Risk factor profile of our society is different.

Dear Editor,

Gupta et al. study microalbiminuria in (COPD) Chronic Obstructive Pulmonary Disease patients at a tertiary care teaching hospital and conclude that as the respiratory illness worsens, the level of microalbuminuria increases.[1] At the end of discussion, they write in their study that the number of pack-years (of cigarette) were not evaluated. However in their study, female enrollment for studying various parameters was less, and that is a nationwide phenomenon.[2] Moreover, we observe in our society that cigarette smoking by women is restricted to elite ones, a segment which hardly visits our public hospitals – except in emergencies and pandemic times. Otherwise, a survey made by researchers of PGIMER Chandigarh suggests that the most common substances used by women here are Beedi and Zardah.[3] In this observational study made 6 years ago, Thakur et al. found that no woman used cigarette as a tobacco product. Therefore, the ambit of a future study should be widened to include these tobacco products too to assess their effects on airway and capability to create endothelial – dysfunction later on – which may be assessed by microalbuminuria.

Second, cooking in India is exclusive job of women due to social hierarchy and for a large section of society, fuel used for the purpose is firewood, cow-dung, twigs, paper and coal. This 'dirty' fuel generates a large amount of smoke, hurts eyes and airways of the people nearby and on prolonged exposure is known to cause irreversible lung damage.[4] Therefore, the causes of COPD in our society differ from those in the industrialized countries and we need to tailor our investigation accordingly. In lieu of that the conclusions we draw, may not be generalizable. Although currently, we are in a transition phase where this unclean fuel is being replaced by cooking gas, still for a large part of our society, the reality is different. Even if we supply the commodity to our masses at a warp speed, chronic effects of previous exposure on vital organs are known to linger on for decades. Besides that, certain households use stove for cooking and fuel used there is kerosene. Although smoke is not around with that medium, its fumes are known to have a toxic effect on our body.

Third, the authors excluded patients who may have microalbuminuria for other reasons. and it contained patients having well-documented cirrhosis. Here we need to realize that consuming alcohol is one of the most common causes of chronic liver disease in our society.[5] And a few patients develop cirrhosis later on. Therefore, obtaining a history of drinking, and then excluding those patients may have got us rid of those subjects having this vital organ dysfunction and entailing confounding of final results. Smoking-drinking co-addiction is prevalent in a certain section in a mistaken belief of its consumers achieving high status. Therefore, when we exclude those having other major organ dysfunction, problem-drinking should be assumed to be a possible marker of advanced disorder of hepato biliary system.

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