Sweet potatoes (Ipomoea batatas) are becoming more and more popular: Whether in soup or as fries, they increasingly compete with “regular” potatoes which, surprisingly, are only distantly related. Although economically not as important as the potato world-wide, the sweet potato has a higher nutritional value and is richer in vitamins. Particularly in Asia, the crop is an important source of nutrients. As with potatoes, there are different cultivars of sweet potatoes available, all displaying their own characteristics. Even cultivars grown in the field under similar conditions may differ strikingly with respect to insect attack. In previous studies, a cultivar known as Tainong 57 had demonstrably higher resistance to field herbivores in comparison to the cultivar known as Tainong 66. When attacked, the plants’ leaves emit a distinct odor bouquet. Researchers at the Max Planck Institute for Chemical Ecology in Jena, Germany, and at the National Taiwan University wanted to find out whether the high insect resistance in one cultivar was related to this odor. They especially wanted to know whether sweet potatoes have mechanisms to activate defense responses via volatile signals, as described in other plant species.

Launch of government’s long-awaited new antiretroviral therapy (ART) guidelines, including the widespread roll-out of the medicine dolutegravir, is imminent.

While hailed by some as a wonder drug, like any other new drug dolutegravir comes with risks and benefits and patients deserve the right to be fully informed before deciding whether they would like to take this new medication. Dolutegravir will be offered to new, returning, and stable patients with suppressed viral load, with the latter making up by far the largest group.

Most of these patients currently take efavirenz and will be offered a single drug substitution to dolutegravir. The new guidelines will suggest that all patients should be counselled about the risks and benefits of making this switch. The following is a list of issues that should be discussed with any patient considering a switch from efavirenz to dolutegravir:

1. Safety in pregnancy

Efavirenz is known to be very safe in pregnancy. There is a roughly eight-fold increased risk of neural tube defects (NTDs) such as spina bifida in women who conceive while taking dolutegravir compared to efavirenz. It’s worth remembering that the absolute risks of NTDs on dolutegravir remains low at about three per 1000 births, but the birth defects are serious.

Can anything be done?

As well as avoiding unintended pregnancy with contraception, it may be possible to mitigate the risk of NTDs by taking folate (folic acid) around the time of conception. This is good advice for any woman wishing to fall pregnant but is so far an unproven strategy for reducing the risks of dolutegravir in pregnancy.

2. Weight gain

Unfortunately, there have been no large-scale randomised studies on the effects of switching from efavirenz to dolutegravir, which makes it difficult to know exactly what will happen. However, studies of new and returning patients, who all tend to put on weight as they return to health, show that patients on dolutegravir tend to put on more weight than those on efavirenz – around 2kg extra in the first two years. The difference is most pronounced in black women; weight may continue to rise beyond two years, and may be aggravated by certain contraceptive methods.

Whilst this cannot necessarily be extrapolated to patients who are currently stable on efavirenz, most experts believe that patients, and particularly black women, will tend to gain weight if they make the switch. It’s not known how much weight they will gain or whether the weight gain levels off over time.

Can anything be done?

Patients who have undesirable weight gain on dolutegravir could request to switch back to efavirenz in the hope that their weight will return to where it was before. 

3. Drug interactions

Both dolutegravir and efavirenz interact with other drugs (don’t mix well in the body). Drug interactions can lead to either toxic or sub-therapeutic levels of either ART or the interacting drug. Dolutegravir generally has less drug interactions than efavirenz but an important one is with rifampicin, the most important drug in standard TB treatment.

Dolutegravir must not be taken with anti-acid medications and can increase blood levels of metformin, a common drug for treating diabetes .Efavirenz has no significant interaction with rifampicin but cannot be taken with some epilepsy medications and can make some hormonal contraceptives less effective. There is a list of other medications that you might require for a shorter period that cannot be taken with efavirenz. 

Can anything be done?

Dolutegravir can be taken twice a day when also taking rifampicin, anti-acids can be safely taken at different times of day, and the dose of metformin can be reduced. Patients on efavirenz may need to use alternative methods of contraception and anti-epileptics and sometimes temporarily switch to another ARV if the interacting drug is only required for a short time.

4. Barrier to resistance

Dolutegravir has a much higher ‘barrier to resistance’ than efavirenz which means that it’s harder for the HIV virus to become resistant to dolutegravir. In practical terms, this means that if patients have difficulty taking their ARVs every day, or stop taking them completely, there is more chance of dolutegravir working in the future than efavirenz. This is of limited relevance to virally suppressed patients who rarely or never miss their medication but might be important for patients who struggle with daily pills. 

Can anything be done?

Patients who do develop resistance to efavirenz would be able to switch to dolutegravir at that point.

5. Short term side-effects

Patients who are currently taking efavirenz may remember some unpleasant side-effects in the first few weeks that they took it, particularly dizziness and vivid dreams. While this will now have passed, there is a risk of new short-term side-effects with dolutegravir. The commonest complaint with dolutegravir is insomnia.

Can anything be done?

Short-term side-effects usually ware off over the first few weeks. Patients suffering insomnia with dolutegravir can take their medication when they wake up.

6. Long term side-effects

The long-term side-effects of efavirenz are quite well known as it has now been used extensively in South Africa since 2005. Liver injury can occur in up to 8% of patients and usually begins in the first eight weeks of starting therapy, so patients who have been taking efavirenz for several years without liver injury are less likely to be affected.

There is some evidence that long-term exposure to efavirenz has a negative effect on brain function in some patients, and this can be worsened when taking isoniazid as TB preventive therapy.The long-term side-effects of dolutegravir are largely unknown so far as it has not been taken by large numbers of patients for long enough. There therefore remains the possibility of as yet unknown but serious side-effects.

So far, there has been a preliminary study showing that patients taking dolutegravir have smaller brains than those who take other ARVs, but this is yet to be confirmed.

Can anything be done?

The current fixed dose combination with efavirenz contains 600mg of the drug. It is known that 400mg of efavirenz is just as effective so it may be possible to decrease the dose and therefore the side effects with no ill effects. 

7. Service delivery

The new guidelines will state that patients can only be switch to dolutegravir if they have a suppressed viral load result within the past six months. This creates a problem for the approximately 1.9 million clinically stable patients who are currently enrolled in differentiated service delivery (DSD) models such as spaced fast lane, facility-based or community-based adherence clubs or external pick-up points.

These patients only have a viral load taken once a year. So, in order to switch within the current guidelines, they would need to make at least one extra visit to see a clinician at their clinic. This may be a significant barrier to many patients who find it difficult to take time off work or childcare to attend clinics, as well as an unwanted burden on the healthcare system.

Can anything be done?

There is little that patients can do about this but a change in the guidelines to allow patients in DSD models with long-term suppression to switch to dolutegravir with a viral load result that is one year old would solve the problem.

Conclusion

In conclusion, there are multiple competing risks and benefits of virally suppressed patients switching from efavirenz to dolutegravir, making counselling a complex issue. Patients are likely to perceive the risks differently based on factors such as childbearing potential or desire, attitude to weight gain, fear of long-term side-effects, and the need for other medications.

All patients deserve to be fully informed of all these issues and have an opportunity to discuss their individual case. Given the large number of clinically stable patients in South Africa, it will be a mammoth task for a pressurised public health system. However, failure to properly discuss these issues will be a failure to provide a level of service that our patients deserve.

Dr Tom Boyles is an infectious diseases consultant at Helen Joseph Hospital, Johannesburg.

Tom Boyles

Children born this year expected to live shorter lives than previously thought, say official stats.

A report says accessing contraceptives and abortion pills in the UK should be easier for girls and women.

More than 10,000 outpatient appointments and surgeries will not go ahead on Monday, Tuesday and Thursday.

The information on Health24 is for educational purposes only, and is not intended as medical advice, diagnosis or treatment. If you are experiencing symptoms or need health advice, please consult a healthcare professional. See additional information.

Liz Knight’s latex allergy is so severe she cannot touch a newspaper or the buttons on the remote controls.

Fans of intermittent fasting (IF) absolutely rave about all the purported benefits, yes. But behind all the talk about what type of fasting schedule is right for you or whether you can combine IF with other diets like keto, there’s an often-overlooked fact: IF can still cause side effects or have its negatives…especially if you’re not doing it right.

“It’s important to figure out which style of IF works for you, whether that’s a shorter versus longer fasting window or only doing it so many days per week,” says Alyssa Koens, lead registered dietitian of weight loss coaching company Profile Sanford. “If you’re consuming too few calories or nutrients during fasting times, you could have side effects.”

But since there aren’t any formal guidelines for how many calories you should be consuming during IF – or for what kinds of foods you should be filling up on during non-fasting hours – it can be hard to hit your IF groove without some bumps in the road first…assuming it’s even the right choice for you at all. And there are some signs to watch out for that might mean it’s just not the best fit for you and your lifestyle.

But first: If you’re wondering why IF is so popular in the first place, there may be potential benefits of intermittent fasting.

There are several potential positive effects of IF, including weight loss, better appetite control, and lower insulin levels. The main issue is that none of those benefits have been heavily researched in any way. The research is also the scantest in humans (compared to, say, the research in mice).

It’s also unclear if the root cause of the purported benefits is intermittent fasting itself (e.g. how it affects your body, say, on a cellular level) or simply the calorie restriction. So it’s kind of trial and error at this point to see whether an IF eating style works for you and your body.

Read more: What you need to know before you try a fasting diet to lose weight

On the other hand, there are a bunch of possible negative side effects with IF.

As mentioned, the upsides of intermittent fasting are still very much in the research phase – but there are some promising findings there. However, there’s also plenty of anecdotal evidence that IF does come with some possible negative side effects, and you shouldn’t start an IF eating plan without hashing those things out with your doctor first.

Here are 10 red flags to watch out for. And if you notice any of these side effects, that means stop IF and talk to your doctor or a nutritionist before proceeding.

1. Feeling hangry

We’re not 100% certain that “hangriness” is a real word, but it’s definitely a real sensation. This is the feeling of grouchiness, grumpiness, or overall irritability that comes with not being able to eat when your body is telling you it’s hungry.

As WH previously reported, teaching your body to go 16 hours without food takes some practice, and some people’s bodies might not ever be happy eating within a restricted window.

In theory, if you’re consuming enough protein later in the day or night, you shouldn’t be starving first thing in the morning. But if you are, that’s a sign you need to make some dietary adjustments during your caloric intake period to avoid turning into a major crank – or it’s a sign that you’re just not vibing well with fasting. For some people (e.g. those who work out a ton), not eating for long periods may just not be ideal for them at all – and that’s definitely something worth considering. Don’t force it.

2. Fatigue or brain fog

Ever found yourself yawning over and over mid-morning, only to realise you never got around to eating breakfast? Since not eating breakfast is typically how most people do IF, realising that you’re excessively tired every day – or making dumb mistakes because you’re wading through brain fog – is a tip-off that you’re not eating the right foods during non-fasting hours or that fasting isn’t fitting in with your lifestyle needs.

“Pay attention to what you’re fuelling your body with,” says Koens. “You can eat what you want on IF, but you should still be fuelling it with good food that will make you feel healthy and strong.” And if you just feel way better eating breakfast most days, listen to your body.

3. Food obsessions

Being on any kind of restrictive diet can affect your relationship with food, says Koens. While some people like the rigidity of IF, others may find themselves focusing way too much on when they can eat and how many calories they’re getting.

Spending an excessive amount of time thinking about the quality or quantity of your food every day can lead to a type of eating disorder called orthorexia. According to The National Eating Disorders Association, having orthorexia means you focus so much on “correct” or “healthful” eating that it actually has a detrimental effect on your overall well-being.

That shouldn’t be the goal of any diet, says Koens: “You want to focus on forming a healthy, positive relationship with food.”

Read more: Would it be a terrible idea to try intermittent fasting while breastfeeding?

4. Low blood sugar

If you’re having persistent nausea, headaches, or dizziness during IF, that’s a red flag that indicates the diet may be throwing your blood sugar out of whack. As WH previously reported, diabetics should avoid any kind of fasting diet for this exact reason: IF can cause you to become hypoglycaemic, a dangerous condition for anyone with insulin or thyroid problems.

5. Hair loss

Seriously? Yup. Koens says that sudden weight loss or a lack of proper nutrients, especially protein and B vitamins, can cause hair loss.

An important point: While IF doesn’t necessarily lead to a loss of nutrients, it tends to be harder to eat a well-rounded diet when you’re cramming a whole day’s worth of eating into a handful of hours. If you think more hair than usual is falling out in the shower every day, re-evaluate the nutrition content of your daily meals and speak with your doctor about whether IF is really a wise move for you.

6. Changes in your menstrual cycle

Here’s another side effect of sudden weight loss (which can be a result of IF): Women who lose a dramatic amount of weight or are consistently not getting enough calories every day might find their menstrual cycles slow down or even stop completely.

Per the Mayo Clinic, women who have excessively low body weight are prone to a condition called amenorrhea, or the absence of menstruation. Sudden weight loss or being underweight can disrupt your typical hormone cycle and cause missed periods; so while you might be rejoicing in the way IF has helped you shed pounds, you could also be depriving your body of calories it needs to function.

If you stop getting your period and think it’s linked to intermittent fasting habits you’re practising, stop fasting and speak with your gynaecologist to troubleshoot.

7. Constipation

All backed up? IF could be to blame. “Any diet can cause an upset stomach if you’re not getting enough fluid, vitamins, protein, or fibre,” says Koens, who emphasises the importance of staying hydrated all day long.

It’s easy, she explains, for people to forget to drink water during fasting hours – but going 16 hours a day without enough fluid is a recipe for (gastrointestinal) disaster. So if you’ve started an IF diet and can’t seem to get your bowel movements to happen regularly (or at all), it’s time to hit pause on your plan and speak with a nutritionist or MD about what’s happening (er, or not happening in this case!).

Read more: Can you drink black coffee while fasting or not?

8. Unhealthy diet

Even if IF doesn’t trigger a serious disorder like orthorexia, it could still bring about some pretty unhealthy eating habits. In addition to not getting the proper nutrients, you could also find yourself making bad nutritious choices during non-fasting hours.

“The main worry is setting off binge-eating behaviour, because you are so hungry you’re eating 5 000 calories [and going way over your daily amount],” Dr Charlie Seltzer,  weight-loss physician and certified personal trainer, previously told WH.

If this sounds like you, you may be better off working with an RD to find a plan that doesn’t force you to restrict your eating hours and instead focuses on fuelling your body with proper nutrients around the clock, not in a specific window.

9. Sleep disturbances

Koens says that many people report improved sleep patterns while doing IF, possibly due to the way IF helps curb late-night snacking habits, and in turn, an inability to fall asleep because your stomach is busy still digesting that 10 p.m. nosh.

However, there is some research pointing to the opposite effect. A 2018 review in the journal Nature and Science of Sleep points to evidence that diurnal intermittent fasting (meaning daytime fasting) causes a decrease in rapid-eye movement (REM) sleep. Getting enough REM sleep has been linked to all kinds of health benefits, including better memory, cognitive processing, and concentration, per the Harvard Business Review. It’s unclear why exactly.

If you notice you can’t fall asleep or stay asleep after you’ve started an IF eating plan, again, hit pause and talk to a pro to make sure you’re not hurting your health.

10. Mood changes

It would be weird if you didn’t experience any moodiness or hangriness during IF, at least in the beginning. And while some people feel a serious boost of energy or motivation once they adjust to fasting, it’s important to remember that it is still a restrictive diet. Feeling obliged to follow it could have negative effects on your mood, especially if you’re becoming isolated from friends or family members due to your diet restrictions.

If you’re feeling down, anxious, or discouraged about IF, it’s crucial to stop and get in touch with a registered dietitian, psychologist, or nutrition coach right away. They may be able to help you create a fasting schedule that better suits your mind and body.

^{This article was originally published on https://www.womenshealthsa.co.za/}

^{Image credit: iStock}

Sarah Bradley

The NHS Digital figures show a rise in patients having to wait more than two weeks in October.

South Africa has the highest HIV epidemic in the world, with 7.97 million people living with HIV. The UNAIDS reports that in 2018, 240 000 people were newly infected with HIV in our country and 71 000 people died from an AIDS-related illness.

But while the figures may seem bleak, the number of new HIV infections fell from 390 000 to 240 000 within the same period. 

Ahead of World Aids Day, experts within the field of HIV/Aids spoke at the Cipla HIV/Aids press workshop and answered some pivotal questions. Health24 also spoke to Professor Ian Sanne, Founding Director and CEO of Right to Care, on how close we are to combatting the demon of HIV.

Searching for a cure: how far away are we?

While HIV prevention and treatment have come a long way within recent years, a cure for the HIV-positive population is still many miles away, say experts.

“There’s a glimmer of hope, but we’re not there yet. And we can’t give people false hope,” said Dr Sindi van Zyl, a specialist in the HIV and Aids field, at the Cipla HIV/Aids press workshop this week. 

“One day we will have a cure, but for now, we applaud the scientists for their ongoing research and we look forward to that cure.”

What about a vaccine?

With vaccines being trialled around the world and results said to be expected around 2023, we asked Professor Sanne whether this is realistic. 

“Vaccine development is well underway, and full protection against HIV would probably include a combination of monoclonal antibodies and a vaccine, but we are hoping that the current studies that are underway will generate at least partial immunity to HIV. 

“Clinical trials are currently being conducted, and they are powered on the new cases that are identified. Should the vaccine arm do better than the control arm, then the Data and Safety Monitoring Board (DSMB) will look at the data for six months in a blinded fashion. 

“If they see a significant difference, they will stop the study and announce the results, and it could happen earlier than 2023, but I’m not allowed to say more,” adds Sanne.

Dolutegravir: New ARV shows promising results, but we should tread lightly

South African Health Minister Zweli Mkhize announced on 27 November the launch of a new three-in-one pill for HIV that could help people suffer fewer side effects than the older drugs and accelerate viral suppression (so those living with HIV may not be able to transmit the virus) in those living with HIV throughout the country.

The new pill is a combination of tenofovir, lamivudine and dolutegravir and will replace efavirenz, an older medicine. However, we should note a few things, says Dr Michelle Moorhouse, co-principal investigator of ADVANCE and Head of treatment strategies at Ezintsha.

“Dolutegravir was just launched, and although the efficacy and safety profile appears to yield positive results, clinical trials based on this drug are very different from the real world of medical practice and care, and we should remember that no drug is safe and effective for everybody,” she explained, adding:

“When drugs are approved there are many data gaps. Registrational studies do not enroll populations representative of the demographics of the HIV portfolio and many important populations are excluded from the Randomised Controlled Trials (RCTs). 

Moorhouse also explained that ADVANCE, an ongoing 96-week study being conducted in inner city Johannesburg in South Africa, has highlighted the importance of studying newer ARVs in African populations, and has shown that efavirenz does perform well for some people, and says that we shouldn’t be quick to vilify older drugs as they may still have a role in ART.

What happens if patients develop resistance to the new pill?

“If this happens, we would definitely be willing to switch people back to efavirenz, but we anticipate that more than 90% of people will do well on dolutegravir,” says Sanne.

The UN’s 90-90-90 target

The United Nations announced an ambitious treatment target in 2013 to help end the HIV/Aids epidemic in countries around the world, and they include the following:

• By 2020, 90% of all people living with HIV will know their HIV status.
• By 2020, 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy.
• By 2020, 90% of all people receiving antiretroviral therapy will have viral suppression. 

This target setting was ambitious, and correctly so, says Sanne.

“It [target] has honed the health system to actually increase the activities in the most under-served communities, and with that we are rapidly progressing with the number of patients that are coming forward for testing and are being put onto treatment,” he adds.

However, out of South Africa’s total population of 7.97 million living with HIV, 3 million people are still not on treatment. The key to reaching these targets are testing, counselling and ensuring that there is an ongoing and reliable source of ARVs, says Dr Moeketsi Mathe, Board member of the Southern African HIV Clinicians Society.

“We need to offer HIV testing broadly, start healthy HIV-positive people on lifelong treatment, and provide counselling to explain the benefits of treatment,” says Mathe.

To achieve the third target, drug adherence plays a key role.

“We need to ensure that patients actually swallow their pills, and for this to happen, there needs to be access to effective, tolerable and cost-effective drugs.

“If you’re unable to swallow a pill because of the size of it, for example, it doesn’t matter how great it is – you’re not going to take it. And if it makes you feel horrible, however good that pill is, you’re just not going to take it. 

“The biggest determinant of whether a person will swallow a pill is the tolerance of it. So the two important questions are: can they take it, and how does it make them feel?”

^{*World Aids Day has been taking place on 1 December every year since 1988, and is dedicated to raising awareness of the Aids pandemic, caused by the spread of HIV infection, and mourning those who have died of the disease.}

^{Image: Getty}

Zakiyah Ebrahim