Magnitude of Problem-

Clinical and subclinical VAD are problems in at least 75 countries.
Clinical VAD occurs mainly in countries in Southeast Asia and sub-Saharan Africa.  Severe VAD – refugee settlements and in displaced populations
Improving the vitamin A status of children with deficiencies (aged 6-59 mo) can reduce measles and diarrhea mortality rates by 50% and 33%, respectively, and can decrease risk rates from all causes of mortality by 23%.

Developing countries –
Estimated 250 million children are at risk for vitamin deficiency syndromes.
Up to 10 million malnourished children, develop xerophthalmia and have an increased risk of complications and death from measles.
Each year, 250,000-500,000 vitamin A-deficient children become blind every year, half of them dying within 12 months of losing their sight.
WHO Fact sheet

Dietary Source
Animal foods-

• Liver, Eggs, Butter, Cheese
• Whole milk, Fish and Meat.
• Fish Liver Oil – richest source.

Plant Foods- Provitamins

• Green leafy vegetable- spinach and amaranth
• Green and yellow fruits and vegetables- Papaya, mango,pumpkin and roots like carrots

Fortified foods-
▫Vanaspati, Margarine, Milk
1 Retinol Equivalent = 1 μg Retinol = 6 μg beta-carotene = 12 μg of other carotene
1 IU= 0.3 μg of Retinol.

Metabolism
Absorption ,Bioavailability and Transport
 70-90% percent of vitamin A from the diet is absorbed in
the intestine.
 Retinol-binding protein (RBP) is the specific carrier used
to transport all-trans retinol in the plasma.
 The all-trans isoform accounts for more than 90% of all
plasma vitamin A .
 Retinol + RBP= holo-RBP.
 Holo-RBP + Transthyretin (TTR- prealbumin)- not filtered
by the glomerulus, but instead freely circulates
throughout the plasma

Storage
50 to 85% of the total body retinol are stored in the liver in hepatic stellate (star-shaped) cells along with droplets of lipid.
Over 90% – stored in the form of retinyl esters + FAOnce hepatic stellate cells are saturated with all the retinol -hypervitaminosis can result.

beta-carotene, can be stored in adipose cells of fat depots throughout the body .

Excretion –
Via- kidneys mainly via renal catabolism and glomerular filtration .
Renal disease
elevated serum levels of RBP and retinol
must be more aware of vitamin A toxicity.

Roles of Vitamin A-

1. Vitamin A is essential to vision -production of retinal pigments for vision in dim light
2. Role in gene expression and transcription, that regulates cell growth and differentiation.( Acts like Steroid Hormone)
3. Retinoic acid is especially important in heart, eye, lung and ear development .
4. The development of gap junctions between cells is also affected by retinoic acid. Regulation- Leucopynes
5. Key role in glycoprotein synthesis ( Retinyl Phosphate) ,mucopolysaccharides and Transferrin
6. Reproductive processes (spermatogenesis) &, bone development, along with maintenance, and immune system function are dependent upon different isoforms of vitamin A.
7. Integrity of glandular & epithelial tissue which line Intestinal, respiratory & urinary tract, skin & eyes. testicular & vaginal epithelium.
8. 8. Vitamin A also has antioxidant properties. ↓ incidence of lung, breast, oral, esophageal, & bladder cancers.

The RDAs of vitamin A for various age groups are as follows:
Infants aged 1 year or younger – 375 mcg
Children aged 1-3 years – 400 mcg
Children aged 4-6 years – 500 mcg
Children aged 7-10 years – 700 mcg
All males older than 10 years – 1000 mcg
All females older than 10 years – 800 mcg

Risk Factors for Vitamin A  deficiency-

Intake Diarrhea, worms (ascaris) & other intestinal disorders impair vit A absorption
Measles, respiratory tract infection & other febrile illness ↑metabolic demands.
Protein Energy Malnutrition (PEM), Zinc & Iron deficiency impairs utilization & transport of Vit A.
toddlers and preschool children living below the poverty line.

Subclinical forms of VAD

Without any symptoms
Higher risk of developing respiratory and diarrheal infections
The growth rate is decreased, and bone development is slowed.
The patient may also report increased fatigue, as a manifestation of VAD anemia.

Occular Sign: WHO classification of Xeropthalmia

Primary signs:
X1A Conjunctival xerosis
X1B Bitot,s spots
X2 Corneal xerosis
X3A Corneal ulceration (1/3rd)

Secondary Signs:
XN Night blindness
XF Fundal changes
XS Corneal scarring

Extra-ocular manifestations:

Phrynoderma: scaly & toad like skin- Follicular hyperkeratosis
Renal & vesical calculi.
Atrophy of germinal epithelium interfere reproductive functions
Dry skin, Dry hair, Pruritus, Broken fingernails
Excessive deposition of periosteal bone secondary to reduced osteoclastic activity
Anemia
Keratinization of mucous membrane
Impairment of the humoral and cell-mediated immune system.

PREVENTION-

• Improvement of diet :
• adequate & regular intake of foods rich in vitamin A and Food Fortification.
• ↓contributory factors eg. PEM, diarrhea, respiratory infection & measles.
• Regular Vit A supplementation: Vit A can be stored in body for 6-9 months administer a single massive dose of 2 lakh IU vit A orally every 6 months to (preschool children/ 1-5 yrs) ½ the dose to (6 months to 1 yr) of age.
• In measles, severe PEM 2 doses oral for 2 consecutive days. Persistent diarrhea or prolonged febrile condition: one dose in each episode (least 1 month interval)
• During pregnancy (not >300 mug retinol/day): ↓ maternal morbidity & ↓ perinatal mortality.
• High dose at Post partum period: ↓ mortality in 1st 4 months of life.
• Consumption of Vitamin A rich food
• Kitchen garden: to grow vit A rich foods.

3 doses at 0, 1 & 30 days
50,000 for < 6 months, 1 lac 6-12 months & 2 lac unit in children >1 yr
Same dose repeat next day & repeat at 4 wks

Local t/t of eye:

1. Antibiotic drops/ ointment X 3 day,
2. atropine drops X 1 day,
3. padding for corneal ulcer.

Vitamin A toxicity

Continous Intake of 15 X RDA

Acute/ pseudotumor cerebri (Intra Cranial Pressure ↑ICP):
headache, vomiting, dizziness, ↑ant. fontanel, papilledema.

Chronic intoxication causes:
nausea, vomiting, anorexia & sleep disorders
skin desquamation → Dermatitis
Enlargement of Liver and Spleen, hypolastic anemia
benign intracranial hypertension
Bone pain, Diarrhea

Teratogenic to fetus:
craniofacial malformation in fetus of mothers on oral retinoid for acne.

Investigations for VAD-

1. A serum retinol study- costly but direct measure using high-performance liquid chromatography. < 0.7 mg/L in children-fluorometry, spectrophotometry
2. A serum RBP study -easier to perform ,less expensive , RBP is a protein and can be detected by an immunologic assay.
3. A zinc level is useful because zinc deficiency interferes with RBP production.
4. An iron panel is useful because iron deficiency can affect the metabolism of vitamin A.
5. Albumin levels are indirect measures of vitamin A levels.
6. An electrolyte evaluation and liver function studies should be performed to evaluate for nutritional status.
7. Imaging Studies -In children, radiographic films of the long bones may be useful when an evaluation is being made for bone growth and for excessive deposition of periosteal bone.

Procedures
Dark-adaptation threshold should be tested.

Recommendations-

1. The American Academy of Pediatrics has recommended vitamin A supplementation for infants aged 6-24 months who are hospitalized with measles and for all hospitalized children older than 6 months.
2. The WHO – UNICEF joint statements recommends -vitamin A be administered to all children, especially those younger than 2 years, who are diagnosed with measles.
3. A Cochrane Database of Systematic Reviews article concluded that daily treatment with 200,000 IU of vitamin A for at least 2 days reduces mortality rates in Measles children less than 2 yrs.
4. A more recent Cochrane Database of Systematic Reviews article, including 43 randomized trials representing 215,633 children, provides strong support for the importance of vitamin A supplementation in preventing childhood mortality.
5. A single dose of vitamin A improves haemoglobin concentration, retinol status and phagocytic function of neutrophils in preschool children.
6. A substantial reduction (40 percent) in pregnancy- related mortality was observed among the women who received vitamin A or beta-carotene supplements on a weekly basis before, during, and after pregnancy (West et al, 1999)

Vitamin A and its derivatives being used in

• Acne
• Psoriasis
• Treatment of Corneal Ulcer
• Role of Vitamin A as anti-oxidant is being studied.
• Studies going on to see if Vitamin A is solution to cancer- specially Breast, lung and Prostate Cancers.

Naturally if you experience more frequent asthma attacks, the more heavily dependent you will become on your inhaled steroid medications—and too many steroids have  negative consequences, including growth stunts in children, and the development of osteoporosis and glaucoma in adults.

While there is no way to control the weather there are some tactics you can take to alleviate symptoms and monitor the amount of exposure to cold air, reducing the need for excess medication. To learn some simple asthma management tips to help keep your asthma regulated this winter, continue reading below.

1. Increase Vitamin D& C

New research suggests that there may be a direct link between a vitamin D-deficiency and lung function.  According to findings published in the American Journal of Respiratory and Critical Care Medicine, asthmatics with a lower dosage of vitamin D in their systems have a higher risk of airway inflammation than asthmatics with a high-vitamin D intake. Researchers also said that higher vitamin-D also helps steroid medication work more efficiently—which means less “puffs” are needed.

That said, it’s important to point out that most vitamin-D is absorbed through the sun. However, in the winter months the sun is less present, and thus it’s harder to acquire the necessary vitamin-D intake. To get the proper daily amount, it would be best to try to get it via diet or in supplemental form and invest in a light box which can stimulate real sunlight. You can purchase a light box at most major retail stores.

In addition, a higher intake of vitamin C during the winter months may help boost your immune system and lower your chances of contracting the flu, which for asthma patients can sometimes result in harsher symptoms and secondary complications.

2. Have a Hot Cup of Coffee

When trying to keep yourself warm you may want to grab a cup of steaming cup of black coffee, tea or hot chocolate. Health experts say caffeine can sometimes work similar to theophylline, a chemical commonly found in asthma medication.  Regular coffee drinkers also seem to have better asthma management, according to studies.

Although caffeine is listed as one of the asthma-fighting power foods, by no means is caffeine meant to replace asthma medication (it is recommended use is for “in-case of emergency” situations only).

3. Participate in Indoor Exercises

Light exercise is an important health benefactor, even for those who have exercise-induced asthma. But to make sure that you decrease your chances of having an attack, exercise indoors. Do not expose yourself to the cold air by running outside—find an indoor track or do mild exercises at home. It’s also recommended to do “winter activities” such as ice skating or playing hockey in an indoor facility.

4. Wear Proper Winter-Wear. Lastly, while the best way to avoid inhaling cold air is to simply stay inside, if you need to step out it’s crucial you wear the proper clothing and bundle up. This means wearing a scarf over your nose and mouth to prevent the cold, dry air from seeping in your lungs and inflaming your airways.

Byline:

This is a guest post from Jacelyn Thomas. Jacelyn writes about identity theft protection for IdentityTheft.net. She can be reached at: jacelyn.thomas @ gmail.com.

The sun sheds invisible ultraviolet rays which can be extremely dangerous to the skin and are responsible for sunburn, premature aging and other types of skin damage including cancer. Skin cancer is the most common type of cancer in the United States (2). In 2006, more than one million people were diagnosed as having basal cell carcinoma or squamous cell carcinoma, resulting in approximately 2200 deaths from both cancers combined. Melanoma, the third and most often fatal type of skin cancer, was diagnosed in approximately 59,940 people and accounted for about 8110 deaths in 2007 (3). Between 1975 and 2004, the annual age-adjusted incidence rate for melanoma (new cases diagnosed per 100,000 people) nearly tripled, from 6.8 to 18.5 cases per 100,000. The rate of deaths attributed to melanoma also increased by about 60%, from 1.6 to 2.6 per 100,000 people (4).

High levels of exposure to ultraviolet (UV) radiation increase the risk of all three common forms of skin cancer, and approximately 65%-90% of melanomas are caused by exposure to UV radiation (5).In summers, outdoor workers have high levels of exposure to ultraviolet radiation and the associated increased risk of skin cancer. It is estimated that more than 8% of the US. National workforce (over 9 million workers) primarily work outdoors (6). High rates of non-melanoma (basal cell and squamous cell) skin cancer have been found among occupational groups that work outdoors, and rates for non-melanoma skin cancer among outdoor workers are significantly associated with cumulative UV exposure (7). Because outdoor workers receive intense and prolonged exposure to the sun and are at increased risk of developing squamous cell cancer, workplace interventions that educate these workers and modify their work environments could provide substantial benefit. Behaviors that can help and reduce skin cancer risk include limiting or minimizing exposure to the sun during midday hours when UV radiation peaks (10 am to 4 pm); wearing protective clothing; and using appropriate sunscreen protection. Thus, it is extremely significant for workplaces to increase awareness among the outdoor workforce , provide knowledge and implement effective intervention policies for skin cancer prevention in outdoor workplaces.

Sun exposure of outdoor workers

There are studies on outdoor workers which demonstrate that they experience a substantial amount of sun exposure on a daily basis, as shown below. In a national population survey of residents in Canada, respondents who worked outdoors reported receiving on average two or more hours of sun exposure per day (8). Half of the outdoor workers interviewed in Malta said they worked in the sun for more than 3 hours per day (9). Likewise, sun exposure of farmers was estimated at 4.15 hours in a survey of Wisconsin dairy farmers (10) and more than 75% of the time spent on the job in a survey of California farmers (11). A Danish study that used time-stamped personal dosimeter readings found that gardeners received most of their UVR dose on working days (12). Construction workers, transportation workers, and mail carriers in the United States also spent a large amount of time working outdoors in their jobs (7.9 hours, 7.0 hours, and 5.1 hours per day, respectively) (13).

Workplace intervention by Employers

Despite the large amount of daily sun exposure, the studies show that some workers are taking precautions due to the workplace policies. About two-thirds of transportation workers in USA compared to approximately 40% of construction workers and mail carriers were observed to be wearing adequate sun protection as measured by the extent to which various body areas were covered (13). The between-group differences were likely due to required clothing policies that were enforced by the workplaces (13). Surveys of a larger sample of postal workers in Southern California revealed that only about one-quarter of letter carriers wore sunscreen and the same proportion wore a wide-brimmed hat while at work (14).

Inadequate knowledge about UV Radiation

Several of the studies examined outdoor worker’s knowledge and attitudes related to sun exposure, skin cancer, and sun protection; specifically their perceived susceptibility to and severity of skin cancer and barriers to sun protection behaviors. In Canada, Ontario farmers felt that sun safety was an important but not well recognized health issue among farmers (15). In USA, fewer than 10% of Michigan farmers and their spouses surveyed felt it was very likely that they would develop skin cancer (16) but 43% of Wisconsin dairy farmers and 66% of Georgia farmers believed they would get skin cancer (17). Most of the Wisconsin and Georgia farmers also felt they were more likely to get skin cancer than the average person as a result of their occupation. Perceived severity of skin cancer was moderate among the Wisconsin and Georgia farmers. While nearly all felt it was serious, almost as many did not expect it to affect their ability to continue farming (17). It was ranked as a “top five” health problem among farmers, but behind accidents/injuries, stress/depression, arthritis, and lung disease.

Wisconsin, Georgia, and Michigan farmers expressed beliefs that prevention strategies were efficacious. A large majority of Wisconsin and Georgia farmers felt that daily protection and/or typically recommended protection strategies would reduce the risk of skin cancer (17). Likewise, most Michigan farmers and their spouses believed that early detection would increase the chances of skin cancer being cured and decrease how long a person had to worry about skin cancer16. Wisconsin and Georgia farmers were well informed about skin cancer with 70% correctly responding to a skin cancer knowledge assessment (17).

Several barriers to sun protection were reported by outdoor workers. Canadian outdoor workers and Georgia farmers said that they did not practice sun safety because they forget, it was inconvenient, they wanted to get tan, and/or they were unconcerned about sun exposure (18). The belief that one looks better with a tan was also expressed by just over half of the Wisconsin farmers (10). Postal workers in California reported that very few received encouragement from either a co-worker or a household member to wear a hat or sunscreen (19). Further, the most frequently expressed barrier to sun protection was that it was too hot to wear protective clothing such as hats, long-sleeved shirts, long pants, and work gloves. Georgia farmers also expressed concerns that it was too hot to wear protective clothing (20). These barriers may keep outdoor workers from practices protection despite moderate concerns about skin cancer and strong beliefs that they are capable of taking adequate precautions. Therefore, it is extremely important to consider workplace policies that should be effective in implementation despite individual employee’s lack of knowledge and interest about UV Radiations.

What should be done

Thus , it is quite evident that despite of lack of knowledge, the issue of UV radiation safety can be dealt with using firm and effective workplace policies. There is a considerable room for improvement in occupational sun protection. Some workers take precautions while working outdoors in the sun, but the vast majority of outdoor workers do not practice adequate or any sun safety. Sun protection may not yet be a priority in most outdoor work environments but changes are beginning to occur in American policies, as indicated by the recent provision in California state law to provide lifeguards who get skin cancer with worker’s compensation benefits (21). Several major unions and employers have developed sun protection guidelines and brochures that can serve as models to other workplaces (22).

To make it effective, workplace intervention policies should be aimed at both the outdoor workers as well as their employers, in terms of risk management. When considering a comprehensive approach to workplace safety, several issues should be considered: seasonal outdoor workers who may be at higher risk because of little organizing capacity, workers in unions vs. non-unions, workers in Federal agencies, and self-employed workers such as those on small farms. Employees who work primarily indoors should not be overlooked. These efforts should be carefully evaluated so that other occupational health and cancer prevention experts can be sure the most effective approaches are adopted and used widely, to achieve the greatest public health benefit.

Thus, it is extremely important to impart knowledge as well as implement workplace policies in order to achieve behavioral changes in the workforce as well as employers to deal effectively with this INVISIBLE RISK.

References

1. As defined by wordnetweb.princeton.edu/perl/webwn
2. Greenlee RT, Murray T, Bolden S, Wingo PA. Cancer statistics, 2000. CA Cancer J Clin. 2000;50:7–33.
3. American Cancer Society Cancer Facts and Figures 2007. 2007.
4. SEER Cancer Statistics Review, 1973–1999 http://seer.cancer.gov/statfacts/html/melan.html
5. Armstrong B. How sun exposure causes skin cancer: An epidemiologic perspective. In: Hill D, Elwood JM, English DR, editor. Prevention of Skin Cancer. Dordrecht, the Netherlands: Kluwer Academic Publishers; 2004. pp. 89–116.
6. US Census Bureau Statistical Abstract of the United States: 2000. US Census Bureau; 2000.
7. Gruber S, Armstrong BK. Cutaneous malignant melanoma. In: Schottenfeld D and Fraumeni JF, editor. Cancer Epidemiology and Prevention. 3. New York: Oxford University Press; 2006. pp. 1230–1250.
8. Shoveller JA, Lovato CY, Peters L, Rivers JK. Canadian National Survey on Sun Exposure & Protective Behaviours: outdoor workers. Can J Public Health. 2000;91:34–35.
9. Scerri L, Aquilina S, Amato GA, Dalmas M. Sun awareness and sun protection practices in Malta. J Eur Acad Dermatol Venereol. 2002;16:47–52. doi: 10.1046/j.1468-3083.2002.00376
10. Marlenga B. The health beliefs and skin cancer prevention practices of Wisconsin dairy farmers. Oncol Nurs Forum. 1995;22:681–686.
11. Schenker MB, Orenstein MR, Samuels SJ. Use of protective equipment among California farmers. Am J Ind Med. 2002;42:455–464. doi: 10.1002/ajim.10134.
12. Thieden E, Philipsen PA, Heydenreich J, Wulf HC. UV radiation exposure related to age, sex, occupation, and sun behavior based on time-stamped personal dosimeter readings. Arch Dermatol. 2004;140:197–203. doi: 10.1001/archderm.140.2.197.
13. Stepanski BM, Mayer JA. Solar protection behaviors among outdoor workers. J Occup Environ Med. 1998;40:43–48. doi: 10.1097/00043764-199801000-00009
14. Lewis EC, Mayer JA, Slymen D. Postal workers’ occupational and leisure-time sun safety behaviors (United States) Cancer Causes Control. 2006;17:181–186. doi: 10.1007/s10552-005-0482-4
15. Ing SY, Ashbury FD, Marrett LD, From L, Perry KV. Use of focus group methodology in the development of an Ontario farmers’ sun safety survey. Chronic Dis Can. 2002;23:65–70.
16. Rosenman KD, Gardiner J, Swanson GM, Mullan P, Zhu Z. Use of skin-cancer prevention strategies among farmers and their spouses. Am J Prev Med. 1995;11:342–347
17. Marlenga B. The health beliefs and skin cancer prevention practices of Wisconsin dairy farmers. Oncol Nurs Forum. 1995;22:681–686. Parrott R, Steiner C, Goldenhar L. Georgia’s harvesting healthy habits: a formative evaluation. J Rural Health. 1996;12:291–300
18. Parrott R, Steiner C, Goldenhar L. Georgia’s harvesting healthy habits: a formative evaluation. J Rural Health. 1996;12:291–300. Shoveller JA, Lovato CY, Peters L, Rivers JK. Canadian National Survey on Sun Exposure & Protective Behaviours: outdoor workers. Can J Public Health. 2000;91:34–35.
19. Lewis EC, Mayer JA, Slymen D. Postal workers’ occupational and leisure-time sun safety behaviors (United States) Cancer Causes Control. 2006;17:181–186. doi: 10.1007/s10552-005-0482-4
20. Parrott R, Steiner C, Goldenhar L. Georgia’s harvesting healthy habits: a formative evaluation. J Rural Health. 1996;12:291–300.
21. State of California Workers’ compensation: lifeguards. Assembly Bill 663. 2001.
22. Programs and resources for outdoor workers http://www.skincancerprevention.org/Tips/OutdoorWorkers/tabid/68/Default.aspx

Article By: Dr. Tarun Batra

Dr. Tarun Batra ia a Environmental, Health & Science Professional , an author , an Artist, a  Philanthropist and President of  an International Non-Profit Organization with operations in US,Latin America,Asia and South Africa.He has a number of articles,health manuals and write ups to his credit.The author is also the member of a number of Environmental Organizations.

Laxatives (purgatives, aperients)

The causes of constipation can vary:

1. Inadequate intake of dietary fiber
2. Less fluid intake
3. Lack of exercise, sedentary lifestyle
4. Changes in life or routine
5. Misconception about normal frequency, amount or consistency of stools
6. Side effects of medications (narcotics, antispasmodics, antiparkinsonism drugs, antidepressants, diuretics, etc.)
7. Diseases like irritable bowel syndrome, hypothyroidism, colorectal cancer, etc.

Laxative or Purgative abuse:

Some individuals are obsessed with using purgatives regularly. Laxative abuse occurs when a person attempts to get rid of unwanted calories, lose weight, feel thin, or feel empty through the repeated misuse of laxatives. This may be the reflection of psychological problem.

Others use a purgative casually, obtain thorough bowel evacuation, and by the time the colon fills up for a proper motion (2-3 days) they get convinced that they are constipated and start taking the drug regularly. Chronic use of purgatives give rise to the risk of laxative dependence, i.e., the inability to do without them. Once the purgative habit forms, it is difficult to break.

Health consequences of laxative/purgative abuse:

1. Constipation and laxative dependency
2. Flairing of intestinal pathology, rupture of inflamed appendix
3. Fluid and electrolyte imbalance, specially hypokalemia
4. Steatorrhoea, malabsorption syndrome
5. Lazy colon, Irritable bowel syndrome
6. Renal failure
7. Liver damage
8. Protein losing enteropathy
9. Spastic colitis
10. Severe dehydration

How laxative habituation occurs?

Normally:
When the sigmoid colon and rectum are filled, the natural defecation reflex empties the large bowel (intestine) up to and including the descending colon.

When laxative is taken:
A large bowel irritant purgative (sennae, phenolpthalein, bisacodyl, picosulfate) clears out the entire colon leading to requirement of a longer period for the next natural defecation to occur. Fearing constipation, the user becomes impatient and again resorts to the laxative, which then produces the desired effect as a result of emptying out the upper colonic segments. Therefore, a “compensatory pause” following cessation of laxative use must not give cause for concern.

Development of laxative abuse cylce:
When the colon empties prematurely, there will be an enteral loss of NaCl, KCl and water. To compensate this depletion of NaCl and water, the body responds with an increased release of aldosterone which stimulates their reabsorption in the kidney. The enteral and renal K+ (potassium) loss add up to a K+ depletion of the body, evidenced by hypokalemia accompanied by a reduction in intestinal peristalsis (bowel atonia). The affected individual infers “constipation,” again partakes of the purgative, and the vicious circle is closed.

No laxatives should be used unless suggested by a healthcare provider. Tapering off laxatives is necessary to prevent problems.