A set is a group of repetitions performed without a long rest.

Training to failure means continuing a set until you cannot complete another full repetition with acceptable technique, despite making your best effort. This is sometimes called momentary muscular failure.

An alternative is to stop while you could still perform one or more repetitions. This is described as repetitions in reserve, or RIR. If you could complete 10 repetitions but stop after eight, you have two repetitions in reserve, usually written as 2 RIR.

Why might training close to failure help?

Muscles are made up of individual cells called muscle fibres. These fibres are broadly classified as type 1 or type 2 fibres and are controlled by the nervous system. The type 2 fibres produce more force and can grow more than type 1 fibres.

A light load is generally one that you could lift for more than 15 repetitions, whereas a heavy load limits you to completing fewer than 10 repetitions. When lifting a light load, the type 1 fibres are active. As the set approaches failure, the nervous system activates type 2 fibres to keep the weight moving.

Lifting a heavy weight activates type 2 muscle fibres from the beginning of the set. With a light weight, type 2 fibres only become activated as the type 1 fibres fatigue later in the set. Light-weight sets therefore need to be completed reasonably close to failure if the aim is muscle growth.

The final possible repetition does not appear to provide a special muscle-building effect. Research suggests that a hard set ending shortly before failure can stimulate muscle growth while causing less fatigue.

What are the drawbacks?

Taking a set to failure produces more immediate fatigue than stopping earlier. A systematic review and meta-analysis, which combines the findings of several studies, found that failure training caused larger reductions in strength, movement speed and power immediately after exercise. It also produced greater feelings of effort and more signs of temporary muscle disruption.

This fatigue can affect the rest of the workout. If the first set of an exercise is taken to failure, the lifter may complete fewer repetitions with good technique on remaining sets. Research comparing failure and non-failure training has also found that recovery can take longer after sets performed to failure.

The effects of training to failure depend partly on the weight and the exercise. Sets using light weights involve more repetitions, last longer and usually cause more breathlessness and the feeling of muscle burn. That discomfort may make the workout less enjoyable or harder to maintain.

Exercise choice also affects safety. A machine leg extension or biceps curl is relatively easy to stop when the muscles fatigue. A technical exercise like a squat or bench press requires more balance, coordination and control. As fatigue increases, technique may deteriorate and the lifter may be unable to finish the repetition safely. Failure training during these exercises is best avoided unless suitable safety equipment or a competent spotter is available.

What does the research show?

A 2022 systematic review and meta-analysis found no significant overall difference between failure and non-failure training for strength or muscle growth. The authors noted that the studies used different programmes and did not always match training volume, meaning the total amount of load lifted during a training session was different.

A later review examined 15 studies of muscle growth. It found no evidence that reaching failure produced more growth than stopping earlier. The researchers concluded that training closer to failure may increase the muscle growth stimulus up to a point, but every additional repetition does not necessarily provide the same extra benefit.

A 2024 analysis found that failure was not necessary for improving strength as it improved across a wide range of stopping points. Muscle growth tended to improve as sets ended closer to failure, although the researchers could not identify an exact number of repetitions in reserve that was optimal.

The American College of Sports Medicine’s 2026 review of resistance-training evidence reached a similar practical conclusion. Regular training with sufficient effort is more important for healthy adults than following a complicated programme or taking every set to failure.

How close to failure should you train?

For many gym users, finishing most sets with about one to three repetitions in reserve is a useful starting point rather than a fixed rule. The final repetitions should feel difficult and the weight should be moving more slowly than it was at the start of the set.

Training closer to failure may be more useful when using light weights, completing only a very short training session, or performing the final set of a technically simple exercise. Occasionally taking a suitable exercise to failure can also help you learn how many repetitions you genuinely have left.

Judging repetitions in reserve takes practice. Research has found that people often underestimate how many repetitions they could still perform, particularly when using lighter weights.

Beginners have little reason to take every set to failure. They can make progress while learning exercises and gradually increasing the weight or number of repetitions. Experienced lifters may use failure selectively when it suits their programme and recovery.

You do not need to take every set to failure to become stronger or build muscle. Sets still need to be challenging, especially when lighter weights are used. Stopping shortly before failure can preserve technique and reduce fatigue while providing an effective training stimulus. For most people, keeping roughly one to three repetitions in reserve offers a sensible balance between effort and recovery.

Paul Hough is Lecturer Sport and Exercise Physiology, University of Westminster.

This article was first published on The Conversation.

Many of us have grown up with the mantra that breakfast is the most important meal of the day.

But whether it’s snatching an extra half hour of sleep, or focusing on getting the kids out of the house, there are various reasons why assembling a healthy breakfast might slip down your list of priorities – especially on a weekday.

So, is it worse to eat unhealthy foods first thing, compared to later in the day? And what about skipping breakfast altogether?

It’s not just about calories

You probably know eating foods high in sugar, salt and saturated fats – especially when they’re highly processed – puts you at greater risk of a range of serious health conditions. These include diabetes, heart disease and some cancers.

Poor diet can also affect our gut health, mental health and reproductive health.

Eating a diet high in vegetables and fruit, lean meat and alternatives, such as chicken and lentils, wholegrains, and reduced-fat dairy and alternatives (such as plant-based yoghurt) will improve your overall health and wellbeing, and reduce the risk of serious health conditions.

For breakfast, aim to include a source of good-quality protein, wholegrains, fruit and/or vegetables and healthy fats.

This could look like: toasted wholegrain bread with avocado, a poached egg and sliced tomato. Or it might be wholegrain porridge oats, with yoghurt, seasonal fruit and some almonds.

What about when you eat unhealthy food?

Let’s look at an example. A big brekkie burger (think: bacon, hash brown, beef patty, cheese, bun, and BBQ sauce) contributes about 36% of an average adult’s daily recommended energy intake (8,700 kilojules).

You may be surprised to learn there’s more sugar in the burger (11.5 grams) than some sweet breakfast cereals (10g a serve) – largely thanks to the refined carbohydrate in the bun, and sugars in the sauce.

Eating the brekkie burger will make your blood sugar levels spike.

If you’re generally in good health, your body will respond by producing the hormone insulin. This moves the sugar out of the blood and into muscles, fat, and liver cells for energy production. Blood sugar will then return to a normal level.

But if your body is regularly exposed to high blood sugar levels, you can develop insulin resistance. This means your body pumps a lot of insulin to get the blood sugar into your cells, but the cells stop responding, and your blood sugar levels remain high.

This can lead to worse health, including type 2 diabetes.

Does when you eat matter?

The short answer is: yes.

Your body has a 24-hour circadian rhythm that regulates when you feel alert or tired (your sleep-wake cycle). Disruptions such as jet lag or shift work can affect this cycle and, if sustained long-term, can affect your health.

Eating late at night can disrupt the sleep-wake cycle, by signalling to your body it’s time to digest not sleep. This triggers insulin spikes, and delays the release of melatonin, the “sleep hormone”.

This is why it’s recommended to eat in time with your body’s natural sleep-wake cycle: eating most of your food early in the day – when your body can process it most efficiently – and reducing how much you eat across the day.

So it may be better to eat more of your calories early at breakfast. But it’s important to get this energy from high-quality protein – such as eggs, beans, nuts or fish – and wholegrains, such as high-fibre bread.

Refined sugars, salt and saturated fat are high in calories but low in nutrition.

But protein is digested slowly, and will help you feel full for longer and stop you craving unhealthy snacks later in the day.

When lunch rolls around, you may be less tempted to eat a large meal. While a big lunch won’t disrupt your sleep-wake cycle, it can still make you feel sluggish while you wait for your body to digest it.

What about skipping breakfast?

Some intermittent fasting regimes – which involve scheduled periods of eating and fasting – involve skipping breakfast altogether or limiting the time you eat to a small window. For example, some people may not eat their first meal until after 11am.

Advocates say these diets have a range of health benefits, including weight loss, blood sugar control, heart and brain health, and cellular repair. However, the evidence for these remains mixed.

It’s also important to consult with your health-care professional, as it’s not recommended for some people, including pregnant women, children or those on certain medications.

The takeaway

You need high-quality nourishment for your body to work properly and feel good.

In the morning, your body can process food more efficiently than later in the day. But if breakfast is high in refined carbohydrates, sugars and fat, you’re more likely to experience a blood sugar spike and feel hungry sooner. And it’s not recommended to skip breakfast.

If time is an issue, consider portable foods that are nutritious, and high in good-quality fibre and protein, such as yoghurt, a banana and a jar of muesli you can mix together at the office.

Katherine Livingstone is Associate Professor, Institute for Physical Activity and Nutrition, Deakin University.

This article was first published on The Conversation.

We went undercover to investigate the booming market for Mounjaro, an injectable that apart from type-II diabetes, can also be prescribed by specialist doctors for severe and complicated obesity. Effective for weight loss, it is not meant for everyone and should not be used without medical advice.

But, as we found, the prescription-only drug is available on tap. From chemist shops and online sellers agreeing to sell Mounjaro without a prescription to unauthorised doctors prescribing the drug as part of beauty treatments in aesthetic salons, many are profiting from India’s obsession with weight-loss – at a steep cost to the health of users.

Watch our investigation.

The new film by Amit Rai, the director of Road to Sangam and Oh My God 2, looks for the divine in the canine. Ohh My Dog is about the bond between humans and their four-legged friends who give more than they ever get in return.

The Hindi film, which is out in cinemas, follows two stories. In a small town in Assam, young Apu’s pet Momo goes missing. Police officer Mohammed (Vijay Mishra) starts investigating, but he’s several steps behind the sharp-brained, tech-savvy Apu (Maahi Rai).

Not for nothing is Apu named after the hero of Pather Panchali. A large poster of Satyajit Ray in Apu’s home suggests that Apu is a younger version of Ray’s fictional detective Feluda. Apu and his tuition teacher Krishna (Sulakhyana Baruah) accompany Mohammed on the quest for Momo, with Apu leading the way.

In a city in Bihar, it’s a person who’s missing. Construction worker Prince (Nikhil Kumar) has vanished, which upsets his adopted Indie Oscar tremendously. Oscar puts his nose to work, turning up results that shame the local police inspector (Rajesh Kumar).

A grisly fate awaits both man and beast. The abductors aren’t fairy tale ogres who will easily be defeated. In keeping with the gravity of the situation, Amit Rai turns a potentially light-hearted tale that would delight children and dog-adoring adults into a deadly serious crime drama.

Keen on proving Apu’s genius and Oscar’s sleuthing kills, the 150-minute Ohh My Dog spells out every move that proves how a kid can make instant sense of a complex kidnapping operation and how a dog can sniff out the truth about its owner entirely by itself.

This refusal to trust viewers leads to overly long scenes, repetition and a fuel-guzzling chase. The movie lasts far longer than the average attention span of children and dogs.

The realistic treatment is at odds with some of the more fantastic moments, especially the sequence lifted from Hungarian director Kornel Mundruczo’s White God, in which hundreds of dogs ignore their territorial instincts to confront their tormentors. (There’s another Hungarian connection in cinematographer Mate Herbai).

Like Mundruczo’s acclaimed film, Ohh My Dog is a parable about the need for goodness in a ruthless world that preys on the weak and the defenceless. Although Amit Rai undermines his screenplay’s impact through stubborn bloat, he displays empathy towards his characters, especially the poverty-stricken Prince, as well as a strong sense of justice.

There are powerful moments in store for patient viewers. Rai invokes religion to bless the efforts of Apu and Oscar. But it’s a handful of humans and one determined dog that make all the difference.

The anguish that Apu and his mother (Geeta Aggarwal Sharma) feel over Momo is as heart-tugging as Oscar’s desperate hunt for Prince. While various nasty authority figures obstruct Apu and Oscar, Apu is taken seriously because he’s better off than Prince’s family and friends on the construction site. Their only champion is the teacher played by Pankaj Tripathi.

Two performances stand out, and neither of them is by the adults, except for Tripathi.

Maahi Rai is a compelling knee-high hero, displaying a confidence that borders on contempt when the adults around him behave stupidly. Oscar, played by Bruno, is terrific, like an unending treat.

Bruno runs and runs, gives the correct expression in emotional scenes, and displays the intelligence associated with his species. Bruno puts the dog in doggedness and qualifies for the canine equivalent of an Oscar for bringing the loyal Oscar to life.

Saloni Khera, a social media manager in Mumbai, gained 30 kg in just six months after the Covid-19 pandemic.

A combination of factors were at work. She had long Covid, a condition in which the virus leaves behind a trail of health problems. She was pre-diabetic and also had a hormonal disorder.

She weighed 153.5 kg.

Her attempts at losing weight through multiple diet regimens – even drinking only water for a week – had failed. “If I lost 15 kg, I gained 25 kg back,” she said.

People with chronic obesity, a lifelong disorder like diabetes or hypertension, can gain weight rapidly, putting pressure on their heart. This can have a cascading effect on their health.

Last year, Khera consulted a gynaecologist in Ahmedabad as she and her husband began to think about having a child. “I wanted to be fit to be able to do it,” the 35-year-old told Scroll.

The gynaecologist referred her to an endocrinologist who advised her to reduce weight first. He suggested she try the weight-loss drug – Mounjaro – an injectable that can help reduce over 20% body weight.

Mounjaro is a brand name for a new medicine called Tirzepatide, which mimics two natural hormones present in the gut – glucagon-like peptide-1, or GLP-1, and glucose-dependent insulinotropic polypeptide, or GIP. The hormones signal to the brain that the stomach is full, release insulin and slow down digestion.

As the drug increases these satiety hormones in the body, a person feels full and eats less.

But, as effective as they are, they are not meant for every one and cannot be used without medical advice. According to the Union health ministry, only cardiologists, endocrinologists and internal medicine specialists are authorised to prescribe GLP-1 drugs and monitor patients.

Khera did exactly that. She lost 35 kg in 11 months.

Even then, the treatment was difficult. In the initial months, she suffered multiple side effects, including diarrhoea, constipation and headaches. “But for the first time I realised that this is actually working for me,” she said about the drug.

She began to read up on high-fibre and high-protein diets as shedding kilos was leading to muscle loss. Last August, she decided to help others and began a support group for GLP-1 users on Instagram. It received an overwhelming response. The community has over 140 members now.

She soon realised that many had embarked on a lonely journey of weight loss using these drugs. But, more worryingly, many had begun taking the drugs without medical advice.

Some had visited a salon and purchased a treatment package of these drugs, some were students trying to reduce weight on their own without informing their parents. A woman in her group confessed that she paid Rs 1.5 lakh at a beauty salon in Ludhiana for weight loss before realising that the clinic was not medically assessing her.

“I advise everyone to do this only under medical supervision,” Khera said. “I only add a person to the community when I know they are doing this under medical supervision.”

Scroll’s investigation into the market for weight-loss drugs bears out Khera’s concerns.

We uncovered a range of irregularities – from unauthorised doctors prescribing the drugs as part of beauty treatment in salons to online medicine sellers and chemists agreeing to sell the medicines without a prescription. Some salons bundled it under a bridal package as a quick fix for to-be brides who wish to lose weight.

‘Everyone wants a share’

About 30% women and 27% men in India are overweight, data from the latest National Family Health Survey shows.

Not surprisingly, the market for GLP-1 drugs in India is booming. According to Pharmarack Technology, the sales of these injectable drugs in India rose from Rs 525 crore in May 2025 to Rs 1,906 crore this May.

The most popular injection, Mounjaro, manufactured by US headquartered Eli Lilly, became India’s top selling drug in 2025. This year, multiple Indian brands have flooded the market with such drugs and brought down the prices.

The glut in demand has led to the drugs being used without safeguards laid down by the medical establishment.

“Everybody wants to get into this. The market is huge,” said Dr Saumil Shah, a Mumbai-based plastic surgeon. Last year, Shah partnered with an endocrinologist and dietician to cater to GLP-1 patients. “However, it is being treated as a beauty product, rather than a health product,” he cautioned.

At beauty salons, rules flouted

In Mumbai’s eastern suburbs, a salon calling itself “India’s first hybrid clinic-salon” offers services ranging from dermatology to beauty – and even slimming packages.

When we walked into the clinic in May and asked about their weight-loss programmes, a receptionist led us to a young dermatologist.

The dermatologist asked this reporter about her weight and height. Over the next 30 minutes, she proceeded to talk about the benefits of Mounjaro. “It is safe. If you have a side effect, it means the drug is actually working," the dermatologist told us.

She advised a three-month course of injections at the cost of Rs 99,000, which would be administered at the salon. For a medical prescription, a Hyderabad-based endocrinologist would write one after a “quick” online call, she assured us.

There were several red flags in the above scenario.

First, according to the Union health ministry, only cardiologists, endocrinologists and internal medicine specialists are authorised to prescribe GLP-1 drugs after a clinical assessment. In the clinic, the dermatologist was handling the entire treatment and an endocrinologist had been onboarded only to write the prescription.

Second, the treatment has been bundled into a beauty package with injections being given only at the clinic along with other supplements.

According to the Central Drugs Standard Control Organisation, those with a body mass index of over 30 with no comorbidity, or those with body mass index of 27 to 30 with other co-morbidities like diabetes or hypertension, are considered for treatment of tirzepatide or semaglutide drugs.

Dr Dheeraj Kapoor, head of endocrinology department in Kokilaben Dhirubhai Ambani hospital, said, “When we prescribe this medication, we do a comprehensive assessment. We check whether the person has a history of gall stones or thyroid through an ultrasound.”

In case a patient has either of those conditions, a doctor can choose not to prescribe GLP-1 drugs. Kapoor said they check “whether the patient has adiposity-based chronic disease” – or obesity that harms other organs – before proceeding to recommend the drug.

Endocrinologist Joshi, from Lilavati hospital, added: “A history of stomach disorder is also checked because it can aggravate nausea and vomiting.” A family history of cancer or thyroid must also be checked before, he added.

The dermatologist in the Mumbai beauty clinic only recommended a blood test and did not ask for such detailed assessments. The clinic also practiced a “standard” dose regime for all patients – 2.5 mg of Mounjaro in the first month, 5 mg dose in the second month and 7.5 mg in the third month for every person.

But endocrinologist Joshi said that GLP-1 drugs cannot be standardised for every patient and a dose is only increased if the person needs it. The sudden rise in dosage without clinical requirement can cause pancreatitis or gastrointestinal distress or hypoglycemia.

Dr Kapoor agreed: “It is not a case of one size fits all.”

In Delhi, at the branch of a leading beauty and wellness clinic chain, popular in the market for its “slimming packages”, these precautions were not followed.

The clinic put us through a test that analysed body composition, fat and muscle percentages, along with a BMI. A young employee broke down the results and advised a three-month plan of Mounjaro as well as therapies to balance muscle loss.

When it came to medical advice, they said we would have to consult with an in-house physician – a general medicine doctor with an MBBS degree and not an endocrinologist or cardiologist – for a prescription.

Both the Delhi and Mumbai clinics were also overcharging their customers.

In Delhi, a three-month package of Mounjaro was Rs 92,000. In Mumbai, the package cost was Rs 99,000 for three months. This is three times the cost of the drugs.

’Not everybody is suited for this’

When GLP-1 drugs are taken without proper medical monitoring, patients run the risk of serious side-effects. The Union health ministry has warned that GLP-1 drugs can cause, “common symptoms like nausea and vomiting to severe complications including pancreatitis, kidney injury, and bowel obstruction”.

In April, Dr Kapoor at Kokilaben hospital attended to a 32-year-old woman with complaints of pancreatitis. She had undergone a liposuction procedure and also wanted body contouring. An aesthetic clinic she consulted in the western suburbs of Mumbai put her on Mounjaro.

In the first month, she took four injections of 2.5 mg each. By next month, her dosage was increased to 5 mg and then 7.5 mg, a standard practice across aesthetic clinics.

She began to experience severe abdomen pain and nausea. One of the rare side-effects of Mounjaro is swelling in the pancreas, the organ that produces insulin and digestive enzymes. She eventually required hospitalisation due to pancreatitis.

The woman’s BMI was 27. She had no other co-morbidity. Kapoor said she was not even eligible for Mounjaro.

Kapoor said he has been getting patients with intestinal obstruction, pancreatitis or gall bladder diseases after taking GLP-1 drugs. “All these are serious side effects of the medicines,” he said.
Dr Jalil Parkar, a pulmonologist in Mumbai’s Lilavati hospital, treated a man in April with severe effects of GLP-1 drugs. The 46-year-old businessman in Bandra weighed 150 kg and was in fact eligible to take the GLP-1 drug for weight loss management.

After four injections of 2.5 mg in the first month, his doctor increased the dosage to 5 mg. “I lost 10 kgs in 45 days,” he told Scroll. “But then I started getting acid attacks, coughing fits, vomiting, muscle pain and constipation,” he added.

Eventually, he required hospitalisation. “I told him to stop taking these drugs. Not everybody is suited for it,” Parkar said.

The 46-year-old told Scroll that he has decided to stop these injections.

No prescription, no worry

The popularity and high demand have led to chemist shops and online portals compromise on mandatory requirements to sell such medication.

Scroll contacted 11 online suppliers across India for 2.5 mg Mounjaro injections. Seven agreed to sell the product without a prescription and provide free home delivery. GLP-1 drugs are a schedule H drug, which means it requires a prescription to be sold and cannot be provided over the counter.

Of the seven, only one supplier warned that “it is better if you consult a doctor because there are contra indications of this drug”. But even that supplier was willing to supply the drug without prescription.

We also tried to buy Mounjaro without a prescription on three e-pharmacy portals – PharmEasy, Truemeds, and Tata1Mg. All offered to provide a free doctor consultation for a valid prescription to make the purchase.

We said we had a body mass index of 27 with no comorbidities and no family history of illness when the doctors from the respective portals called. None asked us to submit a blood test report. According to CDSCO, a person with a body mass index of 27 with no comorbidity is not an eligible candidate for the treatment.

Truemeds and Tata1Mg refused to provide a prescription, saying that the BMI did not fit the eligibility criteria and advised us to instead start exercising to reduce our weight.

But PharmEasy not only provided the prescription, it also sent a delivery boy with a 2.5 mg Mounjaro pen at our doorstep within hours.

On the call with PharmEasy, the doctor asked our age, height, weight, any medical issues, family history of illness, and advised us on how to use the injection. The doctor did not ask for a thyroid or a blood test to check our markers.

When we emailed PharmEasy asking about the lax standards on its portals, it stated, “PharmEasy has partnered with tele-consultation platforms who implement stringent processes which are compliant with applicable laws (including advisories issued by the regulatory authorities) for prescription and dispensation of GLP-1 medicines.”

The e-pharma portal added that the decision to prescribe the medicine rested with the doctor. “It is clarified that neither PharmEasy nor its tele-consultation partners have the right or capability to influence or interfere with the RMP’s [registered medical practitioner] independent clinical judgment during the course of tele-consultation through the PharmEasy platform and the duty to prescribe medication pursuant to tele-consult is the sole and complete responsibility of the RMP,” the portal said.

At brick-and-mortar chemist shops, too, the safeguards were absent.

In Mumbai, we visited 10 chemist shops and seven were willing to sell the injection without a prescription. One said that the drug was showing “fast results with no side effects”. Another said the drug was in “great demand”.

Ganesh Rokade, joint commissioner of drugs in Maharashtra Food and Drug Administration, said they are aware of the sudden rise in sales of GLP-1 drugs and were worried about sales without valid prescriptions. “Last year, we raided several places to curb illegal sales,” he said.

In April, the Union health ministry in its release said that it had inspected 49 businesses across the country, including online pharmacy warehouses, drug wholesalers, retailers, and weight loss clinics to audit GLP-1 use. These inspections looked at violations related to unauthorised sale, improper prescriptions, and misleading marketing. “Notices have been issued to those found breaking the rules,” the ministry said.

A spokesperson for the ministry, however, declined to provide details of the number of notices issued or the action taken in each violation. “We know the scale of the problem is huge,” they said.

Recent reports have highlighted AI-generated “doctors” spreading dubious health advice to millions of social media users. Fabricated wellness trends can travel just as quickly. A supposed “pink jelly” weight-loss treatment, for example, reportedly fooled at least one celebrity.

These examples gain credibility in different ways. Influencers can appear familiar and sincere, while AI-generated doctors can look like qualified professionals. Neither familiarity nor the appearance of expertise tells us whether a medical claim is accurate.

Turning to friends and family for health advice is understandable. They may know our circumstances in ways that a healthcare professional cannot during a brief appointment. They can provide emotional support and practical help, and their advice is usually well meant. But somebody can care about us, speak honestly and still be wrong.

Truth and trust

My own research and wider research on digital health misinformation shows that trust can play an important part in deciding which claims people accept. Trust in clinicians and scientific institutions is generally associated with lower susceptibility to false health claims. Misinformation can nevertheless spread through trusted social networks when people share it because they want to help or warn others.

Social media influencers can reproduce some of the signals of friendship without having a personal relationship with their followers. They address followers directly, share details about their lives and communicate in an informal style. Over time, followers may develop what researchers call a parasocial relationship: a one-sided sense of familiarity with a media figure. A recent meta-analysis found that parasocial relationships can influence health attitudes and behaviour, although their effects vary across different contexts.

AI-generated doctors use a different route to credibility. Accounts designed to resemble real clinicians can borrow the appearance and language of medical authority without providing any reliable way to check who created the content, what qualifications lie behind it or whether the advice is supported by evidence.

Personal stories are especially persuasive. Someone describes being ill, discovering a treatment and recovering. The account is easy to follow and often more memorable than a discussion of probabilities.

Even a completely truthful anecdote cannot show that a treatment caused the recovery or that it will be safe and effective for other people. Symptoms may have improved naturally. The person may have used several treatments at once, received an uncertain diagnosis or left out relevant details. Experiments have found that anecdotes can influence medical decisions even when people are also given stronger statistical evidence.

Fear, hope and accuracy

Emotion can add to the effect. Fear or hope may draw attention to a claim and make it feel urgent. Emotional tone does not show whether the information is accurate. Research suggests, however, that heightened emotional responses can increase susceptibility to digital health misinformation.

Identity can also shape judgment. Advice from another parent or fellow patient may appear more credible because the speaker seems to understand our experience. Rejecting the advice may then feel like rejecting a community to which we belong. A systematic review found that existing beliefs, knowledge, trust and reasoning styles can all affect how people evaluate health claims.

People may also have sound reasons for distrusting healthcare institutions. Dismissive treatment, discrimination, rushed appointments and poor explanations can damage trust. Research on trust in health organisations suggests that mistrust may be a rational response to institutional failure or unequal treatment. Telling patients to trust experts will not repair relationships that healthcare systems have damaged.

So how can we assess a health claim without dismissing personal experience?

1. Examine the claim separately from the person making it

A source may be sincere, charismatic or visually convincing without having the expertise to judge whether a treatment works. Check their relevant qualifications and whether their identity can be independently verified.

2. Look for supporting evidence and independent agreement

Do the NHS, an appropriate professional body or a reputable medical charity offer similar guidance? A single study rarely settles a medical question, so substantial claims should be supported by a wider body of research.

3. Check for commercial interests

Look for products, affiliate links, paid partnerships or private treatment programmes. Financial involvement creates a potential conflict of interest that readers should know about.

4. Be cautious about sweeping promises

Claims that a treatment produces rapid results, works for almost everyone or has no meaningful risks are unlikely to reflect the uncertainty and individual variation involved in medicine.

5. Know the warning signs

Treat secrecy claims and advice to abandon prescribed care as serious warning signs. The greater the potential harm, the more important it is to check the advice with an appropriately qualified professional, such as a pharmacist or GP.

Individuals cannot carry the whole burden of detecting misinformation. Social media platforms influence which claims are amplified, while health services influence whether people feel heard and respected. Researchers are increasingly calling for a systems approach to health misinformation that combines clearer public information, responsible platform design, effective regulation and trustworthy clinical communication.

Friends and relatives can provide valuable support and personal testimony can reveal experiences that medical research may miss. Judging whether a treatment is safe and effective, however, requires evidence that extends beyond any one person’s story.

Anna Stone is Senior Lecturer in Psychology, University of East London.

This article was first published on The Conversation.

Lakshadweep is India’s smallest Union Territory, an archipelago consisting of 36 islands – 10 of which are inhabited – with an area of 32 sq km. But most islands are two to five hours away on choppy seas, and one particular island, Minicoy, takes a 16-hour ship journey from the headquarters, Kavaratti.

It is in this archipelago that India found its first success on TB elimination. Lakshadweep was declared TB-free in March 2021, three years after a strategy document spelt out the task ahead of the administration.

“The strategy was simple in the way many great public health ideas are simple,” says Rakesh PS, who worked as a World Health Organization consultant supporting India’s National TB Elimination Program in Lakshadweep and parts of Kerala. “But simplicity of an idea should never be confused with ease of execution.”

India recorded about 2.7 million cases of tuberculosis in 2025, as ISignal reported in March 2026. Based on population projections for that year, this translates to an incidence of about 185 cases per 100,000 population.

In an upcoming book, Echoes from the Atoll, Rakesh writes about the challenges and the lessons that Lakshadweep’s TB programme holds.

Rakesh is a public health physician, researcher, and health systems specialist, and has worked with the WHO and The International Union Against Tuberculosis and Lung Disease (The Union). A Bernard Lown Scholar in Cardiovascular Health at the Harvard TH Chan School of Public Health, Rakesh holds an MD in community medicine from Christian Medical College, Vellore, and a PhD in public health.

Edited excerpts:

You write about how ending TB depended on “remarkably simple things done consistently”. Elsewhere, you acknowledge that the “strategy looked deceptively simple”. Please explain the size of the task that you had ahead of you.

Lakshadweep had around 70,000 people living across 10 inhabited islands. In each annual round of active case-finding, our health workers and community teams reached and screened nearly three-quarters of the entire census population. But coverage alone was not enough. We had to also ensure continuity of care for every individual who entered the diagnostic and treatment pathway.

Perhaps the hardest part was maintaining the discipline and motivation to keep doing these same essential things, year after year. In public health, there is an understandable excitement around new interventions and new technologies. But elimination also demands the discipline to keep doing the less visible things that already work.

There was nothing glamorous about another round of house-to-house screening or ensuring that tomorrow’s sputum sample was tested promptly. But elimination was built on precisely that repetition.

Then there was the geography. A population that looks small on a spreadsheet becomes a very different operational challenge when a patient, a health worker or a sputum sample may need to cross the sea.

You write about a young woman carrying an intrauterine death, who had to wait four days before evacuation became possible; and a senior treatment supervisor who was stranded for 21 days. How did you and your teams navigate this punishing geography?

On my first visit itself, I realised something: the sea was in charge.

On the mainland, you plan a field visit by checking a calendar. In Lakshadweep, you checked the ship schedule, the weather and the sea, and even then, nothing was certain. Will the vessel sail? If you reach an island today, when can you return? For almost five months of the monsoon, rough seas severely disrupt inter-island movement.

So we could not run the TB programme as though Kavaratti were a district headquarters connected to ten blocks by road. That meant decentralising diagnostics, training local teams and keeping essential supplies available on the islands. It also meant giving local primary health care teams the confidence and space to act.

If surveillance and treatment had depended on a supervisor physically travelling from Kavaratti to every island, the programme would have struggled every monsoon. Fortunately, every inhabited island already had a health facility and local health workers. The principle was simple: whatever could safely and effectively be done on the island should be done on the island.

Screening happened in households. Sputum could be collected locally. Molecular diagnostics were progressively decentralised, allowing an increasing proportion of samples to be tested closer to where people lived and results to become available quickly rather than waiting for the sea to cooperate.

Treatment followed the same principle. A person with TB had a local treatment supporter. Follow-up included clinical assessment, monitoring for adverse reactions and bacteriological evaluation when required. The national programme’s surveillance and reporting systems provided the larger framework, while day-to-day continuity depended on the health teams and frontline workers close to the patient.

I want to dwell on this distance a little further. For instance, we reported in December 2024 about how people living in forest villages in Latehar needed a four-hour trek followed by an ambulance ride to reach a medical centre. Given your experience in Lakshadweep, what are the lessons it holds for reaching remote areas elsewhere in the country?

I would be cautious about saying that what worked in Lakshadweep can simply be copied in a forest village in Latehar. The geographies and communities are very different.

We often call communities “hard to reach”. I sometimes wonder whether we have the language backwards. Perhaps it is the health system that is hard to reach. Similarly, in public health, we spend a lot of time discussing “health-seeking behaviour”. But in remote and underserved geographies, perhaps we should equally ask about the health system’s people-seeking behaviour. How hard did the system try to reach the person?

Lakshadweep taught me to keep asking one question: What is the maximum amount of care that can safely be moved closer to the person? Decentralisation does not mean lowering standards. A molecular test on a remote island should be as reliable as one in a tertiary hospital.

We also need to be careful about applying uniform population norms to profoundly unequal geographies. If geography changes the effort required to reach a person, health-system planning must recognise that. Otherwise, uniformity can unintentionally reproduce inequity.

You speak about your experience scuba diving and say, “To an outsider peering through a diving mask, the underwater world looked impossibly peaceful. Or perhaps I was not sensitive enough to understand their conflicts, fears, and insecurities.” This almost serves as a metaphor for the distance you describe between officials on the mainland and implementation teams on islands. How do you think that gap can be bridged?

I think the first step is humility, the willingness to accept that what you see, as an outsider, may not be the whole truth.

Lakshadweep looks impossibly peaceful from a distance: turquoise lagoons, coconut trees, small populations and high literacy. But, like the reef I saw through my diving mask, there are layers beneath the surface: relationships, histories, fears, rivalries and ways of negotiating change that an outsider may not immediately understand.

During my years working in Lakshadweep, I visited the islands 13 times and made a conscious effort to set foot on every inhabited island. I travelled on ships, speed vessels and fishing boats, sat with health workers, listened to local leaders and spent time with people outside formal meetings. Each visit made me realise how much I had missed on the previous one.

Slowly, I realised that Andrott was not Kavaratti, Kavaratti was not Minicoy, and a strategy that worked on one island could fail on another. That repeated field presence helped us adapt the implementation of national guidelines to the realities of individual islands.

That was also what I learnt underwater. What appears simple from a distance may be a complex living system beneath the surface.

I have worked with national programmes for much of my career, and I have seen the enormous value of that architecture. The question is how to build a stronger learning loop: national guidance informing implementation, and implementation experience continuously informing programme design.

The first step is to recognise that, in a country as diverse as India, edge cases should not sit outside the design conversation. They are valuable stress tests of programme design. One way is to bring frontline implementers into programme design much earlier.

Your book talks about the absurdities of red tape, where to issue a single pill, senior treatment supervisor Rouf had to log in and out using different administrative identities – state, district, sub-district, and health facility – even though all four levels were effectively just him. How can these oddities be addressed?

Rouf’s story is funny when you read it, but it also illustrates a genuine challenge in designing national health programmes for a country as diverse as India. The software was built around the usual administrative hierarchy. In most places, these are separate levels, with different people performing different functions. The problem was that the design had encountered a context it had not anticipated.

National digital platforms have brought enormous value to TB programmes by improving case-based visibility, accountability and continuity of information. National programmes need common definitions and comparable data. The design challenge is to preserve those gains while making workflows increasingly responsive to India's diverse operational settings.

One way to do that is to design systems much more closely with the people who actually use them. One of the most useful design exercises is simply to sit beside a treatment supervisor, an accredited social health activist [ASHA] or a laboratory technician and watch the workflow for a day.

We should periodically ask, what purpose is this step serving? If it protects quality, accountability or patient safety, preserve it. But if a workflow has become unnecessarily repetitive in a particular operational setting, technology should help us simplify it while retaining the necessary safeguards. Technology already allows configurable workflows and role-based access, with permissions and audit trails.

More fundamentally, health workers’ time is also a health-system resource. Every avoidable administrative step consumes time that could have been spent with a patient or in the community.

“Women here often made major health decisions themselves, something I rarely encountered in many mainland settings,” you wrote. Could you elaborate on this?

It was something I noticed repeatedly in the field. If an ASHA visited a household and suggested that a woman undergo an X-ray or a TB test, she could often make that decision herself. That small space between being offered a health service and being able to say, “Yes, I will do it,” is enormously important in public health.

National data also show substantial improvements in women’s participation in household decision-making over time, so I do not want to paint a static or simplistic picture of the mainland. But the ease with which many women in Lakshadweep appeared to make everyday health decisions for themselves struck me.

Part of this may be rooted in the islands’ matrilineal history. Traditionally, men were often away at sea as sailors, fishermen or traders, and women became the stable centre of family life – managing homes, land, finances and family responsibilities. Elements of that social position remain visible even today.

Lakshadweep’s broader health achievements also made me think about this more deeply. Despite its remoteness, institutional deliveries were nearly universal, infant mortality was in single digits and childhood immunisation coverage was very high. Infrastructure, public services and a functioning health system are obviously central to those achievements.

I would not attribute them to women’s autonomy alone. But I do think agency is one part of the environment in which people are able to use the services available to them.

It also shaped the way our TB programme worked. Women were part of the social infrastructure through which it reached households.

Your book describes how Lakshadweep is a closely connected society, where health workers such as ASHAs were already trusted figures. How can this trust be built in areas with different social, cultural and economic circumstances?

I think there is something remarkably powerful in the original design of India's ASHA programme that we sometimes underestimate. We sometimes forget that the “A” in ASHA stands for activist. She comes from the community, lives within it and serves as a bridge between people and the health system.

Of course, social realities such as caste, religion and local divisions can influence these relationships. But across the settings where I have worked, my broad experience is that communities value their ASHAs, particularly when they are visible, accessible and consistently helpful.

Trust cannot be built by communication campaigns alone. It grows when someone belongs to the community, spends time there, is useful and repeatedly demonstrates that she is there for people.

You mention the unique administrative set-up of Lakshadweep where “its entire voice in New Delhi rests on the shoulders of a single elected representative”. How did that help or hurt your efforts?

In our case, the smallness of the system largely helped. I remember the release of our TB elimination strategy very clearly. The entire administrative and elected leadership of the islands was there. That leadership gave the health team the mandate and space to think beyond routine programme delivery and mobilise a wider system around the goal.

Over the years, I also had opportunities to interact with successive Members of Parliament from Lakshadweep. Conversations did not always require appointments or formal offices. We met at airports, on roadsides and near beaches, and a chance encounter could turn into a long discussion about the islands or public health.

You narrate how you brought together panchayat leaders, government officials, youth club members, women’s groups and religious leaders into a single network for achieving TB-free status. You also speak about how this structure has been sidelined over the past few years. How do you think that changes things for the islands in terms of healthcare planning and delivery?

We need to broaden the way we think about expertise. A programme expert may know the guideline in depth. An ASHA may know which house will not open its door. A boat operator knows when the sea will make a carefully prepared plan meaningless. A religious leader may understand a community's hesitation long before it appears in programme data. Good implementation needs all of these forms of knowledge to speak to each other.

For us, the panchayats were active partners in public health delivery. And that partnership created important local ownership. When someone refused evaluation, or a person with TB became tired of treatment and wanted to stop, local representatives sometimes visited the family, sat with them and helped us understand and address their concerns. Their presence often changed the nature of the conversation.

That has direct consequences for coverage, equity and inclusion. A health programme can report that it screened 80% of a population and call it a success. But local leaders often know who is hidden inside the remaining 20%. Is it an elderly person who cannot reach the facility? A family that is hesitant? Someone who fears stigma? Or a group that our routine approach repeatedly fails to reach?

Whenever such structures have a reduced role, the public health question I would ask is: how will those functions now be performed? How will we create the same sense of ownership and acceptance? How will we retain the ability to reach beyond average coverage and understand those who are still being missed?

In a geography where the sea already creates physical distance, we should be careful not to create avoidable distance between healthcare planning and the people it is intended to serve.

Karthik Madhavapeddi is Managing Editor, ISignal.

This article was first published on ISignal (formerly IndiaSpend), which utilises open data to inform public understanding on a range of issues, with the aim of fostering better governance, more transparency and accountability.

Whether it’s trimming off a piece of mushy parsnip or cutting away a slightly mouldy bit of apple, many of us have used produce long after their peak of freshness.

While fruits and veggies are important for our health, they’re also highly susceptible to bacteria, fungi and other pathogenic microbes. Overripe fruit and veg can harbour E coli, Salmonella and Listeria bacteria, all of which can cause food poisoning. Understanding how to properly store fresh produce can maximise their freshness and keep them safe to eat for longer.

The use-by dates printed on packaging are usually a useful indicator of how long fresh produce can safely be stored and eaten. But the environment fresh produce is stored in can affect the shelf-life of produce – so use-by dates may not always be accurate.

Fruit and veg are living – so things like humidity, temperature, atmospheric gas, light, how long it’s been in storage and any potential microbial contamination can all affect how long produce can be stored.

The ideal storage conditions will also be different for each fruit and vegetable.

Fruit

Apples have a shelf-life of around one week at room temperature, and three to four weeks in the fridge. These should ideally be stored in the fridge’s veg drawer and washed before eating.

Apples which are a little bruised are safe to eat but don’t consume if they’re mouldy.

Bananas can last around two to seven days, depending on how ripe the bunch was when bought.

Store bananas at room temperature until ripe, then refrigerate to extend shelf life. Brown or mushy bananas are safe to eat so long as they aren’t mouldy.

Berries have a shelf life of around 3-7 days if refrigerated. Store them in their original packaging. Only wash before eating, as washing may spread fungal spores.

Again, don’t eat if mouldy. Even if only one berry in the punnet has mould and the rest look fine, they may still contain mould. This is because the toxins produced by moulds and other fungi – called mycotoxins – are invisible and directly penetrate food and can spread to adjacent foods.

Mycotoxins, such as the Aspergillus aflatoxin, can cause serious damage to the liver and have been linked to liver cancer.

Citrus fruits are usually good for around one week at room temperature, and up to one month in the fridge. Keep the fruits whole and store in the fridge in a mesh bag that allows airflow. Cut citrus can be kept in an airtight container for up to five days.

Grapes can last several days at room temperature, and up to two weeks when refrigerated. Store them in their original ventilated package to enable airflow, and wash only before eating. As with berries, if any of the grapes have gone mouldy it’s best to bin the bunch to avoid mycotoxin contamination.

Tomatoes should be allowed to ripen first at room temperature, then stored for up to two weeks in the fridge. Slightly soft or mushy tomatoes can be eaten so long as there’s no mould present.

Vegetables

Carrots and parsnips can be stored for up to two weeks in a cool pantry, and for more than a month in the fridge. Just make sure they’re stored in perforated bags to allow airflow.

Sprouted carrots or parsnips can still be eaten, but if they’re mushy or mouldy that means bacteria or fungi are already growing so throw them away.

Cucumbers can be stored in a plastic bag or container for up to a week in the fridge. Cut cucumbers should be placed in a clean plastic bag or container and eaten within 1-2 days, as microbes will start growing quickly.

Lettuce is usually okay to refrigerate for three to seven days if left whole. For mixed lettuce leaves, it’s best to follow the use-by date on the package. Whole lettuce should be stored in breathable packaging in the fridge’s salad drawer. Wash only before use. Any lettuce that has become mushy or turned brown shouldn’t be eaten.

Mushrooms have a shelf life of only one day at room temperature, and three to seven in the fridge. Denser mushroom species – such as shiitake or button – tend to keep longest. Store mushrooms in breathable bags in the middle of the fridge.

Onions can sometimes last more than six weeks when stored in a cool, dry, well-ventilated area. Do not wrap in plastic, as a lack of air flow reduces shelf life. You also shouldn’t store them with potatoes or other veg that release moisture, as this will cause fungus to grow. Sprouting onions can still be eaten if no mould is present.

Potatoes can also last more than six weeks when stored in a cool, dark, dry place.

Do not eat green or sprouting potatoes, as these often contain natural toxins which can cause severe gastrointestinal symptoms such as vomiting, abdominal pain and diarrhoea. Even if you cut off the sprouted or green bits, the toxins may still have spread throughout the entire spud. Importantly, these toxins are not destroyed by cooking.

Exposure to light greatly increases the formation of these toxins.

Maximising shelf life

Storing certain produce together can also affect shelf life.

Certain fruit and veg produce gases during when ripening – most notably ethylene. This gas acts as a ripening hormone, accelerating the process and reducing the shelf life of other produce nearby.

Bananas are high ethylene producers, while apples are even stronger ethylene releasers. Both can prematurely accelerate ripening of other fruit and veg, which can lead to over-ripeness, spoilage and mould growth. It’s therefore a good idea to avoid storing these fruits near other produce.

To minimise wastage, also consider buying only as much produce as you’ll eat within a few days.

Primrose Freestone is Senior Lecturer in Clinical Microbiology, University of Leicester.

This article was first published on The Conversation.

Maybe you’re a new parent or someone who lies awake at night. If so, you may have started to worry you’re not getting enough sleep.

Sleep wearables don’t help. They can show your “sleep debt”, a running total of how far you’ve fallen behind.

But the word “debt” assumes your sleep works like a bank account. It assumes lost hours stack up, carry over, and you must eventually repay them in full.

But sleep doesn’t really work this way. And chasing “enough sleep” may not be helping.

What is a sleep debt?

Two systems control your sleep. One is your body clock, which helps keep wakefulness and sleep aligned with the day and night. The other is the one that matters here: sleep pressure.

Sleep pressure builds the longer you stay awake and eases while you sleep. At its highest, it’s hard to resist. Someone pulling an all-nighter might find themselves nodding off unintentionally.

This biological process is what “sleep debt” is trying to describe. If you sleep less than your body needs, pressure for sleep builds. Given the opportunity to recover after lost sleep, you sleep longer. In this broad sense, the debt metaphor works.

But this metaphor has some assumptions that don’t fit with our biology.

If you have a financial debt, the maths is exact: you owe a precise sum, which stays there until you pay it down. Sleep pressure does none of those things. Our sleep systems are more dynamic and adaptable.

What happens next?

To study the effects of short sleep, researchers bring volunteers into a lab and restrict how much they can sleep, such as four or six hours a night, sometimes for a week or two. Watching what happens under these conditions tells us how our body handles the shortfall.

The first thing it does is reorganise. When sleep is cut short, the body protects its deepest sleep (the stage that does most of the restorative work) and sacrifices lighter sleep.

People also fall asleep faster and spend less time awake in bed. In other words, given less time, the body spends that time more carefully and efficiently.

When people are freed from sleep restriction conditions, we watch what the body does to recover. “Recovery sleep” is characterised by a few nights of longer, deeper sleep. After this point, the debt appears to be cleared. But you do not sleep “back” the same number of hours you lost.

What this means in everyday life is that after a run of short nights, you tend to sleep a little longer and deeper for a night or two, then your sleep settles back to its usual length.

What about the sluggishness that follows after a few nights of short sleep?

These same sleep experiments also measure sleep-sensitive outcomes such as cognitive performance.

These outcomes follow their own recovery timelines and often take a little longer to return to baseline. You may have had all the recovery sleep you are going to get, but you still need a few more nights of normal sleep before your cognitive performance catches up.

Could knowing my sleep debt make things worse?

Receiving feedback about the previous night’s sleep seems to affect your mood, energy levels and alertness the next day.

One study showed giving participants negative feedback about their sleep – for example “your sleep quality was poor” – made them feel more tired and negative the next day.

Another small experiment showed people’s cognitive performance was influenced by how long participants believed they had slept.

No study has directly examined what happens if we tell people how much sleep debt they have. But, based on what we know, it is possible that knowing it can make you more worried about your sleep, and have worse sleep as a result.

False precision and moving targets

There is a deeper problem with the whole idea of calculating a sleep debt.

To calculate a debt, you need to know exactly what you owe in the first place, that is, a precise idea of how much your body needs. Trackers try their best to model how much sleep you need, but it is a slippery number.

How much sleep someone needs varies widely from person to person. Some healthy adults feel fine on around six hours, others need closer to nine.

How much sleep you need is not fixed. You need more sleep when unwell or start training hard at the gym. Sleep shifts with the seasons, with people generally sleeping more in winter.

Sleep trackers also estimate how much sleep you had overnight. They are increasingly accurate, but this is still an estimate, not the truth. So, trackers measure one guess (how much we slept) against another (how much we need).

The bottom line

Sleep debt is a handy metaphor to help us understand sleep regulation. Sleep pressure builds the longer you’re awake, and a short night can leave you needing a longer one to follow.

However, the way our bodies manage short sleep is not an ever-accumulating tally you must repay in full. To calculate a debt you’d also need to be certain how much you need and how much you got, which are both hard to know.

The good news is that we are built to withstand and recover from the times life gets in the way of a good night’s sleep. There’s no need to carry a ledger or chase a sleep debt to zero.

Amelia Scott is Honorary Affiliate and Clinical Psychologist at the Woolcock Institute of Medical Research, and Macquarie University Research Fellow, Macquarie University.

This article was first published on The Conversation.

More than a quarter of India’s births now happen through Caesarean-section (C-section) deliveries, driven primarily by high rates of surgical intervention in private hospitals.

A part of this increase may reflect better access to emergency obstetric care, experts say. As more women deliver in health facilities, doctors are better able to identify complications that require surgical intervention. But coercion and commercialisation are to blame for unnecessary C-section deliveries, they say.

Nationally, the share of births by C-section increased from 21.5% in 2019-21 to 27.2% in 2023-24, according to the sixth National Family Health Survey, the NFHS-6. In public hospitals, which see about three in five births, the rate is 17%. This is close to the globally accepted optimal level, said Kranti Vora, adding that it reflects their improved capacity to provide emergency obstetric care. Vora is a visiting faculty at the Society for Education, Action and Research in Community Health, which provides healthcare in Gadchiroli district.

But in private hospitals, 54% deliveries were by C-section. The World Health Organization (WHO), in a 2015 research note, said C-section rates above 10% do not reduce maternal or newborn mortality at the population level.

Conditions such as failure to progress in labour, foetal distress, placenta previa and breech or transverse presentation may necessitate a C-section delivery, explained Suchitra Pandit, consulting obstetrician and gynaecologist at Surya Hospitals in Mumbai. In addition, multiple pregnancies, severe pre-eclampsia, previous Caesarean sections, and maternal conditions such as obesity, diabetes and hypertension could also lead to the surgical intervention.

The WHO recommends Robson classification, a checklist of 10 obstetric parameters, to determine the need for a C-section. These include factors such as the history of a pregnancy and gestational age.

However, caesarean sections can cause significant complications, disability or death, particularly in settings that lack the facilities to conduct safe surgeries or treat potential complications, the WHO warned.

The medical imperative

Harshada (name changed), a 35-year-old kindergarten teacher, first conceived through in-vitro fertilisation (IVF), and doctors recommended a C-section because of the high-risk nature of the pregnancy. The surgery went smoothly and she delivered a healthy baby girl. Encouraged by that experience, she returned to the same private charitable hospital for her second pregnancy a year later.

On the day of delivery, doctors told her she had developed high blood pressure and advised another C-section delivery. But what was expected to be a routine surgery quickly turned into a medical emergency. Doctors were unable to control heavy bleeding after the operation and subsequently decided to perform a hysterectomy, removing her uterus, Harshada explained.

Her condition continued to deteriorate after the surgery as she had developed jaundice. She sought treatment at a government facility as she could not afford private hospital care. With her uterus removed, Harshada has entered menopause years earlier than expected and continues to deal with the physical and emotional effects of the surgery.

For the IVF, both deliveries and subsequent complications, the family incurred more than Rs 6 lakh in medical expenses, for which they had to take out loans. “We trusted the doctors and did whatever they told us," she said. “Today, we are still paying back the loans, and I have to live with the consequences for the rest of my life.”

Vora and Pandit said the profile of pregnant women has changed significantly over the past two decades. Women are having children later in life, fertility treatments such as IVF have become more common, and conditions such as obesity, diabetes, hypertension and other pregnancy-related complications are increasing.

Vora noted that declining fertility means families often have only one or two children, making each pregnancy more valuable and increasing both parental and provider reluctance to accept risk.

“Once a woman has had a Caesarean, the likelihood of a repeat Caesarean in the next pregnancy increases,” Vora said, adding that this creates a cumulative effect in which higher C-section rates today contribute to higher rates in the future.

Pandit also pointed to rising maternal age, high-risk pregnancies, previous Caesarean deliveries and maternal requests for planned surgery as factors contributing to higher C-section rates.

Vora added that obstetric practice has become increasingly defensive, with doctors often working under the fear of litigation and confrontation if a labour develops complications.

When C-sections stop saving lives

The WHO notes that when medically justified, C-sections can prevent maternal and neonatal deaths and complications. But higher C-section rates do not automatically translate into better maternal and neonatal outcomes, our analysis of state-wise data shows.

For instance, Telangana, which has the country’s highest C-section rate (62.2%) saw a maternal mortality ratio (MMR) of 48 deaths per 100,000 live births in 2022-’24. In comparison, Tamil Nadu (47% C-section rate) and Kerala (41%), with lower rates, reported among India’s lowest MMRs at 25 and 24 deaths per 100,000 live births, respectively.

In Andhra Pradesh, which has a 52% C-section rate, the government told IndiaSpend that the rise is due to a combination of clinical, health-system, and social factors. State-based research found providers were risk-averse, faced time pressures and declining confidence among younger obstetricians in conducting vaginal deliveries. At the same time, family pressure, fear of labour pain and preference for planned delivery dates also led to the increase.

The gap between public (26.6%) and private hospitals (63%), the state government said, is evidence that “non-clinical, provider- and market-driven factors contribute substantially alongside genuine clinical need”.

The state government said it has strengthened audits of C-sections through a cross-verification mechanism in public hospitals and District Task Force committees that review whether surgeries in private hospitals meet approved clinical indications. In addition, the state has undertaken a midwifery-led strategy to encourage normal births. It said 60 trained midwives deployed across 14 government hospitals “have been associated with a 6% reduction in C-section rates”.

Further, all public-sector obstetricians were trained in Assisted Vaginal Birth techniques through workshops. It also introduced structured childbirth classes and counselling for pregnant women, and expanded its C-SAFE programme, which combines clinical mentoring, indication-based audits and surgical safety protocols to reduce medically unnecessary Caesarean deliveries.

Even states with the highest maternal mortality had a higher C-section rate than envisaged by the WHO to prevent mortality. Uttar Pradesh, where 19.5% of births are delivered by C-section, had the highest MMR (154 deaths per 100,000 live births). Madhya Pradesh, with a C-section rate of 16%, recorded an MMR of 135.

But even as Karnataka’s C-section rate of 46% is comparable to Tamil Nadu’s, it had a maternal mortality ratio of 73, nearly three times Tamil Nadu's. Similarly, West Bengal and Punjab, which had 45% and 47% C-section rates, saw MMRs of 94 and 77 deaths per 100,000 live births.

“The objective is not to maximise Caesarean-section rates but to ensure that women who need surgery receive it,” said Dileep Mavalankar, honorary distinguished professor of public health and former director of the Indian Institute of Public Health, Gandhinagar. “Beyond that point, improvements in maternal and newborn survival depend far more on the quality of care than on the number of operations performed.”

“High-performing states like Kerala and Tamil Nadu already achieved good maternal and neonatal outcomes,” says NS Iyer, consultant for maternal, newborn, child and adolescent health at the United Nations Children’s Fund. “Rising C-section rates seem to reflect how maternity care is organised – crowded referral hospitals, fewer midwives, and less continuous labour support – rather than additional improvements in outcomes.”

“Some increase is expected when more women deliver in hospitals and complications are identified. But after about 10%-15%, it cannot be explained by complications alone,” said Mavalankar.

“If we take the WHO standard and even allow some margin, around 20% of deliveries may genuinely require a Caesarean section. What we are seeing now is that three out of every five Caesarean sections in India’s private sector are medically unnecessary,” said national co-convener of Jan Swasthya Abhiyan, Abhay Shukla.

Jammu & Kashmir had the highest C-section rate in private hospitals at 90%, followed by 88% in West Bengal and 84% in Telangana.

Rising Caesarean rates are no longer confined to large cities, said Anand Pawar, executive director of Samyak, a Pune-based advocacy group that works for sexual and reproductive health rights of women in Maharashtra and Rajasthan. In many rural and semi-urban areas, institutional deliveries have increasingly shifted into private maternity facilities, where women are often encouraged to view childbirth as a high-risk event requiring medical intervention. Pawar said fear and anxiety around pregnancy complications are frequently used to steer women towards surgical deliveries.

And this is showing up in the numbers. Across India, 40.5% of urban births were delivered by C-section, compared to 22.8% of rural births.

Further, a 2018 study across 51 countries found that neonates born by vaginal birth had more than double the chance of being breastfed in the first hour as compared to C-section births, as IndiaSpend reported in August 2018. Women who deliver by caesarean section often face important challenges in initiating breastfeeding, such as managing the effects of anesthesia, recovering from surgery and finding help to hold the baby safely, the study noted.

Early initiation of breastfeeding is important for both the mother and the child. The first breast milk contains colostrum, which is highly nutritious and has antibodies that protect the newborn from diseases. It is recommended that children be put to the breast immediately or within one hour after birth. IndiaSpend reported in 2019 that a delay of just a few hours can increase the risk of mortality.

Rising costs

As more women give birth in health facilities and C-section rates continue to rise, childbirth remains a significant source of out-of-pocket spending for many Indian households, particularly those using private hospitals.

A delivery in a private hospital costs more than Rs 39,000, on average. This is 17 times the cost of delivery in a public hospital. For many households, as IndiaSpend reported in June 2026, high out-of-pocket spending leads to borrowing, selling assets, or cutting down on other essential expenses such as food and education.

Between 2018 and 2025, average childbirth expenditure in rural areas rose 73%, while in urban India, it rose 63%. States with high C-section rates also have some of the most expensive private maternity care in India. In Telangana, delivery in a private hospital costs Rs 53,355, 31 times as the spending in a public facility (Rs 1,714). Tamil Nadu’s expenditure per childbirth was nearly Rs 70,000 in private hospitals, about 50 times the costs in a public facility.

Iyer said states such as Kerala and Tamil Nadu had largely completed the transition from a maternal mortality problem to a maternity care market, where most women deliver in institutions and private hospitals play an increasingly dominant role. Once institutional delivery becomes nearly universal, he argued, further growth often comes through greater medical intervention, specialised care and higher-cost services rather than improved access alone.

“These were the states which had the first and largest public-private health insurance schemes,” Shukla said. “The government subsidised people to go to the private sector. They expanded the market and induced people to seek care in private hospitals on a much larger scale than before.” He added that while these schemes increased utilisation of services, they also accelerated the growth of private-sector maternity care, where C-section rates are substantially higher than in public facilities.

The push for surgery

Shukla argued that high C-section rates in private hospitals cannot be explained by medical need alone and reflect the increasing commercialisation of maternity care.

Pawar described how, in rural and semi-urban areas, private maternity centres often become the default option for pregnant women, with doctors and referral networks shaping perceptions of risk and encouraging women to view C-section delivery as the safer option.

Experts also pointed to what might be called the “arithmetic” of hospitals. A normal delivery can take six to twelve hours – or longer – of continuous monitoring, labour support and observation, while a C-section is scheduled, predictable and completed within a much shorter time frame.

Iyer said that this challenge has become more acute as the traditional cadre of trained midwives has largely disappeared from the health system. In the past, midwives and experienced labour-room nurses played a central role in monitoring women through labour and supporting normal deliveries. Today, deliveries are increasingly concentrated in district hospitals, medical colleges and specialist maternity facilities, where doctors must manage large numbers of patients with limited staff and crowded labour rooms.

“Normal deliveries are being conducted by nurses and midwives in many countries, and even in India much of the monitoring can be done by trained nursing staff,” Vora said. “Normal delivery requires less resources, but more patience and time.” She added that obstetricians often remain responsible for a woman throughout labour, knowing that complications can arise unexpectedly at any moment.

Financial incentives may further reinforce these pressures. Mavalankar argued that payment systems often reward C-sections more than normal deliveries, creating incentives that favour surgery. Referring to earlier experiments in Gujarat, he noted that when private hospitals were paid a fixed amount regardless of whether a woman delivered vaginally or by C-section, surgical delivery rates remained comparatively low.

Pawar described a parallel dynamic in private rural hospitals, where maternity centres operated by BAMS and BHMS practitioners invest in infrastructure, operation theatres and specialist consultants, creating financial pressure to recover costs.

IndiaSpend has reached out to the Ministry of Health and Family Welfare, and health ministries in Telangana, Andhra Pradesh and Tamil Nadu for comment. We will update this story when we receive a response.

This article first appeared on IndiaSpend, a data-driven and public-interest journalism non-profit.

On May 7, as India launched military strikes in Pakistan, the government quietly released a tranche of data that to a great extent reveals the true cost of the Covid-19 pandemic.

India recorded at least 37.4 lakhs excess deaths in 2020 and 2021 compared to two pre-Covid years, 2018 and 2019, according to the data on registered births and deaths released last week.

Excess deaths or mortality refers to the difference between the total number of deaths during a pandemic or any other natural disaster compared to the number of deaths that would have been expected under normal conditions. The difference is an indicator of the likely death toll, as it captures deaths that went unreported.

The total deaths in 2018 and 2019 was 145 lakh. But the number of deaths in the two pandemic years – 2020 and 2021 – was 183 lakh, shows data from the civil registration system, which is the official record of births and deaths registered with the local government bodies.

This indicates 37.4 lakh excess deaths. In contrast, India’s official Covid-19 toll till date is 5.33 lakh. The first death due to the virus was reported in March 2020.

That is to say, India possibly undercounted Covid-19 deaths by seven times. If the government releases civil registration data for 2022, the gap could be higher. The civil registration system records events such as births, deaths and still births.

“The latest report confirms what we already know. India had undercounted its deaths caused by Covid-19,” said public health expert Chandrakant Lahariya.

The excess mortality figures in India is closer to the World Health Organisation’s estimates of excess deaths during the Covid-19 pandemic in the country.

The mathematical model by the WHO had estimated 47.4 lakh excess deaths for India in the period between January 2020 to December 2021.

When the WHO had released its report on excess mortality in 2022, the Indian government had objected and questioned the “validity and robustness of the models” used by the international organisation.

Since many births and deaths go unregistered, especially in rural regions, the government also conducts a sample registration system survey to estimate deaths.

The civil registration system counted 37 lakh excess deaths in 2020 and 2021, compared to 2018 and 2019. However, according to the sample registration system, there are 19 lakh excess deaths in the same period – which is four times the official Covid-19 toll.

Scroll looked deeper into the state-wise CRS and SRS data to understand how Covid-19 mortality varied by state. Our analysis of the state-wise CRS and SRS data shows that Gujarat, Bihar, and Chhattisgarh were worst hit by the pandemic, even though their official tolls remained low.

What the latest government data shows

Across India, the total number of deaths recorded in 2021 was 102 lakh and the corresponding figure for 2020 was 81 lakh, CRS data shows.

The figure is a big jump from pre-Covid years.

In 2018, India registered deaths of 69 lakh people and in 2019, 76 lakh.

While the overall registered births between 2020 and 2021 decreased slightly by 0.1 %, deaths rose by a significant 25.9%.

Moreover, data from the SRS indicates that the Covid-19 pandemic affected rural areas more than urban centres. The death rate in rural areas stood at 7.9, while it was 6.6 in urban areas – a reflection of the difference in healthcare facilities in these regions.

States guilty of massive undercount

In some states, the estimate of excess deaths was higher than others.

In Bihar, there was a 65.9% jump in the total registered deaths in the first two years of Covid-19 pandemic compared to the two pre-Covid years of 2018 and 2019.

The state recorded 3.78 lakh excess deaths in the state in this period. Its official Covid-19 toll till date is 12,315 deaths – which means the state’s likely toll is 30 times the official figure.

The death rate – the number of deaths per 1,000 people – in the state also rose from 5.5 in 2019 to 6.6 in 2021, data from the SRS report shows.

Dr Shakeel from Jan Swasthya Abhiyaan in Bihar blamed the state’s poor health infrastructure for the devastating impact of the pandemic. “People had nowhere to go for treatment,” he told Scroll.

Another state which massively underreported its death toll was Gujarat.

The state has reported only 11,101 deaths due to Covid-19 from 2020 till 2025.

But if excess mortality of just 2020 and 2021 is considered, the Covid-19 toll stands at 3.53 lakh – that is to say, the state undercounted deaths by at least 31 times.

Moreover, compared to 2018 and 2019, Gujarat saw a 39.5% jump in registered deaths in the pandemic years.

The rise in Gujarat’s death rate has also been the sharpest compared to other states, from 5.6 in 2019 to 8.5 in 2021.

Similarly, Chhattisgarh’s death rate rose from 7.3 to 10.1, SRS data shows.

Uttar Pradesh, the most populous state, recorded 3.74 lakh excess deaths in 2020 and 2021 compared to 2018 and 2019. This is 15 times more than its official total Covid-19 toll of 23,743.

Madhya Pradesh’s Covid-19 toll, too, could be 28 times higher than it reported. The state recorded 3 lakh excess deaths, but has only 10,788 Covid-19 deaths in official records.

In the south, Telangana and Andhra Pradesh also underreported their Covid-19 deaths.

Andhra Pradesh recorded 2.33 lakh excess deaths, 15 times more than its official toll so far of 14,733. Telangana’s official Covid-19 toll is 4,111, about 17 times less than the excess deaths found in 2020 and 2021 – 72,730 more people died compared to 2018 and 2019.

Better performers

The gap between excess deaths and the Covid-19 toll is narrow in only a few states like Kerala, Delhi, Rajasthan, Maharashtra, and Karnataka. This means that these states made an effort to count and report Covid-19 deaths truthfully.

Shakeel blamed the lax Covid-19 fatality reporting on a poor system of classifying medical deaths in many states. “The cause of death certification is still not undertaken in many hospitals in Bihar,” Shakeel pointed. “If that was done, our official Covid toll would be much higher.”

Across India, only 23.4% of registered deaths are medically certified to list the cause of death.

Few substances are as deeply woven into everyday life as alcohol. It is a fixture at holiday celebrations, work-related social gatherings, sporting events, airports, and brunch or dinner tables. A raised glass for a toast, the ubiquitous wedding open bar or drinks shared during a Fourth of July celebration all demonstrate how deeply alcohol has become embedded in social customs and cultural traditions.

Yet alcohol contributes to millions of deaths globally each year and is linked to cancer, liver disease, unintentional accidents, violence and, importantly, dependence and addiction. Despite this, the disconnect between alcohol’s cultural role and its serious health burden is striking.

Although drinking patterns vary substantially across countries, an estimated 2.3 billion people worldwide consume alcohol. It is deeply integrated into social life across the globe, despite its well-documented health risks.

As a physician working in addiction medicine, I regularly care for patients whose alcohol use affects nearly every organ system. It is often not until these patients end up admitted to the hospital that they learn the impact of alcohol on various parts of their body besides their liver.

No such thing as a ‘safe’ amount

Newer evidence challenges assumptions about what was long considered “safe drinking.” Even moderate drinking carries risk and is not as harmless as people, including experts, once thought.

Many people associate alcohol risk primarily with addiction or legal complications such as driving while intoxicated. However, its effects extend far beyond this, into nearly every aspect of a person’s well-being.

While alcohol may transiently improve mood and ease social anxiety, long-term alcohol use can lead to a worsening of mood, cognition and sleep, which can further compound use.

A 2021 literature review found that consuming approximately two standard drinks roughly doubles the odds of sustaining both motor vehicle and non-motor vehicle injuries.

The review also found that heavy episodic (binge) drinking can increase the risk of injury by 20- to 50-fold, depending on the amount of alcohol consumed and the type of injury. While alcohol’s effects on the liver are well known, it can also lead to gastrointestinal complications and heart disease

The World Health Organization estimates that 2.6 million deaths each year are attributable to alcohol, accounting for nearly 1 in every 20 deaths worldwide.

Mixed messaging around alcohol and cancer

While many people recognise the risks of alcohol addiction, people are generally much less aware of the links between alcohol use and cancer risk.

The World Health Organization classifies alcohol as a Group 1 carcinogen, – the same category as tobacco and asbestos. In other words, these are agents classified as having sufficient evidence that they cause cancer in humans.

In 2025, a US Surgeon General advisory emphasised that alcohol increases the risk of at least seven cancers and called for updated warning labels. It concluded that alcohol increases an individual’s risk of developing seven types of cancer, including cancers of the breast, colorectal, liver, oral, esophagus and larynx.

Yet fewer than half of Americans recognise alcohol as a risk factor for cancer, particularly for cancers such as breast cancer that are not commonly associated with alcohol use.

The relationship between alcohol and cancer is nuanced. Throughout the 1990s and early 2000s, observational studies suggested that moderate alcohol consumption might offer cardiovascular benefits.

Over the past decade, however, higher-quality studies have challenged those findings, suggesting that much of the apparent benefit may have reflected differences in the health and lifestyles of moderate drinkers rather than a protective effect of alcohol itself.

According to the Dietary Guidelines for Americans, current evidence increasingly suggests that even low levels of alcohol may increase cancer risk.

The guidelines acknowledge that adults should “consume less alcohol for better overall health.” However, the most recent version of the guidelines for 2025-2030, updated in January 2026, removed the previous recommendation to limit intake to no more than one drink per day for women and two for men. It also omitted explicit discussion of alcohol’s links to cancer.

These changes have drawn criticism from public health experts, who argue that the revised language downplays the growing evidence of alcohol-related harms and provides less specific guidance to consumers. Against this backdrop, Dr Mehmet Oz, Administrator of the Centers for Medicare & Medicaid Services, characterised alcohol as a “social lubricant” that brings people together, rather than emphasising its well-established health risks.

That may be true physiologically, at least temporarily, but it obscures the fact that relying on alcohol as a social lubricant can lead to chemical and psychological dependency. In my view, statements to that effect are shortsighted, prioritising short-term social effects over more insidious and long-term issues, including addiction.

A seismic cultural shift

While many dangerous mind-altering substances are hidden from public perception, alcohol is often placed at the centre of it – a trend that shows no sign of changing imminently.

Further, large companies often profit from ads that appeal to young people.

Looking back at the history of tobacco smoking provides some helpful insights. In 1965, 42.4% of the US population smoked. By 2022, that figure had dropped to 11.6%.

This dramatic decline did not happen because of a single intervention, but through decades of accumulating scientific evidence, public education campaigns, warning labels, restrictions on advertising, smoke-free policies, higher tobacco taxes and shifts in social norms. Together, these efforts transformed smoking from a widely accepted social behaviour into one broadly recognised as a major health risk and, correspondingly, less socially accepted.

Although alcohol consumption has modestly declined in recent years, it remains deeply embedded in social life in ways cigarette smoking no longer is.

People often assume that if a substance is legal, common and widely socially accepted, as well as encouraged, then it must also be safe. But public health history suggests those assumptions can and should change.

Emma Fenske is Addiction Medicine Fellow and Internal Medicine Physician, Oregon Health & Science University.

This article was first published on The Conversation.

Honey has been used by humans as a natural sweetener and energy source to sustain work and physical performance for thousands of years. Recently, it has re-emerged as a natural option for fuelling exercise, with some social media users claiming it’s the perfect thing to eat before a workout if you need an energy boost.

Interestingly, Sebastian Sawe, the first man to run a sub two-hour marathon, fuelled up before his race with bread and honey.

Research actually does suggest honey can work comparably to commercial products such as energy drinks and gels. But where it may be most beneficial is when it’s used as a recovery tool.

Honey and energy

Honey is primarily made up of carbohydrates – more specifically, glucose and fructose which are simple sugars. These carbs provide a rapid and accessible source of energy, which is particularly useful during exercise when the body needs fuel quickly.

Our bodies store carbohydrate as glycogen in the muscles and liver. These stores are depleted during moderate‑to‑high intensity exercise – especially during prolonged bouts of physical activity lasting longer than 60 minutes. When glycogen levels fall, fatigue increases and performance declines.

Consuming carbohydrates before or during exercise ensures energy is available, allowing us to sustain exercise for longer.

The science behind honey’s role in exercise is therefore straightforward: it supplies fast‑acting energy when needed. However, what is more interesting is that honey contains a natural combination of both glucose and fructose.

These sugars are absorbed through different pathways in the gut, allowing them to be used simultaneously. This increases the amount of carbohydrates absorbed, puts less strain on the gut, and helps sustain the amount of energy being delivered to working muscles during workouts. This may also potentially delay fatigue.

This science is also behind why many sports drinks and energy gels contain multiple carbohydrate sources to maximise fuelling efficiency.

Research has shown that consuming both glucose and fructose together enhances the amount of carbohydrate your body is able to use for energy compared to a single sugar source. Honey therefore represents a natural version of this evidence‑based approach.

In practical terms, one generous tablespoon of honey provides around 20 grams of carbohydrate. This is comparable to the amount of carbs found in a commercial energy gel.

Consuming around 1tbsp or 1.5tbsp of honey before training can top up glycogen stores, particularly in the liver. This can be important if training in the morning when liver glycogen stores are lower from an overnight fasting period.

But while honey can help provide the body with the energy it needs during a workout, whether honey actually boosts performance is less certain.

Previous research found that using honey as a drink given before and during 75 minutes of football training (a total of around four heaped tablespoons per participant) was not found to have improved performance.

A commercial sports drink containing the same amount of carbohydrates was also tested. Neither the sports drink nor the honey proved to have any performance benefit over the placebo (water only) – showing that both carb drinks had no effect.

However, other studies have shown that honey does perform similarly to other carbohydrate sources and may improve performance.

For instance, a study which gave cyclists 15g of honey every 16km over a 64km time trial resulted in cyclists having greater power output in the final 16km compared to those who were given a placebo.

Additionally, a recent study in trained cyclists who were given 90g of honey per hour over three hours of cycling found that performance was comparable to traditional sports gels.

So while honey might not boost your performance over other types of carbs, it may work just as well.

Additional benefits

Where honey shines may well be in its role in recovery. Research has shown that consuming a honey‑based drink after exercise helps maintain higher blood glucose levels, which can affect subsequent performance – particularly when the body is under extra stress (such as when it’s hot).

In one study, ten recreational runners performed two one-hour runs in the heat, with a two-hour rest in between. After the first run, they were given a drink containing honey. The researchers found that the runners were able to run around 10% further in the second trial after consuming honey than they had run during the first trial.

This suggests that honey may be particularly effective at restoring energy between bouts of exercise. As honey contains both glucose and fructose, this can help replenish the body’s energy stores quickly.

Beyond its carbohydrate content, honey also contains small amounts of vitamins, minerals, amino acids and important plant compounds such as flavonoids and phenolic acids. These compounds may have antioxidant, antimicrobial and potentially antiviral effects, which may be particularly beneficial for athletes during stressful training periods.

However, not all honeys are the same. Their taste, texture, sugar composition and contents vary depending on factors such as flower source, climate and processing methods. For instance, Malaysian and Manuka honey contain higher levels of anti-bacterial and anti‑inflammatory compounds, which could better support recovery and immune function.

Some research also indicates certain types of honey can influence inflammatory signalling pathways, potentially helping regulate the response. This means honey may reduce muscle soreness and improve recovery, offering more than just a source of energy.

However, there’s currently little evidence to suggest that one type of honey is significantly superior to another as an exercise fuel.

Based on current evidence, honey does appear to be comparable to other sports products such as energy gels. This makes honey an effective, low cost, natural alternative to commercial sports fuels for athletes.

This article was first published on The Conversation.

Henry Chung is Lecturer, School of Sport, Rehabilitation and Exercise Sciences, University of Essex.

Charlotte Gowers is Senior Lecturer- Performance Physiology and Nutrition, Anglia Ruskin University.

Justin Roberts is Professor of Nutritional Physiology, Anglia Ruskin University.

As an optometrist, I see how aging affects my patients every day. Their eyes are no exception. Losing their vision, and consequently, their independence, is one of the greatest fears older people have. Those who lose their vision are severely affected by it psychologically.

Jacqueline and Henri are patients of mine and both suffer from multiple eye conditions. Henri, a former truck driver, has had diabetes for several years. After noticing black spots and distorted lines in his sight, he failed to seek optometric advice before the black curtain of blindness fell. As a result, he can no longer look after himself and needs help with daily tasks.

Jacqueline suffers from advanced cataracts. She is delaying having a surgery because she doesn’t want to leave Henri without immediate care. She also fears developing macular degeneration. Her parents suffered from it, which left them visually impaired towards the end of their lives.

Older people with reduced vision often feel helpless. But there are resources to support them. Rehabilitation centres offer support and services to people with visual impairments. Support groups provide an opportunity to talk to people who are going through the same experience.

But above all, there are ways to prevent the harmful effects of aging on eye health. Let’s examine them.

Diabetic retinopathy

Diabetes is the leading cause of preventable blindness. Damage typically appears, on average, 10 years (type 1 – juvenile) or 20 years (type 2 – adult) after diagnosis.

In Canada, 18% of people aged 60–79 are affected by diabetes. In terms of vision, this disease affects the ability to read, the movements of eye muscles and causes the deterioration and/or proliferation of blood vessels, the main causes of diabetes-related vision loss.

Initially, there are mild alterations in the blood vessels (swollen veins, small localised hemorrhages, lipid deposits in the retina, etc.); then, as the disease progresses, the new vessels rupture, leading to hemorrhages. This is the proliferative form, which can also lead to glaucoma that is almost impossible to treat.

However, blindness is preventable. Seeing an optometrist regularly after the age of 45 or as soon as diabetes is diagnosed by a family doctor is critical. In fact, 20% of patients already have retinal damage at the time of their diagnosis.

Vision is sometimes clear, sometimes blurred, and it changes from day to day. An increasing number of floating black spots, or even more stationary black patches, the presence of flashes of light and difficulty distinguishing colours that you have always been visible are all symptoms of diabetes. Henri had experienced these symptoms, but he didn’t see an optometrist in time. Had he acted sooner, the condition could have been detected and medically managed, reducing the risk of complications.

Glaucoma

Henri also suffers from glaucoma, but of a specific type caused by the new blood vessels associated with his diabetes. This is not the more common form of glaucoma, known as open-angle glaucoma, which affects five to seven per cent of Canadians over the age of 60.

Open-angle glaucoma, which is not linked to diabetes, is the second leading cause of preventable blindness in the country. There is a strong hereditary link: patients whose parents had glaucoma are at greater risk of developing it themselves.

Like diabetes or high blood pressure, glaucoma develops without the patient really noticing it. Contrasts may be harder to see, particularly in the evening or in low light. Most notably, peripheral vision slowly narrows. People become accustomed to turning their heads to see something that is actually right next to them. Patients eventually notice this while they are driving, narrowly avoiding accidents.

Here again, seeing an optometrist regularly is critical. During an examination, glaucoma will be visible in the optic nerve, which pales and becomes deeper. The pressure inside the eye increases. Measured visual fields will show defects, and glaucoma will be diagnosed.

If treated in time, glaucoma can be managed. There will always be minor losses in the visual field, but these are minimal compared to what happens if the condition is untreated – blindness. Eye drops may be prescribed, although increasingly, improving the circulation of fluids within the eye is achieved by treating the eye with a laser (trabeculectomy) or via micro-invasive surgery performed by an ophthalmologist.

Cataracts

As we age, the lens inside everyone’s eyes becomes cloudy. This is a cataract. Vision becomes blurred, like a window that gradually becomes dirty. At first, reading and fine details appear blurred, sometimes doubled. Then faces become harder to recognise on the other side of the street, road signs difficult to read, and there is glare when you go out, day or night.

Cataracts occur because from birth onwards, the eye lens absorbs the sun’s ultraviolet rays to protect the retina. This constant exposure alters the metabolism of the lens and it loses its transparency. People must take care to protect their eyes from UV rays by wearing UV400 sunglasses from childhood. Children who do not wear suitable sunglasses, or a hat, will develop cataracts at an early age.

As a result, we should protect ourselves by wearing sunglasses throughout our lives, regardless of whether the sun is shining. We can also ask for a (transparent) UV filter to be added to our clear glasses. Many contact lenses also contain efficient UV filters. An optometrist can recommend the best products based on your condition. Eating a healthy diet and watching your overall health also help.

These measures will delay the onset of cataracts, but cannot prevent them entirely. Once a cataract appears, it’s time for surgery and to consult an ophthalmologist. The procedure is quick, well-established and restores vision, provided the retina (the back of the eye) is intact. Both eyes can be operated on during the same procedure.

A cataract that is too advanced can lead to a longer post-operative recovery time and more complications.

Macular degeneration

Risk factors for age-related macular degeneration include a family history of the disease, smoking, being female, having a Caucasian background, consuming a diet high in refined carbohydrates and inadequate protection from ultraviolet (UV) radiation. Fortunately, Jacqueline doesn’t smoke and Henri gave up cigarettes a few years ago. Second-hand smoke can be just as harmful as the smoke you inhale.

But she cannot combat the primary cause of macular degeneration – the incidence increases with age. More than 2.5 million Canadians suffer from the disease.

There were no signs of the disease during Jacqueline’s last optometric visit, so there’s no immediate cause for concern. In the long term, what can she do? Taking omega-3 (in the form of triglycerides, 800 mg EPA/DHA per day) was found to be beneficial in one study.

Recently, Vitamin B compounds (6-9(folic acid)-12) have been found to have a protective effect. A healthy diet, medical management of high blood pressure, diabetes and cholesterol, as well as not smoking, also help protect eye health.

New therapeutic approaches using microcurrents may help preserve vision in cases of the dry form of the condition, while an ophthalmologist will treat it using medications injected into the eye when the condition progresses to the wet form, which is accompanied by hemorrhages and leaking blood vessels.

Lifelong care

Jacqueline and Henri remind us that we must not take our vital sense of sight for granted.

Aging plays a significant role in the development of conditions that can lead to blindness.

But most of these can be prevented or delayed by being aware of when symptoms start, seeing your optometrist regularly, maintaining a healthy lifestyle and managing any underlying health conditions.

Langis Michaud is Professeur Titulaire. École d'optométrie. Expertise en santé oculaire et usage des lentilles cornéennes spécialisées, Université de Montréal.

This article was first published on The Conversation.

Cutting all sugar from your diet sounds like the healthy thing to do. But a recent study suggests it may do more harm than good. Instead of improving metabolic health, it appears to make it worse.

Before rewriting your shopping list, though, it is important to note that this research was conducted on rodents, tracking an extremely small sample size of just six mice per group. Mice have fundamentally different digestive systems than humans. However, the findings offer a warning about the possible hidden dangers of extreme diets.

This surprising conclusion falls squarely within the cultural obsession with “clean eating”. That’s no coincidence: decades of data link eating too much sugar to the global rise in diseases such as obesity and type 2 diabetes. Consequently, health advice has consistently promoted the radical reduction of added sugar in order to prevent these diseases. People who rely on processed foods inadvertently take in large amounts of added sugars, increasing their risk of developing disease.

This has led to a widespread belief that if an excess of sugar is toxic, absolute zero must be perfect. But trying to “clean” your body by eliminating an entire nutrient class might end up starving the very system you want to heal.

This research offers a fresh way to look at health, moving far beyond the usual focus on calories and weight loss. In the experiment, the mice on the strict zero-sugar diet did not gain weight. By typical measures of health, they looked perfectly fine.

Yet, beneath the surface, their metabolism failed. Their hormones signalled that their gut was in crisis, and they lost the ability to clear glucose from their blood. This suggests that you can be slim and still be metabolically unwell if your gut ecosystem crashes.

To understand why, we have to look at the microbes living in the digestive tract. Certain families of good bacteria rely on simple sugars to survive. When these bugs feed on carbohydrates, they produce vital chemical byproducts. These byproducts help keep the gut lining healthy and support the body’s ability to absorb nutrients. They also trigger the release of hormones that help regulate appetite and improve the body’s response to insulin.

When a zero-sugar diet halts the production of these fuels, the cells lining the gut lose their main energy source, and the gut barrier begins to break down. The strict diet also killed off helpful microbes that assist the immune system.

Leaky gut

When good microbes die from a lack of simple carbohydrates, harmful, stress-adapted bacteria rush in to fill the gap. This shift creates a “leaky gut”. Bad bacterial toxins slip through the damaged gut wall and circulate through the body, sparking an intense immune response.

It’s important to note that the diet in this experiment was strictly low fat. This is very different from the high-fat, high-sugar western diets that cause widespread disease in the real world. If you eat a diet heavy in fat and calories, reducing sugar remains a very healthy choice.

However, this research proves that aggressively removing every last trace of sugar from your meals carries its own risks. A resilient body requires a diverse, well-fed gut. Instead of treating your diet like an exercise in extreme elimination, focus on giving your internal ecosystem the wide, varied mix of nutrients it needs to thrive.

So, if you are worried that your diet might be harming your gut and health, try these strategies.

• Provide your gut with a variety of food. Your gut bacteria need different types of fuel to thrive. Rather than cutting carbohydrates entirely, eat a wide variety of fruits, vegetables and grains. The natural sugars and complex fibres in these foods keep your entire microbiome well supported.

• Although the research shows that sucrose (table sugar) is needed to support gut bacteria, it is not advocating the consumption of sugar via processed foods. You should aim to consume your five fruits and vegetables a day, which will provide sucrose in a natural form.

• Recover your gut bacteria by introducing fermented foods into your diet. If you have followed a very strict low-sugar diet. You can introduce good bacteria back into the gut by consuming foods like kefir, sauerkraut or live yoghurt.

Guy Guppy is Lecturer in Performance Nutrition and Exercise Physiology, Kingston University.

This article was first published on The Conversation.

Strength training has long been seen as something you mainly do to build muscle or look good. But a new study adds to a growing body of evidence that shows lifting weights does far more than change how we look. It may help us live longer – even if you don’t spend hours each day in the gym.

The study drew on three long-running US studies that followed nearly 150,000 nurses and other health professionals for up to 30 years. Every couple of years, participants reported how much time they spent on strength training and aerobic exercise such as walking, cycling and swimming. Over the three decades almost 36,000 of them died, which let the researchers track how muscle-strengthening activity related to the risk of dying early.

They found a clear sweet spot. People who did around 90 to 120 minutes of strength training a week – or roughly an hour and a half to two hours – had about a 13% lower risk of dying from any cause than those who did none.

The benefit of strength was strongest for two of our biggest killers: a 19% lower risk of dying from cardiovascular disease (which includes heart disease and stroke) and a 27% lower risk of dying from neurological conditions, mainly dementia.

Interestingly, more wasn’t necessarily better. Beyond about two hours of weightlifting a week, risk didn’t fall any further.

The lowest risk of all was seen in people who paired strength training with regular aerobic exercise – measured across everyday activities such as walking, jogging, cycling and swimming. Doing at least the recommended amount of moderate aerobic activity (around 150 minutes a week) was on its own linked to between a 26% and 43% lower risk of death.

But combining plenty of aerobic activity with one to two hours of strength training brought the risk down furthest of all – by around 45%. Aerobic exercise still did most of the heavy lifting, but the two clearly work best together, not as rivals.

There was one exception to the pattern: for cancer deaths, only smaller amounts of strength training (under an hour a week) were linked to lower risk.

Muscle and mortality

So why would weightlifting help us live longer? The answer lies in muscle – and what muscle actually does, beyond simply helping us move around.

Muscle, specifically the skeletal muscle we build through resistance training, is one of the body’s most metabolically active tissues. After a meal, it’s where most of the sugar, or glucose, in our blood is sent. Insulin, the hormone released when we eat, signals muscle to absorb glucose from the bloodstream, and it mops up around 80% of it – either burning it for energy or storing it as glycogen, a ready fuel reserve, rather than letting it circulate or be stored as fat.

Keeping muscle strong and plentiful therefore helps the body manage blood sugar and protects against type 2 diabetes, itself a major driver of heart disease and early death.

Muscle is also an organ in its own right. When muscles contract, they release hormone-like messengers called myokines into the bloodstream. These help to dampen the chronic, low-grade inflammation that quietly underlies heart disease, diabetes and many cancers.

Myokines also allow muscle to communicate with the liver, fat tissue, blood vessels, bone and even the brain. They send out signals that influence how those organs burn fuel, control blood flow and stay healthy. In effect, every time we use our muscles, they release a burst of chemical signals that benefit the rest of the body.

The heart and circulatory system benefit too. Over time, regular resistance training can help lower blood pressure and keep arteries flexible rather than stiff, which protects against cardiovascular disease.

Strength itself is also a remarkably good barometer of health. Grip strength – how hard you can squeeze with your hand – is widely used as an indicator of whole-body strength. In one large international study, grip strength predicted the risk of dying early even more accurately than blood pressure. Stronger muscles also mean fewer falls and fractures, more independence in later life and less frailty as we age – all of which shape how long, and how well, we live.

The link between strength training and brain health is newer and less certain, but plausible. Resistance training appears to drive beneficial changes in the brain. The same improvements in blood sugar and blood vessels that protect the heart are also tied to a lower risk of dementia. That may help explain the 27% drop in deaths from neurological disease the study found.

It’s worth being clear about what this study can and can’t tell us. It was observational, so although it can show a strong link between strength training and a longer life, it can’t prove that one directly causes the other.

People who lift weights may be healthier in other ways, though the researchers adjusted for many such factors, including diet, smoking and aerobic activity. Strength training was also self-reported, and the study couldn’t capture how hard people trained.

The encouraging message is that the amount linked to a longer life is genuinely achievable. You don’t need a gym membership or a heavy barbell, either. Two short sessions a week where you work all the major muscle groups, alongside some aerobic exercise each day, appears to be plenty when it comes to improving your overall health and longevity.

Jack McNamara is Senior Lecturer in Clinical Exercise Physiology, University of East London.

This article was first published on The Conversation.

Fruits and vegetables are an important part of our diet. They provide nutrients and fibre, and many contain additional compounds (known as bioactives) that can improve health. But not all foods are created equal – with big differences in the amount of bioactives we get from cabbages, carrots, pulses and peppers.

The well-known “five-a-day” campaign forms the basis of current dietary recommendations for fruit and vegetable consumption. The campaign focuses mainly on reminding people to consume at least five portions of fruits or vegetables each day.

This is a sensible approach, because it’s always better to eat some fruits and vegetables instead of none. But could we do better? Could choosing fruits and vegetables more carefully help us to get important bioactives from our foods?

My latest research suggests this is the case. We found that following current dietary recommendations might not be good enough when it comes to getting these important, health-boosting bioactive compounds from fruits and veggies. This could have particularly important implications for heart health.

In the study my colleagues and I conducted, we specifically investigated flavanols. This group of bioactive compounds are found in many plant-based foods, including tea, apples and berries.

Flavanols have been shown to reduce the risk of heart disease. About 500mg of flavanols per day are enough for most people to see health benefits from flavanols.

We wanted to find how many people eat at least 500mg of flavanols per day – and whether these are the people who eat their five-a-day and follow dietary recommendations.

To do this, we did not rely on food diaries or dietary questionnaires – methods that are known to be unreliable. People often forget what they’ve eaten, and the flavanol content in food is very variable.

Instead, we measured flavanol intake directly, using a biomarker in urine that reflects what the body actually absorbed. We did this in around 30,000 participants across two large studies in the UK and the US.

Our findings revealed there was good and bad news. The good news was that it’s perfectly possible to get 500mg of flavanols per day from a normal diet. The bad news was that fewer than one in five participants actually did this – even among those who ate their five a day.

This is not surprising. Many fruits and vegetables do not contain a lot of flavanols. Cauliflower, carrots or cucumber, for instance, don’t contain any, while mangoes, medlars and kiwis only very small amounts. When choosing a random selection of five fruits or vegetables, it’s very unlikely that they’ll add up to 500mg a day.

Another surprising result was that there was a big difference between participants in the US and UK.

US participants were more likely to get their daily flavanol intake if they followed US dietary recommendations (which are similar to the UK’s fruit and veg recommendations) – although only one in five did so. Around 20% of US participants consumed 500mg of flavanols daily.

But in the UK, the opposite was true. Only about 10% of those who consumed their recommended five portions a day also consumed 500mg of flavanols. Yet this number was closer to 20% in those who did not follow these recommendations.

We also found that those who reported eating the smallest amount of fruits and vegetables daily had the higher flavanol intake.

There may be a couple of key reasons for these findings.

There are some key differences between the two studies: the UK participants came from the Epic Norfolk study, which was designed to be representative of the general public. The baseline diet data we used was collected in the 1990s. In contrast, the US participants of the Cosmos study were recruited in the 2010s and generally had a better diet than the population average.

But if we look at just the UK cohort alone, the explanation for the disparities in flavanol intake can be found in a cup of tea. Literally.

Tea is a great source of flavanols, and a few cups of tea daily can already provide 200-300mg. In a country where tea is a staple, this can make an important contribution. It’s not surprising that the UK has one of the highest flavanol intakes in Europe.

In countries where coffee is the staple drink – such as the US – tea consumption is often associated with an overall healthier diet. But this is not the case in the UK, where tea is not a marker of a particular healthy – or unhealthy – lifestyle. Indeed, people with high tea consumption don’t eat more fruits and vegetables than others.

Although tea is not part of any dietary recommendations, it may be the main driver for flavanol intake in the UK. This means that a good cup of tea may do more for flavanol intake than a randomly chosen portion of fruit or veg.

What does this mean?

People who follow current dietary recommendations are unlikely to consume a sufficient amount of flavanols. It’s likely the same applies to other bioactives, such as carotenoids, (which can support vision).

There’s also huge variability in the bioactive content of different fruits and vegetables. A random selection of five fruits and veg each day is unlikely to provide meaningful amounts.

This isn’t surprising, as bioactives are generally not part of dietary recommendations. But our increasing understanding of the important role of bioactives in disease prevention and public health raises the question of whether this should change.

Five-a-day guidance continues to be an important dietary recommendation, especially as most of us do not eat enough fruits and vegetables. But as we learn more about the benefits of different plant compounds, we should consider prioritising consumption of certain fruits and vegetable daily to increase intake of these compounds. Whether you manage two portions or five, choosing wisely makes a difference.

Gunter Kuhnle is Professor of Nutrition and Food Science, University of Reading.

This article was first published on The Conversation.

The first half of 2026 has been marked by three different disease outbreaks: Ebola, hantavirus and, in Australia, diphtheria. Each has exposed vulnerabilities in how we detect, communicate and respond to infectious disease outbreaks.

Each of these outbreaks has its unique challenges. But a common thread has been distrust in health care or a lack of information where misinformation has filled the vacuum.

We’ve seen this play out in different ways across the globe, with devastating results.

So how do we address this distrust so we can better respond to future outbreaks?

Ebola

Distrust, rumours and misinformation have repeatedly emerged as major barriers to controlling Ebola. This includes in the current outbreak in the Democratic Republic of the Congo (DRC).

For example, past surveys of community members have identified misunderstandings about Ebola (including believing it’s not real), about how people are diagnosed, and revealed low levels of trust in health care.

These issues have hampered how cases of Ebola are identified, discouraged people to seek timely health care or to hide cases, and have undermined public health interventions.

For example, in late May, we heard how some DRC residents set fire to a tent set up by the humanitarian group Médecins Sans Frontières for suspected and confirmed Ebola cases. This led to 18 people suspected of having Ebola leaving the facility.

The trigger for this and similar examples was the announcement of a ban on large funeral wakes and gatherings. Authorities, rather than families, would now also start to manage the burials of suspected victims due to the infection risk associated with infected bodies, body fluids, contaminated clothing, and other personal items.

In 2014 the World Health Organization developed a safe and dignified burial protocol for local health authorities, in response to past clusters. This stressed the handling of human remains should be kept to a minimum and that cultural and religious concerns must be considered. It also stressed no burial should begin until the family agreed.

For families to accept the safe burial practice, they must both trust the health-care providers implementing the protocols and the institutions directing the response.

This was clearly not the case where the unrest occurred at the Ebola treatment centre, and at another centre where family members tried to retrieve the body of a man suspected of dying of Ebola.

Hantavirus

Misinformation often thrives and spreads where trust is weak and communication is absent. For instance, when transparent public health messaging is delayed, rumours and speculation can quickly fill information vacuums. We’ve seen an example play out with the recent cruise ship hantavirus outbreak.

Several public health experts based in the United States have argued the US Centers for Disease Control (CDC) was less visible, slower to communicate publicly and less internationally prominent than in previous outbreaks.

At the start of the outbreak top CDC officials didn’t appear on TV shows or give interviews about the risk to the US public. In the past, the agency would often take the lead in coordinating responses to such events.

Instead, others have filled the vacuum, including influencers and others spreading misinformation via social media about the virus’ pandemic potential, unproven treatments, and false links to vaccination.

Diphtheria

The recent diphtheria outbreak in Australia is another example of how information vacuums can undermine an outbreak response.

Warlpiri man Eugene Penhall told Guardian Australia locals were frustrated with the lack of information about diphtheria – including what caused it and how to prevent it. In particular, they wanted information that applied to daily life in a community where housing is overcrowded and living standards are poor.

Here, the challenges are complex, including inequitable access to health care in remote communities, and dealing with a disease many health workers and communities had not encountered for decades.

But unlike an outbreak of hantavirus, diphtheria can be prevented by vaccination. So, if vaccination is to succeed, health authorities need to better target communication about the vaccine and explore ways to enhance local delivery to build and maintain trust.

What can we do?

Transparency in a complex outbreak response should acknowledge what is known. That is, it should provide clear explanations for the reasons behind certain decisions. It should also acknowledge what is unknown. That means recognising policy drawbacks or scientific uncertainties.

When we learn more about a disease, public health messages can change and this should be communicated transparently and honestly. It’s not a back-flip. Science evolves and so should public health advice.

From the lessons learnt during past events, such as the Covid pandemic, frequent press conferences, social media updates and direct engagement with the public helps build trust. Different messengers and tailored formats are required for different target audiences.

Upskilling local health staff, working with community-based or civil society organisations, outreach workers, and local leaders can also support successful communication. These groups are likely to be met with less scepticism than “outsiders” such as international public health agencies.

We also need community-driven action, as we’ve seen with the Social Mobilisation Action Consortium in Sierra Leone. This engaged communities to take ownership over preventing Ebola. It resulted in behaviour change around safe burials, early treatment, and social acceptance of Ebola survivors. There were thousands of community mobilisers and trained religious leaders, partnering with more than 30 radio stations. There have not been any Ebola cases in the country since its 2014 outbreak.

But trust can be difficult to establish during a crisis, when emotional and financial stresses are high.

So we also need to proactively build rapport and shared understanding between health-care workers, stakeholders, community organisations and the community before an outbreak.

That way we can identify and address concerns and allow better design, uptake of, and trust in measures to control the next outbreak.

Holly Seale is Professor, School of Population Health, UNSW Sydney.

Bianca Middleton is Senior Research Fellow, Global and Tropical Health Division, Menzies School of Health Research.

Md Saiful Islam is Lecturer, School of Population Health, UNSW Sydney.

This article was first published on The Conversation.

Millions of people use a wearable health and fitness tracker. These devices can be useful for monitoring activity levels, sleep quality and heart rate. But for some, wearables can have unintended consequences on wellbeing.

This is something I encountered recently. At a public talk, I got to chatting with a man who told me a story that stayed with me.

He’d just finished a long hike and felt great. Then he glanced at his smartwatch. Heart rate: 130 bpm. Instant panic.

About 30 minutes later he realised the cause: the altitude. Yet in that moment, he’d gone from feeling perfectly fine to feeling awful – all because of the smartwatch’s reading.

This man isn’t alone. Some users have found their wearable increased anxiety so much they needed to stop wearing it.

A key reason wearable health devices may increase anxiety for some people comes down to a mismatch in expectation and what the device says.

Our brain is a prediction machine. It continuously, automatically generates and updates a mental model of our environment by comparing its predictions to the sensory information it receives.

Processing every sensory input from scratch would be slow and inefficient. By predicting what it expects to encounter, the brain can interpret noisy sensory information quickly and usually accurately.

Some examples of this happening include feeling your phone vibrate when you’re expecting an important message – only to discover it never rang at all. Or being abel ot raed tihs snetnece despite the typos, because your brain predicts what should be there.

The same principle applies to our bodily states. Our brains don’t simply read bodily states, they predict them.

We move through the day with an internal model of what our body “should” be doing: roughly what our pulse, temperature and breathing typically feels like when we’re calm, active or nervous.

When sensory information arrives that doesn’t match those expectations – such as having a higher heart rate – the brain generates a “prediction error”. This alerts us that the sensory information does not meet our expectations.

Most prediction errors are trivial and simply a mismatch between expectation and incoming information. The brain often resolves these errors automatically by updating its model and adjusting its predictions.

Since this process usually happens automatically, we typically don’t notice it. But if it does reach the level of our conscious awareness, we may search for an explanation for why our expectations and experience differ.

So if your heart rate feels faster than expected, you may link this to the fact that you drank too much coffee. Because we expect our bodily sensations to vary throughout the day, such explanations may be enough to prevent us becoming concerned by the prediction error.

The same thing can happen when we get a wearable reading that goes against expectation. However, because smartwatch readings appear clear and objective, we may place greater weight on them and may not dismiss an unexpected reading as readily. Even if you feel perfectly fine, seeing an elevated heart rate on your smartwatch may make you think something is wrong and kick off a cycle of worry.

My research suggests this may particularly be a concern in people prone to anxiety, who already tend to pay close attention to their internal bodily signals.

Research my colleagues and I conducted during Covid also found the more anxious a person was generally, the more likely they were to monitor their bodily states through objective measures (such as taking their temperature).

This behaviour in people with anxiety is unsurprising. Hypervigilance towards the body can feel protective, a way to spot problems early and reduce uncertainty. But it can quickly lead to a cycle of worry and seeking reassurance.

When such safety-seeking behaviour is reduced through therapy, anxiety symptoms tend to ease – at least partly because people are less hyper-focused on their bodies.

Yet the relationship can go both ways. In that same Covid study, we found a bi-directional link between anxiety and attention to bodily signals. Paying more attention to bodily states increased anxiety, and anxiety increased attention to bodily states – a negative loop.

Emerging research hints that wearable devices might amplify that loop. In a study on people with atrial fibrillation, heart rate trackers were linked to more frequent symptom-checking and higher anxiety.

A larger study, involving a random sample of around 500 smartwatch users, found a similar pattern. People reported feeling anxious when their physiological data looked abnormal. Some participants even reported feeling dependent on their health tracker, and become frustrated when they couldn’t wear their device or forgot to. Some recognised the effect and considered giving the device up altogether.

However, wearables don’t appear to have the same effect on everyone. For some, this information can be reassuring and may even reduce anxiety.

Critically, we don’t know why for some wearables provide reassurance, and for others they increase anxiety.

Avoiding health anxiety

There are many reasons people may wish to use wearables. Often, it’s because this health information can be useful – such as alerting us to issues we may otherwise miss. But monitoring the body in this way can also sometimes make us feel worse.

Taken together, the current evidence suggests this effect may be especially pronounced in people prone to anxiety, as well as in conditions where hyper-monitoring the body or behaviour can be maladaptive – such as eating disorders.

As with many things in life, it’s all about moderation. If you find yourself worrying about your data more than your wellbeing, try an experiment: leave the watch off for a day or hide the data so you’re not receiving constant feedback about your body.

Notice how your body feels without the tracking. You might discover what that hiker did: that sometimes trusting what you feel is better.

Jennifer Murphy is Associate Professor in Psychology, University of Surrey.

This article was first published on The Conversation.

The Union government on Tuesday notified an amendment to the 1945 Drugs Rules to ban the over-the-counter sale of all syrups, including those consumed to treat cough. The purchase of syrups will require a doctor’s prescription.

The Ministry of Health and Family Welfare notified an amendment that removed the word “syrup” from the list of items exempted under 1940 Drugs and Cosmetics Act. The rules had earlier exempted syrups, lozenges, pills and tablets for cough.

With the amendment, the sale of cough syrups in villages with a population of less than 1,000 will be required to take place only through licensed pharmacies. The rules had earlier permitted the sale of cough syrups in smaller villages without requiring compliance with some retail sale licensing provisions.

Pills, tablets and lozenges for cough would continue to be available without a prescription.

The change had been made to “strengthen regulatory oversight of syrup formulations” and to align the exemptions with public health and safety requirements, the ministry said.

“The measure is expected to promote responsible distribution and sale of cough syrups while ensuring greater compliance with regulatory standards across the country,” it added.

The rules have been amended following a series of cases of contaminated cough syrups leading to deaths of children.

Starting September, deaths had been reported in Madhya Pradesh and Rajasthan. Several children, who had been suffering from fever and cold, consumed the Coldrif syrup, resulting in vomiting and difficulty urinating.

In February, Reuters quoted Drugs Controller General of India Rajeev Raghuvanshi as having said that the Central Drugs Standard Control Organisation had inspected about 90% of the manufacturers of cough syrup in the country and found compliance lapses.

Written by Nachiket Deuskar. Edited by Tanya Shrivastava.

When work gets stressful, the standard advice is familiar: exercise more, eat better, sleep more and cut back on unhealthy habits. But our new research study suggests not all healthy habits offer the same protection from chronic work stress.

Using data over 10 years from a long-running national survey of 2,871 Canadian workers, we examined whether five health-related behaviours outside work helped weaken the relationship between work stress and general health over time: nutrition, exercise, sleep quality, alcohol use and smoking frequency.

What we found was more uneven – and more interesting – than the usual wellness advice suggests. Some behaviours appeared to offer real stress-specific protection. Others were linked to health overall, but did not seem to buffer the effects of work stress specifically.

Some habits protect; others don’t

Sleep quality stood out most clearly. Nutrition also mattered. Exercise remained good for health overall, but did not buffer the health effects of work stress in the same way once the other behaviours were considered together.

For many workers, work stress is chronic. It builds through heavy workloads, difficult or unpredictable schedules, after-hours emails and text messages, and the feeling that work keeps spilling into evenings, weekends and family time.

Over time, that kind of stress can wear people down physically and psychologically. Research has linked work stress to burnout, depression, anxiety, fatigue, cardiovascular disease, Type 2 diabetes and mortality.

Our study asked: when stressful work conditions persist, are there things people do outside work that actually help protect their health? Our findings suggest the answer is yes, but selectively.

Sleep may matter more than people think

Sleep quality stood out as the strongest buffer against the health costs of work stress. Good sleep supports attention, emotional regulation, recovery and the self-control needed to maintain other healthy behaviours in the first place. In that sense, it functions less like one good choice among many and more like a foundational resource.

Nutrition also showed a meaningful buffering effect, suggesting that diet may help sustain the physical and psychological reserves needed to cope with sustained strain.

The exercise finding pushed against popular assumptions. While more frequent exercise was associated with better general health overall, it did not significantly weaken the relationship between work stress and health. This could reflect the way exercise was measured in the survey, or it could mean exercise helps health in ways that are real but not specifically stress-buffering.

Being healthy and being protected from stress are not always the same thing.

The alcohol finding was the most unexpected and warrants particular caution. Lower alcohol use was associated with better overall health, as expected. But the data showed that higher work stress was more strongly associated with poorer general health among people who reported lower alcohol use than among those who reported drinking more frequently.

This should not be read as evidence that drinking protects people from the health effects of work stress, however. People who drank more frequently still reported worse overall health. More likely, this pattern reflects something our data could not fully unpack, such as prior health conditions, different coping profiles or non-linear patterns in alcohol use and health.

Healthy habits don’t excuse unhealthy work design

When work is chronically stressful, some forms of self-care may protect health more than others. Most importantly, wellness interventions cannot compensate for a job that is structured to exhaust people.

Organisations are still responsible for designing healthy workplaces. Employees should not be expected to sleep or meal-prep their way out of excessive workload, unreasonable expectations or poor work design.

What our findings suggest is not that individual behaviour replaces organisational responsibility. Rather, certain behaviours may help protect people when work remains stressful and structural change is absent, incomplete or slow to arrive.

Our study is explicit that these behaviours should be understood as complementary to, but not substitutes for, broader organisational change.

That has practical implications for both workers and employers. For workers, the message is not to do everything perfectly. It’s that some behaviours may offer more protection than others when work stress is high, and sleep deserves to be taken especially seriously.

For employers, the lesson is not to moralise wellness or shift responsibility onto individuals. It’s to make protective behaviours easier to sustain by reducing after-hours communication, allowing real on-the-job breaks, improving scheduling and designing work in ways that do not erode recovery.

Nick Turner is Professor and Future Fund Chair in Leadership, Haskayne School of Business, University of Calgary.

A Wren Montgomery is Assistant Professor of Sustainability & General Management, Western University.

Erica Carleton is Associate Professor of Leadership, Hill and Levene Schools of Business, University of Regina.

Serra Al-Katib is MSc Student in Organization Studies, Levene School of Business, University of Regina, University of Regina.

This article was first published on The Conversation.

The latest Ebola outbreak is showing no signs of slowing.

On April 24, the first suspected case of the rare Bundibugyo strain of Ebola was detected in the Democratic Republic of the Congo. On May 17, the World Health Organisation declared the outbreak a “Public Health Emergency of International Concern”.

The current Ebola outbreak is the third-largest in world history, with 906 suspected cases and 223 deaths in the DRC alone as of May 27.

And it may have spread to other continents. Health authorities are now investigating a suspected case in Italy, and two possible cases in Brazil. All three are believed to be travellers returning from either the DRC or Uganda. One American man who tested positive for Ebola is currently being treated in Germany.

As concerns grow, the Coalition for Epidemic Preparedness Innovations has committed more than A$86 million in funding to fast-track the development of three potential vaccines, targeting the Bundibugyo strain.

But in the meantime, could this outbreak spread further? And how concerned should we be?

A deadly virus

Ebola is a rare but potentially fatal virus that mainly spreads through direct contact with the bodily fluids – such as blood, faeces and vomit – of an infected person.

Early symptoms of Ebola include sore throat, headaches, fever, fatigue and body pain. Severe Ebola cases can cause skin rashes, shortness of breath, vomiting, diarrhoea, abdominal pain and seizures.

Ebola was first identified in humans in 1976. Since then, there have been more than 40 outbreaks around the world, with the majority occurring in African countries.

The current outbreak is the third ever to be caused by the rare Bundibugyo strain. The majority of past outbreaks were driven by the more deadly Zaire strain, which kills up to 90% of people compared to up to 34% for Bundibugyo.

What is driving this latest outbreak?

The factors driving this latest outbreak also contributed to the devastating West African outbreak of 2014-’16, where more than 11,000 people died.

In both outbreaks, the virus had been circulating for months before an outbreak was declared, and initial cases had non-specific symptoms.

Both outbreaks also rapidly spread in urban areas. Transmission in health-care settings is another common factor.

Political instability and social unrest also contributed to both outbreaks. Most recently in the DRC, crowds have set fire to hospital tents, prompting some patients to flee isolation wards.

And certain cultural practices – including traditional burial rituals that often involve handling dead bodies – may have accelerated the spread of both outbreaks.

How it crossed continents

Similar to the West African outbreak, this latest Ebola outbreak has spread to other continents through travel.

Nine cases and one death have already been reported in Uganda, which shares a border with the DRC.

An American man who tested positive for Ebola while working in the DRC, is in a stable condition after being treated in Germany.

In Italy, authorities are monitoring a traveller who recently returned from the DRC to the city of Cagliari.

According to some reports, Brazilian authorities are investigating two suspected Ebola cases. They are believed to be two travellers, one who returned from the DRC to São Paulo and the other from Uganda to Rio de Janeiro.

Importantly, both suspected cases have been diagnosed with other illnesses. The São Paulo patient presented with fever and was later diagnosed with severe meningitis. The Rio de Janeiro patient tested positive for malaria after developing a cough, chills and diarrhoea, but has since tested negative for Ebola.

So for now, no Ebola cases have been confirmed in Brazil. But these suspected cases have prompted the country to activate its Ebola safety protocols, including patient isolation, laboratory testing, and epidemiological investigations.

Meanwhile, several countries have imposed travel restrictions to prevent Ebola from reaching their shores.

Both the United States and Canada are temporarily restricting entry for travellers from the DRC, Uganda and South Sudan. The US and other countries such as India and Mexico are also strengthening public health screening and disease monitoring measures, particularly at airports. Some countries have mandated a 21-day quarantine period for their citizens returning from the DRC.

Could it spread further, including to Australia?

At this stage, the risk of Ebola reaching Australia is very low.

Australia has not put in place any travel or quarantine requirements for affected countries, but federal health minister Mark Butler says authorities are still monitoring the outbreak “very closely”.

Based on lessons from past outbreaks, there are three main ways the current Central African outbreak could play out.

Without effective control measures, cases may surge in the coming months. Some models suggest that by mid-May, up to 1,000 cases had already occurred in the DRC, compared to official figures of about 900 cases. So the actual number of Ebola cases may be much higher than authorities realise.

In a more favorable scenario, a strengthened public health response could bring this latest outbreak under control. This would be possible with continued support from the international community, the rapid development of vaccines and community engagement.

However, the most realistic outcome is cases will continue to rise before authorities successfully contain the current outbreak.

Nevertheless, the international community responded much more swiftly to this outbreak, particularly compared to the devastating 2014-’16 West African outbreak. That alone may protect us from an outbreak of the same catastrophic scale and cost.

Abrar Ahmad Chughtai is Senior Lecturer, Infectious Diseases Epidemiology and Control, UNSW Sydney.

Holly Seale is Professor, School of Population Health, UNSW Sydney.

Md Saiful Islam is Lecturer, UNSW Sydney.

This article was first published on The Conversation.

For decades, people have been told that their weight problems can be solved by math: Calories in, calories out. If weight were a simple math equation, more people would likely be the weight they desire. But it is much more complicated.

There are several theories as to why it is difficult to lose weight. Some focus on genetics and metabolism while others claim environmental and social factors are more important. But which of these theories is correct, if any? Are people destined to be the weight their genetics, metabolism or environment dictate?

I am a diabetologist and physician specialiding in obesity medicine. Understanding what’s known and uncertain about these theories can help you potentially overcome your own biology to change your weight.

Set point weight

The concept of set point weight has been around since the 1950s. It suggests that the body has a regulatory system that defends a predetermined level of adipose tissue – commonly called fat – it maintains by changing hunger cues and energy expenditure. That predetermined fat level is governed by genetics, physiology and environmental factors.

This idea is supported by observations that after weight loss, appetite is increased and energy expenditure decreased until weight is restored. In theory, this process prevents the body from starving, even with significant weight loss. One study found that hormones that cause hunger remain elevated and hormones that promote fullness are suppressed for at least 62 weeks after weight loss, and even after regaining weight.

A related concept called metabolic adaptation seems to influence energy balance, although the evidence for this effect in people is less clear. This process refers to a reduction in energy expenditure beyond what is predicted by changes in body composition. In other words, as you lose weight, you burn fewer calories than expected for someone at that same weight who has not undergone recent weight loss.

Metabolic adaptation manifests as an increase in appetite and a decrease in resting metabolic rate, which is the energy you burn to sustain background processes such as heartbeat, temperature regulation, respiration and digestion, even if you lie in bed all day. In metabolic adaptation, resting metabolic rate decreases after approximately 5% weight loss. The energy burned from exercise decreases after around 10% weight loss.

This means that as a person loses weight, the amount of energy used for the background processes to stay alive decreases. Furthermore, a person must increase exercise as they lose weight to see continued weight loss. So the more weight a person loses, the harder it is to lose more.

This decrease in energy expenditure may persist for years after weight loss, as was seen in a study of participants in the TV show “The Biggest Loser”. However, some studies have found metabolic adaptation to not be as significant as once thought.

There are several strategies to overcome set point weight and the metabolic adaptation expected with weight loss. Bariatric surgery – a procedure for weight loss – appears to alter set point weight, reducing hunger without decreasing energy expenditure and patients rarely become underweight. GLP-1 and similar medications may not affect metabolic adaptation while reducing weight. Nutritional strategies include increased protein intake, decreasing glycemic load and increasing high-fiber foods, although evidence for the effectiveness of these tactics varies.

Set point suggests your body has one set weight it likes to stick at and will adjust your metabolism and appetite in order to move you toward and keep you at it.

Settling point model

An alternative theory to set point weight is called settling point. This model proposes that weight regulation occurs through passive feedback without biological control. Rather than the body actively controlling weight through changes in hormones, this theory suggests that body weight is a result of your habits and surroundings.

The settling point is defined as where body weight stabilises because energy intake equals energy expenditure. This is determined by the physical and metabolic costs of maintaining body mass. People with more body mass expend more energy due to the increased energy needed to move and maintain a larger body. Therefore, people living in a larger body would have larger food intake needs.

Settling point may sound like the old “calories in, calories out” model, but it also considers environmental and societal influences. Think of it as an open window. The room may warm from the sunlight during the day, then cool down overnight. Over time, the room will tend to hover around the same temperature. The temperature isn’t fixed but will naturally settle based on the weather, insulation and airflow. It may be colder in the winter and warmer in the summer.

Now let’s apply this concept to a person. If you have a job where you are on your feet all day and eat home-cooked foods most of the time, your weight might be stable. If you switch to a desk job and start eating more calorie-dense foods and larger portions, your weight may increase until it becomes stable again. In both scenarios, your weight eventually stabilises at different settling points based on your current set of circumstances.

However, the settling points theory fails to explain biological and genetic aspects of weight.

Dual intervention point model

The dual intervention point model integrates both set point weight and settling point. This theory proposes an upper and lower threshold that define the boundaries of each person’s “acceptable” body weight, called the zone of indifference. The lower threshold is the point where starvation is prevented while maintaining all biological and metabolic needs.

Within the zone of indifference, settling point concepts prevail: The body will adapt to energy and environment. But when body weight falls below the lower threshold, it triggers physiological mechanisms to defend against further weight loss and prevent starvation. The body’s hormonal systems increase appetite and reduce energy expenditure.

When body weight rises above the upper threshold, biological mechanisms should theoretically engage to prevent further weight gain. Researchers have documented this process in numerous studies in animals, hypothesising that this is most likely due to the increased risk of predation from weight gain. Animals with more fat are targeted or can’t get away from predators. However, this process isn’t always seen in people and there is weaker evidence supporting it.

The dual intervention point model also suggests that the zone of indifference varies widely between individuals. This would account for why some people maintain a relatively stable weight and others have greater variation over time. Some may recognise this as the old struggle of “losing the same 10 pounds over and over again”.

Additionally, the drifty gene hypothesis proposes that the upper threshold for the body to intervene has gradually drifted upward as people moved into safer, more stable environments. The evolutionary pressure to maintain a lean physique for survival, such as avoiding predators like a hungry lion, has largely disappeared.

Which theory holds the most weight?

So which theory of body weight regulation is correct? The answer is none of them fits real world experiences exactly. But there seems be to a difference between how your metabolism responds to active weight loss compared to weight maintenance, so how to approach each goal may be different.

Decreasing food intake seems to be the most beneficial for attaining weight loss. Conversely, exercise seems to be key for weight maintenance.

Overall, the big takeaway is that weight balance is complex. It isn’t a simple math problem to solve. Adequate medical care for overweight and obesity encompasses nutrition, exercise, sleep, stress and other factors that influence weight. Changes in these factors can be combined with medication or surgery to achieve a sustained reduction in weight.

Weight loss is often not linear, and plateaus are expected. Each case is individual, and one size – or theory – does not fit all.

Kim Pfotenhauer is Assistant Dean for Clerkship Education and Assistant Professor of Osteopathic Medicine, Michigan State University.

This article was first published on The Conversation.

For the last two weeks, Jaskirat Singh, a government school teacher in Punjab, has been going to a nearby village every afternoon after work.

The teacher from Amritsar knocks on doors, asking people hundreds of questions. “On average, I tick off eight households from my list every day,” Singh, who is in his 50s, told Scroll. “Then I return home exhausted around sunset,”

Singh is one of 28,000 government employees deputed by the Punjab government to conduct the state’s first ever Drug and Socio-Economic Survey – an exercise meant to quantify drug addiction in the border state and assess the socio-economic and educational background of those dependent on drugs.

Chief Minister Bhagwant Mann, while announcing the survey in April, had said that the aim was to “understand the drug problem and then make targeted policies which will have better outcomes”.

But, on the ground, enumerators like Singh are running into hurdles.

In the last 15 days, the government school teacher in Amritsar has surveyed 120 households. “Only two or three families conceded that some of their family members were into drugs,” he said.

The survey’s format makes the majority of respondents evade questions related to drugs, Singh said. “Which mother will reveal to a stranger that her son or daughter is into drugs?” he asked. The teacher requested that his real name not be disclosed, because he feared government action for speaking to the media.

Difficult to admit

Weeks after it began, the “drug census” of 65 lakh households has spawned more questions than answers. Opposition parties have called it a “pre-poll exercise” by the ruling Aam Aadmi Party to gauge voter sentiment in the final year of its term.

Most strikingly, experts have warned that the survey, carried out through a mobile app, might throw up a distorted picture.

“It’s likely that the survey will come up with a positive figure like 80% of Punjab is free from drugs,” said Mohan Sharma, an anti-drug activist and former project director of the Red Cross drug de-addiction centre in Sangrur district. “[In that case], the results will go in favour of the government.”

Before the state-wide census, the Punjab government had carried out a pilot study across 11 villages of the state, according to a report in The Tribune. That study, the government said, had established that local residents were forthcoming on information about drug addiction.

Enumerators say they have not encountered such frankness.

In contrast, most people not only dodge questions about family members using drugs, but even those related to availability of drugs in the neighbourhood.

Singh explained: “The survey asks if drugs are available in the neighbourhood. If a respondent says yes, then the app throws up a new bunch of questions like: Where are the drugs available? Who is selling those drugs?”

He said that residents “tend to avoid answering these questions in the affirmative because it leads to many other questions that they are not comfortable answering”.

Mohan Sharma, the veteran anti-drug campaigner who has been creating awareness about drug abuse for over two decades, said he was not surprised.

Over the years, Sharma and his team members have held hundreds of awareness programmes in villages. But to gain the residents’ confidence remains difficult.

“Every time, I ask those who have become addicted to come forward,” he said. “Despite promising them free treatment and counselling, hardly anyone does.”

Many families have pragmatic reasons to deny that their family members are addicted to drugs – or even that they died of an overdose, Sharma said.

“They would rather pass it off as a cardiac arrest because they have an unmarried girl at home,” he said. “If they say that their family member died of a drug overdose, nobody will want to marry her.”

Ritu Bala, assistant professor and head of Punjabi University’s department of social work, said the survey’s methodology does not align with the principles of social science research.

“You cannot ask sensitive questions straight away and then expect people to answer them easily. Nobody will give an honest answer,” Bala said. “In social sciences, this type of research is always done after framing a proper research methodology. One of the key elements of this type of research entails having a strong rapport between the enumerator and the respondent.”

Fails to address gaps

Several studies have been carried out in the past to assess the extent of drug abuse in Punjab.

A 2015 study by All India Institute of Medical Sciences and the Ministry of Social Justice and Empowerment had estimated that over 2.3 lakh individuals in Punjab were opioid-dependent, with heroin as the most common opioid used.

In 2017, a study by Chandigarh’s premier Postgraduate Institute of Medical Education and Research had estimated that 14.7 % (29.7 lakh) of Punjab’s population was addicted to substances like alcohol, tobacco, opium, charas and heroin.

Alcohol topped the list of substances abused, with 22 lakh people being dependent on it, the survey said. Between 1.7 lakh and 2.7 lakh people were addicted to opioids.

The latest estimate is included in a 2023 report tabled by the Parliamentary Standing Committee on Social Justice and Empowerment before Lok Sabha. It put the number of opioid-dependent population in Punjab at 21.36 lakh. Of these, 3.43 lakh users were children in the age group of 10-17.

Mohan Sharma, the former director of Sangrur’s de-addiction centre, says the ongoing survey makes a mistake by not categorising alcoholism as drug abuse.

“They have left out the main substance to which people are hooked,” he said. Sharma, who has authored five books on drug abuse, said alcoholism in Punjab has wreaked havoc in the society. “My research shows that there are at least 16 widows in every Punjab village who have lost their husbands to alcohol consumption. How can they leave out alcoholism from the survey?”

Moreover, experts warned that the survey is unlikely to plug existing gaps in the data – for example, on the number of women addicts.

In 2015, a survey by Punjab’s ministry of social justice and department of health had estimated that 1% of the state’s 2.32 lakh opioid users were women. Many argue that the numbers may be much higher.

Dr Ritu Bala, the assistant professor from Punjabi University, Patiala, had little hope that the Punjab government’s survey would help reach a credible number. “Do you think a woman is in a position to come forward and confess about her addiction in a survey?” she said. “Even men shy from accepting their dependence on substances. One can just imagine how difficult it’s for a woman.”

Drug survey or political feedback?

The Punjab government has also drawn criticism for the nature of questions included in a survey ostensibly about drug abuse.

The survey includes approximately 160 questions, which take around 30-35 minutes to complete. “Many of these questions are related to the government’s schemes for the public,” said another government school teacher in Ludhiana, who asked not to be identified. “Rather than a drug survey, it looks like a political feedback survey.”

The Ludhiana teacher said the survey includes questions about every government scheme launched by the Bhagwant Mann government. “We have to ask respondents if they have benefitted from a scheme. For example, we have to record how much a household saves monthly on account of free electricity provided by the government,” he said.

In many cases, he added, the respondents are unaware of many government schemes. “In that case, we have to explain that scheme to them and inform them how they can benefit from it,” he added.

Some questions suggest that the survey’s findings may be used to devise the ruling party’s strategy ahead of the Assembly elections scheduled early next year. For example, the survey asks respondents to identify three issues which should be addressed by the government on priority.

Opposition parties in Punjab have questioned the ruling Aam Aadmi Party government’s intent in carrying out the survey.

Early in May, Congress Punjab state president Amrinder Singh Raja Warring alleged that the census was a “pre-poll” move to gather voter data at the cost of public funds.

Ravneet Singh Bittu, Bharatiya Janata Party leader from Punjab, accused AAP national convener Arvind Kejriwal of trying to damage the image of the state through the survey. “Data has become a powerful tool in today’s world,” Bittu said. “There appears to be a conspiracy to defame Punjab’s youth through these figures.”

In the 25 years I have spent watching how new health technologies travel through the global system, they have followed a predictable route. There is one tier for wealthy populations whose chronic diseases are treated with the best available medicine. The other is for everyone else: they are told to manage with whatever their underfunded health system can afford.

The latest example is a new class of injectable drugs that are better known by their brand names – Ozempic, Wegovy, and Mounjaro, or by the shorthand GLP-1, which refers to the hormone they mimic.

These drugs mimic the hormone the body produces to regulate appetite and blood sugar, resulting in significant weight loss and improved metabolic health.

They have transformed how wealthy countries treat obesity and are moving through the global system faster than most new health technologies. But the two-tier pattern is following close behind.

The intellectual property situation is changing rapidly.

The patent on semaglutide – the active molecule in Ozempic and Wegovy – has already expired in India, Brazil, China, Canada, and Turkey, covering roughly 40% of the world’s population. This means manufacturers in those countries can now produce their own versions without paying licensing fees to the original developer.

One analysis estimates the cost of producing a generic injectable version could be as little as $28 (approximately Rs 2,700) per person per year, a fraction of the $936 (approximately Rs 90,000) a month that Ozempic costs in the United States.

On paper, access for patients in low- and middle-income countries looks unusually promising. In December, the World Health Organization added GLP-1 drugs to the Essential Medicines List and published a global guideline encouraging countries to manufacture generic versions, buy collectively to reduce costs and price them on a sliding scale based on a country’s ability to pay.

Under the surface, however, there’s a different story.

Data on availability and use in low-income and middle-income countries is scarce. Only a few high-income countries are likely to afford coverage for GLP-1 receptor agonists for obesity management.

The commercial machinery for selling these drugs to wealthy markets is scaling up at a speed the public health architecture cannot match.

Eli Lilly’s Mounjaro and Zepbound generated $39.5 billion in revenue in the first nine months of 2025 alone, surpassing Merck’s cancer drug Keytruda as the world's best-selling medicine.

This illustrates how global health markets work.

One tier of the global metabolism is for populations in high-income countries whose obesity is treated as a chronic disease requiring long-term pharmacological management, reimbursed by insurance systems and employer health plans.

Another tier for the populations in low- and middle-income countries who carry the heaviest burden of obesity and metabolic disease. They are told to manage with lifestyle counselling in health systems that cannot consistently provide insulin at affordable prices.

In 2022, one in eight people globally was living with obesity, double the figure from 1990. The prevalence of the condition is associated with a low socioeconomic position globally. The people who need these drugs most are, by definition, the people least likely to receive them under current market conditions.

Access to effective treatment is inversely correlated with need.

The patent expiry changes the price equation but not the governance question. The arrival of affordable injectable semaglutide generics in 160 countries by the end of 2026 will be a genuine breakthrough – but only if the health systems receiving them have the clinical guidance infrastructure, prescribing capacity, monitoring protocols, and regulatory frameworks to deploy them safely.

A drug entering the market before supporting health infrastructure exists creates a new set of problems, as recent pharmaceutical history shows.

In rural India, for instance, a randomised controlled trial between 2002 and 2005 showed that oral misoprostol, an inexpensive drug for preventing postpartum haemorrhage, significantly reduced maternal bleeding when administered by trained auxiliary nurse-midwives.

Yet global reviews showed correct use depended critically on health workers’ training and supporting guidance. Programmes distributing the drug without sufficient training led to misuse and worsened outcomes.

A drug alone is not enough. Without proper systems in place, its benefits cannot be realised.

GLP-1 therapies require regular injections, clinical monitoring for side effects, and careful dose adjustment. In health systems unable to reliably stock insulin, such infrastructure is unlikely to be in place.

There is also the manufacturer’s response to consider.

Brand-name manufacturers could seek to extend market exclusivity by creating patent thickets – filing multiple additional patents on delivery devices such as the injection pen for rather than the obesity drug itself. This creates a web of legal protection that prevents generic manufacturers from producing the complete product.

This is a well-documented strategy in the pharmaceutical market. There is no reason to believe GLP-1 manufacturers will behave any differently from their predecessors.

The governance architecture required to prevent this does not currently exist at the global level. The inclusion of GLP-1medicines on the WHO Essential Medicines List means the world’s leading health authority considers a drug a basic necessity – but it does not mean any government is required to fund it, any insurer is required to cover it or any manufacturer is required to supply it at an affordable price.

Developing transparent, evidence-based strategies for allocating access to GLP-1 drugs, deciding which patients qualify, under what clinical conditions, and who bears the cost, is especially critical in low- and middle-income countries, where affordability and equity challenges are most acute.

However, overcoming these hurdles will require political will that multilateral health diplomacy has consistently struggled to generate for interventions that threaten pharmaceutical revenue.

What is missing from most discussions of GLP-1 equity is an honest account of who makes the decisions that determine access to these medicines. It is not the World Health Organization, nor the health ministries in most countries.

The decisions are made by pharmaceutical companies setting tiered prices, by insurance systems determining coverage criteria, by multilateral lenders deciding whether obesity treatment counts as productive health investment, and by donor governments deciding whether to include metabolic disease in their bilateral health agreements.

For instance, the bilateral health agreements the United States is currently negotiating with 31 countries – described by the US State Department as a shift from aid to trade – say almost nothing about obesity or metabolic disease. They are focused on HIV, malaria, and maternal health: the conditions that generate the most optics and the most straightforward programme metrics.

The chronic disease burden of obesity or metabolism that will define the health economics of the developing world for the next 50 years is not part of that conversation.

That absence is a diplomatic choice.

The question global health diplomacy needs to confront is not whether GLP-1 drugs should be available everywhere. They should. The question is who bears the cost of building the system that makes availability meaningful, and who bears the cost when that system does not exist and the drugs arrive anyway.

In global health, the answer to both questions has historically been the same population: the one that was already carrying the heaviest burden before the new technology arrived.

That is what a two-tier global metabolism means in practice.

Sunoor Verma is a former cardiothoracic surgeon and director of partnerships and advocacy at the World Innovation Summit for Health, Qatar Foundation. He writes in a personal capacity and his views are independent of his institutional affiliations.

Some of the most powerful interventions to slow or improve frailty are also the most ordinary: regular movement, adequate nutrition and meaningful social connection.

It almost sounds too simple for a condition now recognised as one of the strongest predictors of hospitalisation, disability, poor recovery from illness or surgery, nursing home admission and death in later life.

Older adults living with frailty have less physiological reserve: the body’s spare capacity to cope with illness, injury or stress. A relatively small event, such as a chest infection, a medication change or even a few days in bed, can trigger a sudden loss of independence. Meanwhile, a more robust older adult may recover quickly from a more serious illness.

How we age can vary greatly, even between people of the same age. One 82-year-old may stay active and independent, while another struggles to rise from a chair and becomes increasingly dependent after a short hospital stay.

The growing recognition that frailty, rather than age alone, shapes how people age is changing the way clinicians and researchers think about later life. While living longer is one of society’s greatest achievements, frailty and its evidence-based management have become increasingly important public health and clinical concerns.

Checking for frailty is now routine in many healthcare settings for adults aged over 65. Assessment increasingly focuses on how robust or frail a person is physically, cognitively and socially

Frailty assessment

There are two main ways frailty is assessed. The first sees frailty as a physical syndrome marked by weakness, exhaustion, slow walking speed, unintentional weight loss and low physical activity. People with one or two of these features may be considered “pre-frail”, while those with several are considered frail.

The second approach views frailty as the accumulation of health problems over time. In this model, chronic illnesses, mobility problems, memory difficulties, hearing or vision loss, poor nutrition and social isolation all contribute to a reduced ability to cope with a stressful event for the body, such as a fall, infection or hospital stay.

Frailty is often spoken about as though it is permanent, something a person simply becomes. You are either robust or frail, independent or dependent, strong or declining. But research suggests the reality is far more fluid.

Frailty exists on a spectrum from robustness to pre-frailty, mild frailty, moderate frailty and severe frailty, and people may move in either direction over time. Although frailty often progresses, it can sometimes be delayed or improved, depending on the underlying cause and the support available.

Frailty isn’t always permanent

A large review involving more than 42,000 older adults found that, over an average follow-up period of almost four years, around 14% of people improved their frailty status, nearly 30% became more frail, and just over half remained stable. The findings suggest frailty is dynamic and, for some people, potentially reversible.

Rather than simply asking whether someone is frail or not, clinicians are increasingly looking at where a person sits on the frailty spectrum and what supports might help build resilience. Early signs such as slowing down, fatigue or unintentional weight loss are now recognised as an important opportunity for intervention through relatively simple lifestyle changes.

Regular physical activity that includes resistance-based exercise, such as using weights, elastic bands or body weight to build strength at least twice per week, can help improve frailty or slow its progression. The benefits can be even greater when exercise is combined with nutrition or cognitive interventions, such as memory, attention and problem-solving activities.

An Irish trial of a home-based frailty programme delivered through primary care targeted older adults living with mild frailty or less. The programme combined strengthening exercises, regular walking and dietary protein guidance. Frailty rates in the intervention group fell from 17.7% to 6.3% after three months, while they slightly increased in those receiving usual care.

Recovery also appears to depend on more than physical health alone. In a study of more than 5,000 adults aged 75 and older, nearly one-third of those who were frail at the start of the study recovered to a less frail state within two years. Recovery was more likely among those who took part in exercise-based social activities, rated their own health more positively, trusted their community and regularly interacted with neighbours.

Activities that challenge memory, attention and problem-solving can support cognitive health and may help reverse frailty. Psychological resilience, the ability to adapt to stress or difficult life events and recover from them over time, has also been linked to better frailty outcomes.

Frailty is now recognised as more than an inevitable part of ageing. While it remains a powerful predictor of hospitalisation, disability and death in later life, growing evidence shows it can often be prevented, slowed or improved. Everyday choices, including how much we move, who we spend time with and the activities that give us purpose and connection, can help support healthier ageing.

Ide O'Shaughnessy is Associate Professor, School of Allied Health, University of Limerick.

Christina Hayes is Assistant Professor, Ageing Research Centre, University of Limerick.

Katie Robinson is Professor of Occupational Therapy, University of Limerick.

This article was first published on The Conversation.

Consumption of ultra-processed foods – including soft drinks, snacks and ready meals – is growing worldwide, despite evidence they are unhealthy.

Ultra-processed foods make up about 70% of packaged food products on supermarket shelves, and even more in convenience stores.

In our new research, we explore how companies that produce these foods play on human nature to make such products seem the easiest, most rewarding and compelling option.

We show that ultra-processed foods are designed to make us crave them and eat more. They are marketed to all groups, particularly children, in a way that makes them seem the most delicious and convenient option, giving the best value-for-money, despite many health harms.

Our attraction to ultra-processed foods is no coincidence. Ultra-processed foods companies combine a range of tactics to drive up consumption. Many of these tactics exploit the ways we think, feel and behave.

Why we keep eating UPFs

Ultra-processed foods are the most processed foods on the market. According to medical journal The Lancet, they are commercial formulations made from cheap ingredients extracted or derived from whole foods, combined with additives, but mostly containing little to no whole food in the end product.

Ultra-processed foods are heavily branded and marketed, and most are produced by large international corporations.

But diets high in UPFs carry a risk of developing a wide range of serious health conditions, including excess weight or obesity, type 2 diabetes, hypertension, heart disease, cancer, chronic kidney disease and depression, as well as premature death.

Our research asked why we keep eating diets high in ultra-processed foods when we know how unhealthy they are. To answer this, we decided to zoom out and explore the system that develops, produces and markets ultra-processed foods, and investigate how human nature is caught up in it.

We reviewed a decade of published research on the food science and marketing of ultra-processed foods, and then worked with experts in these fields to create and refine system diagrams to visualise how it works.

These maps are called “causal loop diagrams”, and their power is in showing reinforcing (positive) feedback loops that drive the system towards its ultimate purpose: selling more ultra-processed foods.

We found the system is made up of many interconnected loops that capture parts of human behaviour and biology as key elements.

Designed for maximum consumption

One feedback loop includes the use of addictive combinations of ingredients, particularly refined carbohydrates and fats. Biologically, carbohydrates (including but not limited to sugars) and fats activate different reward pathways between the gut and brain. When they are consumed together, their effects become addictive.

These ingredients can be combined in many different concentrations to hit sensory “sweet spots”. In other words, they maximise pleasure and craving responses while minimising negative responses.

Further strategies include processing methods that suppress peoples’ natural sense of being full or speed up digestion in order to give an immediate but quickly fading sense of “reward”, making us want more, sooner.

UPF marketing strategies

In terms of marketing, products are formulated to be easy and convenient to store and eat, and to appeal to our sense of getting good value.

Various promotional techniques aim to capture consumers’ attention and desire, as well as giving the illusion of healthiness. Strategies targeting children in particular employ popular culture associations with coolness or fun.

Another example of a feedback loop is how corporations collect large and complex data on our purchasing habits and our online lives, informing targeted digital marketing on social media platforms. This tends to be effective at driving purchases, providing more data to further refine these promotion strategies.

Overall we identified 11 different reinforcing feedback loops. Our research is the first study to show this web as part of the ultra-processed foods system, designed to essentially trap people into buying and eating more and displacing healthier options in diets.

This product-level system also connects with feedback loops further up the supply chain in economic and financial spheres of the global UPF production.

This matters because unhealthy diets and excess body weight cause 18% of preventable premature death and disability in New Zealand. Both risk factors are linked to eating too much ultra-processed foods.

Unfortunately, New Zealand hasn’t undertaken national nutrition surveys since the 2000s and we have to rely on data from similar countries such as Australia to estimate that ultra-processed foods make up about half of our energy intake.

What to do about it

Diets high in ultra-processed foods are not the result of people’s free personal choice or weak willpower, but of an intentionally designed system.

Our research shines light on how the ultra-processed foods system is taking advantage, particularly of children. International experts have framed ultra-processed foods as a major global health issue, and advise strong government policy to regulate these products to counter some of these mechanisms.

Policy leadership already exists in other parts of the world, particularly in Latin America. New Zealand could follow other countries that have implemented taxes on ultra-processed foods and sugary drinks, regulations restricting advertising to children, strong front-of-pack labelling and transparency policies such as public disclosure of lobbying in government.

Complacency is not an option. The food system needs rebalancing so that it serves and nourishes people now and in the future.

Kelly Garton is Senior Research Fellow in Population Health, University of Auckland, Waipapa Taumata Rau.

Boyd Swinburn is Professor of Population Nutrition and Global Health, University of Auckland, Waipapa Taumata Rau.

This article was first published on The Conversation.

We’ve all heard the advice: eat your fruit and vegetables, get your vitamins, and stay healthy. For the most part, that guidance holds up. But some nutrients have a more complicated story, and vitamin B12 is a fascinating example.

Also known as cobalamin, B12 is essential for life. It helps the body produce red blood cells, keeps the nervous system functioning, and plays a central role in how cells copy and repair DNA.

B12 is found naturally in animal products such as meat, fish, eggs, milk and cheese. Some cereals and breads are also fortified with it, helping people who do not eat meat get enough. Most people following a varied diet get the recommended amount, but vegans, people with certain gut conditions and older adults who absorb nutrients less efficiently may need supplements.

Without enough B12, things can go wrong, sometimes seriously, especially if deficiency is not recognised and treated. Yet in recent years, researchers have been asking whether high levels of B12 intake or high levels of B12 in the blood could be linked to cancer.

Staying balanced

The body is constantly making new cells. Every time a cell divides, it needs to copy its DNA accurately. Vitamin B12 is critical to that process. When levels are too low, DNA can be copied incorrectly, leading to mutations that, over many years, may increase the risk of certain cancers, particularly colon cancer. This is why B12 deficiency is taken seriously.

A 2025 case-control study from Vietnam found what researchers described as a U-shaped relationship between B12 intake and cancer risk, with both lower and higher intakes associated with increased risk. Because this kind of study can show an association but cannot prove cause and effect, the takeaway is not that B12 is dangerous. It is that balance matters.

It might seem logical that if B12 helps healthy cells thrive, taking extra doses should offer extra protection against cancer. But research does not fully support this. Vitamin B12 supports cell growth generally, not only the growth of healthy cells. One concern is that, if pre-cancerous cells are already present, very high availability of growth-supporting nutrients such as B12 could, in theory, support their growth too. But this remains difficult to prove in humans.

Overall, studies of high-dose B vitamin supplements taken over long periods have not shown clear protective effects against cancer incidence or cancer deaths. One analysis did report a reduced risk of melanoma, but this was a cancer-specific finding rather than evidence that high-dose B vitamins prevent cancer generally. Some observational research has also suggested a slight increase in lung cancer risk linked to long-term, high-dose B6 and B12 supplementation, particularly among men and smokers, although this kind of study cannot prove that the supplements caused the cancers.

Doctors have noticed that many cancer patients show unusually high levels of B12 in their blood. This raises an important question: does elevated B12 contribute to cancer, or can cancer itself cause B12 levels to rise?

Research in 2022 concluded that high B12 in cancer patients is often an “epiphenomenon”. In other words, the vitamin appears alongside the disease but does not necessarily trigger it. Further research from 2024 reached a similar conclusion.

This effect is thought to involve two main mechanisms. First, tumours can affect the liver, which stores large amounts of B12. When the liver is damaged or under strain, it may release more B12 into the bloodstream. Second, some tumours may increase proteins that bind to B12 in the blood. This can push blood test readings higher without necessarily meaning the body’s cells are receiving or using more B12.

Useful indication

Researchers are also recognising that elevated B12 may not be a cause of cancer, but it could be a useful marker of whether cancer is present or progressing. A large 2026 study found that colon cancer patients with very high B12 levels survived a median of around five years, compared with nearly eleven years for those with normal levels.

Similar patterns have been found in oral cancer and in patients receiving immunotherapy, where elevated B12 has been associated with poorer outcomes. This means that unexplained, persistent high B12, especially when it is not caused by supplements, should not be ignored. It may point to liver disease, blood disorders or an underlying cancer that has not yet been detected.

For most people, this is not something to worry about. B12 from a normal diet containing meat, fish, eggs, dairy or fortified foods is not usually the issue: it is very difficult to consume too much B12 from food alone. Deficiency remains a more common and better-established problem than excess.

The concern is prolonged high-dose supplementation without medical advice, or a blood test showing persistently high B12 when someone is not taking supplements.

The broader message is simple: more is not always better. Cancer cannot be prevented by loading up on any single vitamin. Long-term habits matter more: eating a balanced diet, exercising regularly, avoiding smoking, protecting your skin and attending routine health screenings.

So what about vitamin B12? Get enough through food or supplementation if you need it, especially if you are vegan, older or have a condition that affects absorption. But leave the megadoses on the shelf unless a doctor advises them. With B12, as with many nutrients, the goal is not as much as possible. It is the right amount.

Ahmed Elbediwy is Senior Lecturer in Cancer Biology & Clinical Biochemistry, Kingston University.

Nadine Wehida is Senior Lecturer in Genetics and Molecular Biology, Kingston University.

This article was first published on The Conversation.

Parveena Khatun, 45, runs a tea stall on Baba Gangnath Marg in Delhi’s Munirka. The shortage of cooking gas cylinders has affected Parveena’s income.

When supplies fell in March, she kept her stall closed for a week but without the income, survival became difficult. Then, she built a brick stove (chulha), bought coal and gathered firewood. In Delhi’s intense summer, working throughout the day on a chulha is dangerous.

Temperatures around the chulha remain high, leading to thermal discomfort and heat stress, and the set-up leaves Parveena gasping for breath at the end of the day. Her hands have burn marks – she’s never worked on a chulha before.

“Yesterday afternoon,” said Parveena, who moved to Delhi from Bihar’s Siwan in 2002, “the heat was so intense that between the smoke and the heat, I started feeling dizzy. I sat under a tree for a while and washed myself with cold water; my whole body was restless.” She was speaking of April 23, when Delhi saw a maximum temperature of 43 degrees celsius.

The Commission for Air Quality Management issued an order on March 13, 2026, giving temporary permission to burn diesel and biomass (wood, dung cakes, and coal) and waste-derived fuel in Delhi-NCR, which has been extended until May 13, 2026.

Solid fuel like firewood, cow dung and dry grass are highly damaging to health, as IndiaSpend reported in April 2019. Cooking on traditional chulhas leads to incomplete combustion, and emission of particles such as suspended particulate matter, carbon monoxide, polyaromatic hydrocarbons, polyorganic matter and formaldehyde. All these are harmful for respiratory health.

Women and younger children who spend the most time at home are the most vulnerable, we had reported. Exposure to air pollution during pregnancy leads to outcomes such as low birth weight and stillbirth.

In 2022, India saw 113 deaths per 100,000 people due to household air pollution, according to the Lancet Countdown on Health and Climate Change report 2025. For the estimated population of 1.46 billion that year, this works out to 1.65 million deaths from indoor pollution. Household air pollution also contributes to 22%-52% of ambient air quality, studies suggest.

And this is before the effects of heat are considered.

Each time a woman cooks over a chulha in this heat, her body is fighting two battles at once – trying to cool down while also breathing in harmful smoke, explains Vidhya Venugopal, professor of occupational and environmental health at the Sri Ramachandra Institute of Higher Education and Research, Chennai. “It is a killer combination. This is far more dangerous than either problem alone and can quickly lead to exhaustion, dizziness, and breathing difficulties. For women working long hours outdoors, this combination can become a serious health emergency.”

A May 2025 study in Geo Health shows that risk of premature mortality during hot and polluted days was higher than normal days. “The compound increase in PM2.5 and temperature intensity could elevate the risk of fatality,” the study said.

Another study published the same month in Environment International, which analysed 3.6 million deaths across 10 Indian cities between 2008 and 2019, found that air pollution becomes much more dangerous as temperatures rise.

Shortage, black market

The war in West Asia has led to stalled shipments, and India depends on imports for 60% of its liquefied petroleum gas consumption. Domestic production rose 25%, and is being directed to household consumers, after which hospitals and educational institutions are being prioritised.

Since the first week of April, reports of migrant workers returning home from Delhi-National Capital Region began surfacing, with a large number of labourers seen heading back from Delhi’s railway stations.

By May 8, the government said, commercial LPG availability stood at 70% of pre-crisis levels. But many roadside eateries depend on the black market for their cooking gas needs.

India’s LPG consumption fell 16% this April, compared to April 2025, government data released by the Petroleum Planning and Analysis Cell show.

“At retail shops, gas is being sold for Rs 350-400 per kg,” Parveena said. “If I buy Rs 100 worth of gas for Rs 400, I would have to raise the price of a cup of tea from Rs 10 to Rs 40. Who would buy it?"

Prices for commercial cylinders, which stood at Rs 1,768.5 for 19 kg on March 1, rose to Rs 3,071 earlier this month.

“I have a domestic connection, but the cylinder ran out 15 days ago. I am using the chulha at both my stall and home,” said Parveena, whose elder daughter is studying for a bachelor’s degree and the younger just finished school. “I have booked a refill, but it hasn’t arrived yet.”

Reena Kumari, 30, living in the Coolie Camp of Vasant Vihar, was cooking on a chulha in the bright afternoon sun. The family does not have a gas connection, and earlier got the 5-kg cylinder refilled, but now shops have stopped refilling them. “Even where gas is available, it’s costing Rs 400 for one kg. I cannot afford it.

“I have two small children who get very distressed by the smoke and start crying. But I have to cook; I won’t let the children starve.” Kumari’s husband is 34, and works as a cook in a hotel.

"Every time someone cooks over wood or coal in a closed kitchen, they breathe in smoke that is far more toxic than outdoor city pollution,” said Venugopal. “In the short term, this causes burning eyes, coughing, and headaches – but over the years, it quietly damages the lungs and heart, sometimes leading to serious diseases like COPD [chronic obstructive pulmonary disease] or even lung cancer. The tragedy is that for many families, there is simply no other option.”

The government has asked states to improve access to free-trade LPG cylinders, which hold 5 kg gas and have lower documentation needs. These are typically meant for consumers such as migrant workers and students. The government has doubled allocations to states and oil companies are organising awareness campaigns. Retail prices of refills have also increased.

The shift back to polluting cookstoves

Sanghamitra Patra, 28, who came to Delhi from Odisha in search of employment in 2022, runs Chandini dhaba in Munirka. Since the crisis began, she has been running it using two wood stoves. “While cooking on the chulha, the flames spread far. It feels like being thrown into a furnace,” she says.

Her family does not have an LPG connection. Earlier, she used to buy refills by paying delivery persons a little extra but now, a refill costs up to Rs 4,000 on the black market. “My two children go to school; I can’t even make lunch for them. After school, they come here to the dhaba to eat."

“I had never cooked on a chulha before. Now I only make dal, roti, and rice because it takes much longer to cook on the chulha,” she said. “The dhaba gets filled with smoke, so many customers turn back. My income has decreased by half. It has become difficult to pay the rent for the shop and the house.”

“Women, especially those in low socio-economic status, are the ones standing over the fire for hours every day, so they breathe in the most smoke and feel the most heat,” Venugopal said. “When you add poverty, poor nutrition, limited healthcare, and no real choice of fuel, the body simply has fewer resources to cope and recover. These women are not weak, but they are being exposed to hazards – an impossible situation with no support."

On April 24, the Union Ministry of Petroleum and Natural Gas stated in a press conference that the supply of domestic LPG remains smooth. Meanwhile, at an Indane gas agency in Masoodpur, near the Jai Hind Camp slum, long queues were seen on April 23 at 4 p.m. Ramveer, a gas mechanic at the agency, explained that the crowds were there to resolve persistent technical issues with their bookings. When asked about the 5 kg cylinders, he said they are not seeing many new applications.

We reached out to the ministry for comment on the challenges faced by migrant workers and concerns over the affordability of the 5 kg cylinders. We will update this story when we receive a response.

Double burden of pollution

Urban slums suffer from a double burden of pollution. They are exposed to the high ambient particulate matter of cities and the household air pollution from unclean cooking fuels. According to a survey report by CEEW, 45% of urban slum households in India use traditional fuel like dung cakes and firewood for cooking.

"Migrant workers were never adequately covered by clean fuel access even under conditions of good LPG supply,” said Kalpana Balakrishnan, professor and dean (research) at SRIHER. “The crisis has heightened the need for expanding clean energy access to all vulnerable populations, including the urban poor, who often face risks greater than the rural poor.

“In lower socio-economic status households, cooking expenses account for more than 30% of their limited income. Any financial shock forces them to look for alternatives,” Balakrishnan added. “However, India has made significant progress in clean cooking, especially through the Pradhan Mantri Ujjwala Yojana. Despite this, it has been challenging to bear the costs of increasing usage and to reach the bottom 10% of the poorest population. Now, the rising number of people reverting to solid fuels has made the situation even more serious."

"Those who can afford to switch to solar should be encouraged, freeing up LPG for the most vulnerable,” she added. “Cities like Delhi can rebalance energy use through redesigned, smarter subsidy structures and lead the transition to renewable cooking nationwide."

Shivam Bhardwaj is an independent journalist based in Bareilly.

This article first appeared on IndiaSpend, a data-driven and public-interest journalism non-profit.

Iodine deficiency is often seen as a problem of the past, but this isn’t entirely true. During the 20th century, the iodisation of salt became one of the most effective public health interventions for preventing conditions caused by a lack of this mineral, including goiter (enlargement of the thyroid gland) and preventable damage to neurological development.

The World Health Organization (WHO) still views iodised salt as a safe and effective strategy, while UNICEF notes that it is the most widely used way of improving iodine intake worldwide.

However, the success of this simple measure means iodine has all but disappeared from public debate. And today, in several countries, signs of insufficient intake are once again being detected in certain groups, particularly in pregnant or breastfeeding women and people on restrictive or poorly planned diets.

What we are witnessing is not a dramatic resurgence of the most severe symptoms everywhere, but rather a silent risk of deficiency in contexts where vigilance has waned.

Iodine’s role in the body

Iodine is an essential micronutrient for the synthesis of thyroxine (T4) and triiodothyronine (T3), hormones that regulate metabolism, growth, and many physiological processes. Adequate intake during pregnancy and early childhood is particularly important for the normal development of the central nervous system and for the early stages of brain maturation.

In addition, the body’s needs increase during pregnancy and breastfeeding due to increased maternal production of thyroid hormones, greater renal excretion of iodine, and the transfer of this mineral to the fetus and the infant.

Why deficiency is on the rise again

The issue is not that people have stopped consuming salt, but rather that the type of salt they consume has changed, as have the sources of sodium in their diet. In recent years, iodised salt has been replaced in many households by “gourmet” or “natural” salts. These include sea salt, pink Himalayan salt, flaked salt and kosher salt, which are often perceived as more sophisticated or healthier, even though they are not always iodised.

In a way, iodised salt has an image problem. Compared to the culinary prestige of its trendy rivals, it has come to be viewed as something ordinary, outdated even.

Today, lot of our salt intake also comes from processed and ultraprocessed foods, meaning the use of iodised salt cannot be guaranteed. For this reason, the World Health Organization has called for coordination between policies that aim to reduce sodium intake and those that promote iodised salt.

The makeup of our diets has also changed a lot. Iodine is naturally present in all seafood, some dairy products and in eggs, though the quantity may vary from one region or food system to another. When a person reduces or cuts out several of these sources at once while not also consuming iodised salt or fortified foods, the risk of deficiency increases.

The result is that a basic, inexpensive, and effective micronutrient has fallen out of the spotlight just as certain groups are once again at risk of not getting enough iodine.

Plant-based diets

Vegetarian and vegan diets can be healthy, but they must take iodine into consideration. A 2023 review in the British Journal of Nutrition concluded that people following a plant-based diet, especially vegans, may find it hard to get the recommended amount of iodine from these foods alone.

This does not mean a plant-based diet is inherently lacking – and the solution is straightforward. Just as vitamin B12 is is commonly recommended for those who reduce their consumption of fish or dairy – or when people replace animal products with unfortified plant-based alternatives – so too should iodine.

Pregnancy and breastfeeding

Iodine deserves special attention during pregnancy. There is strong evidence that a severe deficiency of this micronutrient can affect fetal development and thyroid function, which is why many organisations use specific thresholds to assess iodine status in pregnant women. The US National Institutes of Health states that a urinary concentration of 150–249 micrograms per liter (μg/L) in pregnant women is considered adequate for the general population.

But there is a caveat to this. Concerns about mild or moderate deficiency are legitimate, but there is no conclusive evidence as to the cognitive benefits of supplementing all pregnant women who show a mild deficiency. Reviews and trials have indicated that there is plausible biological concern, and some studies suggest an association with poorer outcomes, but controlled experiments have not unanimously shown clear improvements in infant neurodevelopment.

Nevertheless, several scientific societies have adopted a cautious stance. The American Thyroid Association, for instance, states that women who are planning to conceive, pregnant or breastfeeding should receive 150 μg of iodine daily in prenatal or multivitamin supplements, usually in the form of potassium iodide, to help meet increased requirements.

Why ‘more salt’ is not the answer

Another important clarification is needed here. Advocating for iodised salt does not mean recommending a higher salt intake. The WHO maintains its recommendation to reduce sodium intake due to its link with high blood pressure and cardiovascular disease. In terms of public health, the solution is not “more salt”, but less – though the salt we do eat should be iodised.

In fact, the WHO itself has emphasised that reducing salt intake and fortifying salt with iodine are compatible, provided the concentration of the mineral is properly adjusted and salt used by the food industry is also fortified.

This point is key because it avoids two common pitfalls: turning the issue into a nostalgic defence of table salt, or the other extreme of assuming that any reduction in sodium intake will automatically solve all health problems without any nutritional consequences. But it is possible to strike a balance between preventing cardiovascular disease and iodine deficiency.

José Miguel Soriano del Castillo is Catedrático de Nutrición y Bromatología del Departamento de Medicina Preventiva y Salud Pública, Universitat de València.

This article was first published on The Conversation.

Chronic obstructive pulmonary disease, or COPD, is one of the world’s leading causes of death, responsible for 3.5 million deaths in 2021 alone. It is often thought of as a disease of older smokers. But that picture is too simple. COPD usually develops slowly over many years, often long before symptoms become obvious.

COPD is a long-term lung condition that makes it harder to move air in and out of the lungs. It includes damage to the airways, often described as chronic bronchitis, and destruction of the tiny air sacs in the lungs, known as emphysema. Because this damage builds up gradually, many people do not realise anything is wrong until symptoms become difficult to ignore. There are treatments that can help, but there is no cure, and by the time COPD is diagnosed the damage is often permanent.

Common symptoms include a long-term cough, bringing up mucus and shortness of breath. These symptoms often appear later in life, which helps explain why COPD is so often seen as an older person’s disease. But in many cases, the damage started decades earlier.

Many environmental irritants can harm the lungs, but cigarette smoke remains the main cause of COPD. Cigarette smoke contains thousands of chemicals, including toxic gases and cancer-causing substances, that injure lung tissue and trigger oxidative stress, a form of cellular damage that drives inflammation.

Inflammation is part of the body’s normal defence and repair system. Usually, it settles once the source of harm has gone. But in COPD, the lungs may be exposed to cigarette smoke day after day, so the inflammatory response never properly switches off.

Over time, immune cells sent to repair the damage can end up injuring the lungs further. The airways become narrower, the lungs produce more mucus, and the tiny air sacs known as alveoli can break down. Together, these changes make breathing increasingly difficult.

As the disease progresses, the lungs are physically altered in ways that cannot be fully reversed, even if someone stops smoking. COPD inflammation also does not always respond well to standard anti-inflammatory medicines such as steroids, which is one reason prevention matters so much.

Although cigarette smoking remains the main driver of COPD, e-cigarettes are also raising concerns. Vaping aerosols can contain nicotine, ultrafine particles and flavouring chemicals that may irritate the lungs and contribute to inflammation. The long-term effects are still unclear because these products are relatively new.

That matters particularly for younger people. In Great Britain, recent survey data suggest that 7% of 11- to 17-year-olds currently vape. While that does not mean they will go on to develop COPD, it does mean more young lungs are being exposed to substances whose long-term effects are not yet fully understood.

COPD is often diagnosed only after major lung damage has already occurred. Because it develops so gradually, people may dismiss early breathlessness, coughing or mucus production as a consequence of getting older, being unfit or smoking. Respiratory organisations warn that symptoms such as cough, phlegm and shortness of breath should not be treated as a normal part of ageing, while studies show that COPD remains widely underdiagnosed, including among people with respiratory symptoms.

The burden on health systems is huge. A 2023 study estimated that COPD could cost the global economy around INT$4.3 trillion between 2020 and 2050. International dollars adjust for differences in prices between countries; in broad terms, this is roughly equivalent to US$4.3 trillion in US purchasing power, or about £3.2 trillion if treated as US dollars at current exchange rates. Hospital admissions often rise in winter, when people with COPD are more vulnerable to bacterial and viral infections that can worsen symptoms and speed up decline.

That is why the most important window for action may come much earlier in life. By the time many people are diagnosed, the disease has been developing for years. Better education about lung health at school age could help people understand that choices made in their teens and twenties may shape their breathing decades later.

COPD care has traditionally focused on treating symptoms once they appear. But by then the lungs may already be permanently damaged. Seeing COPD as a disease that develops slowly over decades could shift attention towards earlier prevention and, ultimately, reduce its human and economic cost.

This article was first published on The Conversation.

While some people can spring out of bed at six in the morning and go straight into their day, others prefer to wake up later as they’re most productive in the afternoon or evening. This difference is due to your chronotype – the biological tendency to prefer certain times of day for sleep, waking and activity.

But these aren’t the only factors affected by your chronotype. A growing body of research also suggests that your chronotype can affect the benefits you see from exercise.

People who naturally rise early and feel sharpest in the morning are “early chronotypes”, whereas those who prefer to wake later and function better in the afternoon or evening are “late chronotypes”. People who fall in between are “intermediate chronotypes”.

Your chronotype is determined by your circadian rhythms – the body’s natural daily cycles that repeat around every 24 hours. Although these are strongly influenced by our environment, they function even without external cues such as daylight and food. These rhythms affect our physiology, behaviour and health.

Our circadian rhythms are controlled by the body’s circadian system, which is made up of tiny biological clocks composed of proteins, which are found in organs and tissues. These clocks rely on genes that help coordinate when different processes happen, such as when we feel alert or sleepy.

The circadian system also influences many other bodily functions, including blood pressure, heart rate, blood sugar regulation and blood vessel function. As these factors are also affected by physical activity, this may explain why aligning your workouts to your natural chronotype can be beneficial.

Some studies support this, suggesting that the time of day people exercise can influence health outcomes – including cardiovascular fitness and reducing the risk of cardiovascular disease, obesity and some cancers.

However, as these were observational studies (which only show associations rather than cause and effect), they can’t definitively prove that the findings were solely caused by the timing of the exercise.

But a recent randomised controlled trial has investigated whether aligning workouts with chronotype could enhance the benefits of exercise. The researchers specifically looked at people who were at risk of cardiovascular disease.

Participants were grouped according to their chronotype, which was measured using a specialist questionnaire. Morning types exercised between 8–11am and evening types exercised between 6-9pm. A third group exercised at the opposite time to their chronotype (morning types in the evening and evening types in the morning).

Participants whose exercise was aligned with their chronotype experienced greater improvements in blood pressure, aerobic fitness, blood glucose, cholesterol and sleep than participants whose training times were misaligned with their chronotype.

But though these improvements show that timing exercise to your chronotype can enhance its health benefits, there are a couple of important nuances.

Even the group that exercised at the supposedly wrong time still experienced health benefits, showing that exercise is beneficial even when it doesn’t align with your chronotype. The study also did not include intermediate chronotypes, who make up around 60% of the adult population. For these people, the timing of exercise may be less important.

Based on the available evidence, exercise timing appears to be a meaningful consideration, particularly for people who are strong morning or evening chronotypes.

Beyond your chronotype

So how do you know your chronotype?

Most people have an intuitive sense of this based on when they naturally prefer to sleep and wake. However, work schedules and care-giving responsibilities often force us into routines that conflict with our chronotype. Over time, this makes it harder to be sure of your chronotype.

For this reason, researchers developed a questionnaire to help you determine your chronotype. The 19 questions include what time you feel you’re at your peak and how easy you find it to wake up in the morning.

Once you have a clearer sense of your chronotype, you can start thinking about when to schedule your training.

However, chronotype isn’t the only factor that can affect training and how you respond to exercise. This is good news for those who may not be able to align workouts with their chronotype.

For instance, body temperature usually peaks in the afternoon regardless of chronotype, which enhances muscle function. This is why strength, speed and coordination tends to be best in the afternoon, making it a prime window for resistance training and technical practice for most people.

Habitual training time can also shift performance over time as the body adapts to the time you regularly train. So even if you’re naturally a night owl, consistent morning training may eventually make you perform better at that time.

Another critical factor to consider when deciding when to workout is sleep.

If you haven’t slept well the night before, research suggests it’s better to exercise earlier in the day, regardless of your chronotype. This is because the drive to sleep, known as “sleep pressure”, builds steadily from the moment you wake up and peaks just before you fall asleep. By evening, growing sleep pressure makes exercise feel harder and can impair your performance.

Exercising late in the evening can also reduce sleep quality, particularly when the session is intense. As a general rule, leave at least a two-hour gap between exercise and bedtime.

There’s no single best time to exercise that works for everyone. While the evidence on the long-term health benefits of matching exercise time to chronotype is growing, some principles apply broadly.

Peak performance varies by chronotype, and matching your workout time to yours may help you train harder and achieve better health benefits. However, any exercise is better than none – regardless of timing.

If you’re a night owl but can only train in the morning, a warm-up is essential. Wear extra clothing and start with 10-15 minutes of light aerobic activity to gradually increase body temperature and increase alertness.

If evenings are your only option, opt for moderate or low-intensity activities (such as yoga or a jog) to avoid disrupting sleep.

Paul Hough is Lecturer Sport and Exercise Physiology, University of Westminster.

This article was first published on The Conversation.

You’re standing in a supermarket aisle, weighing up whether to buy a microwave meal or a bunch of fresh carrots.

We all know making healthy eating choices can be tough. That’s especially true if you are hungry, or have a hungry household to feed.

There are so many reasons for this, and many are outside our control. But one you might not be aware of is a psychological concept known as “decision fatigue”.

So what exactly is decision fatigue? And could it help or hinder your healthy eating goals?

What is decision fatigue?

Decision fatigue, also known as choice overload, describes what happens when we make many effortful decisions over time.

Whenever you make a decision, you use a small amount of mental energy. As that energy runs low, you tend to make worse decisions.

This means you’re more likely to act without thinking, or simply choose what is easy or familiar. You might also find it harder to plan ahead and resist certain impulses.

This means you might be more likely to grab a takeaway instead of the ingredients to make a meal, or default to familiar comfort foods instead of making intentional, healthy choices.

How might it affect my eating habits?

The average person makes hundreds of food decisions each day.

You may think you’re just choosing a meal. But that one decision involves making many layered choices about what and how much you eat, as well as where, when and how you eat it.

You may make these choices subconsciously or automatically. But they each require to you weigh up various factors, such as taste, costs, time, expectations and more.

When decision fatigue sets in, you’re less likely to make thoughtful, health-focused choices. Instead, you may gravitate towards options that require less effort and offer quick rewards. You may also become more influenced by outside cues. An example of this is advertising that promotes convenient but high-calorie options such as fast food, snacks or indulgent treats.

Having too much information can make these decisions even harder. Nutrition advice often assesses the value of foods by how much protein, fat, fibre or vitamins they contain. This way of thinking, sometimes called nutritionism, can make food choices more complex. Instead of choosing food as food, we try to calculate and juggle many numbers at once.

Not the only factor

Several other factors may affect your food choices.

One is stress. One study from 2022 showed parents who experience high levels of both stress and decision fatigue found it more difficult to stick to positive food-related behaviours, such as making meals from scratch or eating together as a family.

Another is tiredness. One 2017 study showed time of day affected meal choices. It found between mealtimes, and especially in the afternoon, people were more likely to choose the simpler default food choice than one that required more consideration. This suggests having lower blood sugar and less mental energy meant people made less considered decisions.

How can I reduce my decision fatigue?

Here are four tips.

Have healthy foods on hand

When we’re low on mental or physical energy, we usually turn to what’s easy or familiar. That’s why it’s important to have healthy food options within reach. Thankfully, this doesn’t need to be complicated. It could look like pre-cutting fruit or having some healthy frozen meals in the freezer. And research suggests removing unhealthy foods – for example from the pantry or fridge – can be just as helpful when you’re trying to make healthier food choices.

Plan your meals

Planning meals could help too. This may involve setting some weekend time aside to decide what meals you’ll cook and eat. That’s instead of making last-minute decisions at the supermarket or on the drive home. Meal kits and batch cooking, which both reduce the number of food-related decisions you have to make, may also reduce decision fatigue.

Reframe your eating choices

How you frame choices may also improve your eating habits. For example, you may be more likely to “eat a colourful meal” rather than simply telling yourself to “eat more vegetables”.

Outsource some of the decision-making

If you’re looking for healthy, tasty recipes, you don’t need to re-invent the wheel. You can find a wealth of free ideas on the Eat for Health, Heart Foundation and National Nutrition Foundation websites. And if making food decisions feels overwhelming, Accredited Practicing Dietitians and Registered Nutritionists can help you turn complex nutrition advice into manageable steps.

The bottom line

We often think eating should be simple and intuitive, but blame ourselves when it doesn’t feel that way. However, the concept of decision fatigue shows healthy eating is not just about willpower. It’s also about noticing when you’re tired, stressed or time-poor, and taking practical steps to make healthy foods the easiest option.

Emma Beckett is Senior Lecturer, Nutrition and Food Science, Australian Catholic University.

This article was first published on The Conversation.

Most people know about “good” and “bad” cholesterol. But few realise there is another type called lipoprotein(a). It can raise the risk of heart attacks and strokes, even in people who do everything right.

This lesser-known cholesterol particle, often written as Lp(a), is gaining increasing attention from researchers and drug companies.

Lp(a) isn’t included in routine cholesterol tests and there’s currently little we can do about it. That may now be changing.

What is lipoprotein(a)?

Lipoprotein(a) is a cholesterol that carries lipoprotein – particles made of fats and proteins – in your blood. It’s structurally similar to LDL (low-density lipoprotein, or “bad” cholesterol), but with an additional protein attached called apolipoprotein(a).

This extra protein component seems to make Lp(a) more likely to contribute to the build-up of fatty deposits in arteries. It may also promote blood clotting. Together, these processes increase the likelihood of cardiovascular disease (heart disease and stroke).

Large-scale studies and international guidelines now recognise Lp(a) as a risk factor for heart disease and stroke.

What determines your Lp(a) levels?

Unlike most other cholesterol measures, Lp(a) is largely determined by genetics.

Around 70%-90% of variation in Lp(a) levels is inherited. This is driven mainly by differences in the LPA gene, which controls the structure of apolipoprotein(a).

Because of this strong genetic control, Lp(a) levels are usually set early in life and remain relatively stable over time, with little influence from diet, exercise or body weight.

There are some smaller influences. Levels can vary by sex, ethnicity and hormonal changes, and may be slightly affected by factors such as menopause or kidney disease.

How does it affect your risk?

A growing body of research shows higher Lp(a) levels are associated with an increased risk of heart attacks, strokes and aortic valve disease.

Importantly, the relationship appears continuous. In long-term studies, cardiovascular risk rises step by step as Lp(a) levels increase.

Lp(a) also adds to overall risk. For example, someone with high LDL cholesterol and high Lp(a) is likely to be at higher risk than someone with elevated LDL cholesterol alone.

For people with higher Lp(a) levels, cardiovascular risk rises mainly when inflammation is elevated.

This helps explain why some people develop cardiovascular disease despite otherwise favourable risk profiles.

Can you lower lipoprotein(a)?

There are currently few options to lower Lp(a).

Lifestyle changes that improve heart health, such as eating well, being physically active and not smoking, remain essential. But they have minimal effect on Lp(a) itself.

Most commonly used cholesterol-lowering medications, including statins, do not reduce Lp(a). In some cases, statins may even increase Lp(a) slightly. Despite this, statins still reduce overall cardiovascular risk and remain a cornerstone of treatment.

Some newer drugs, such as PCSK9 inhibitors, can lower Lp(a), but typically only by a modest amount of around 15%-30%.

Several drug companies, including Novartis, Amgen and Eli Lilly, are racing to develop treatments that specifically lower Lp(a). These new medicines work very differently from statins. Instead of helping the body clear cholesterol from the blood, they use a “gene silencing” approach that reduces how much Lp(a) the liver makes in the first place.

This means it switches off production of cholesterol rather than trying to remove what is already there.

In early clinical trials, these drugs have lowered Lp(a) levels by 80–90%, far more than existing treatments. This is why Lp(a) is suddenly getting attention.

If upcoming trials show these large reductions also lead to fewer heart attacks and strokes, it could change how cardiovascular risk is assessed and treated, especially for people whose risk is driven largely by genetics rather than lifestyle.

Should you get tested?

Lp(a) is not included in standard cholesterol tests. A specific blood test is required.

Medicare doesn’t cover these blood tests, so if your doctor orders one you’ll have to pay out of pocket – around A$25 to $80 – plus any costs associated with the consultation.

International guidelines now recommend measuring Lp(a) at least once in adulthood, particularly for people with a family history of early heart disease or unexplained cardiovascular risk.

Because levels are largely genetically determined and stable, a single measurement is often considered sufficient for most people.

What should you focus on?

Learning you have high Lp(a) can feel frustrating, especially given the limited options to lower it directly.

But it’s important to see Lp(a) as one part of your overall cardiovascular risk.

There are still many factors you can influence to lower your overall risk, and particularly your LDL cholesterol. These include:

• LDL (bad) cholesterol

• blood pressure

• smoking

• physical activity

• diet quality

• managing conditions such as diabetes

For people with elevated Lp(a), managing these factors may be even more important.

What happens next?

Research into Lp(a) is moving quickly. If current clinical trials show targeted therapies reduce cardiovascular events, testing and treatment may become more common.

For now, awareness is an important first step.

If you are concerned about your cardiovascular risk, it may be worth discussing Lp(a) testing with your doctor, especially if you have a strong family history of heart disease.

At the same time, the broader message to maximise heart health through healthy behaviours remains unchanged. Even as new risk factors emerge, the foundations of good heart health are still the things we can control.

Lauren Ball is Professor of Community Health and Wellbeing, The University of Queensland.

Kirsten Adlard is Honorary Research Fellow, The University of Queensland.

This article was first published on The Conversation.