IN SOUTH ASIA, AS ANYWHERE ELSE, HEREDITY, HORMONES, STRESS, DIET AND DISEASE CAN EACH CAUSE HAIR LOSS.
Just about everything we see in English-language media out of South Asia represents those people who live in the middle and upper classes. There remain many millions whose lives are defined by grinding poverty, which includes a lack of access to quality health care. Don’t even begin to think in terms of expensive hair loss cures — 40 percent of the country would be happy with hygienic drinking water, clean food and a lower infant mortality rate.
First, a primer: Gradual thinning of the hair is a normal part of the aging process. However, when hair loss exceeds the rate of regrowth, or new hair growth is thinner than that which was shed, then baldness occurs. Men and women all over the world, including those in South Asia, experience hair loss. They want to know its causes, and they look for solutions.
Several causes of hair loss remain consistent around the globe. Androgenic alopecia (pattern baldness) is related to hormones, particularly DHT (dihydrotestosterone).
“DHT is formed from the hormone testosterone [T] and the 5-alpha-reductase enzyme [5ARD],” explains Dr. Arvind Poswal, a groundbreaking hair transplant surgeon based in New Delhi, India, who is regarded as a pioneer for his innovative hair restoration solutions. “A high concentration of this enzyme produces a high level of DHT around the hair follicles. DHT sends chemical signals to the genetically marked follicles and the miniaturization process begins. This process happens on a large time scale [years]. It begins even from the age of 20, sometimes even after the person reaches 40 years of age.”
Heredity (pattern baldness that can come from either side of one’s family) is the root cause of pattern baldness in both men and women. Heredity affects the age at which hair loss commences, as well as the speed and extent of the baldness.
Of course, hair loss can also be caused by diseases such as diabetes and lupus, medical treatments such as chemotherapy, scarring from burns and injury, hormonal changes and excessive hairstyling (traction alopecia, or overuse of chemical relaxers and heated styling tools resulting in central centrifugal cicatricial alopecia [CCCA]). Emotional stress also can lead to hair loss.
In countries with high poverty rates, such as India, Bangladesh, Pakistan, and Afghanistan in South Asia, a variety of other factors come into play.
Says Dr. Sanjoy Mahendra, a hair restoration specialist in Kanpur, India: “Although heredity plays a leading role in hair loss in all parts of the globe, we find that both men and women in India and the rest of Southern Asia experience hair loss due to stress and an unhealthy diet in higher than expected percentages when compared to the rest of the world.”
Mahendra explains that hair loss in women of the region points to issues beyond heredity.
“While the total number of men in Southern Asia who complain of hair loss isn’t out of the normal range when looking at the global averages, that isn’t the case for women,” he said.
“With women here complaining of thinning hair and hair loss at rates much higher than average, we can safely theorize that a substandard diet and stress play key roles in the need for hair restoration [HLDC emphasis].”
Poverty, poor nutrition and hair health
Poverty, which is rampant in South Asia, typically leads to an unbalanced diet. The result of an unbalanced diet is poor nutrition — and that leads to a wide array of health concerns, diseases and, certainly, hair loss.
To understand the domino effect in play in South Asia, one must fully comprehend the poverty in this region of the world. In India approximately 40 percent of the population live below the poverty line and nearly 43 percent of the children of the country suffer from malnutrition. The average annual income in Bangladesh is only U.S.$580 per person, and 60 million people in the country go hungry each day. Bangladesh also has the world’s highest rate of babies born with low birth weight. In Pakistan, more than 60 percent of the population live on less than U.S.$2 per day. In Bhutan, a small country in South Asia, half of the country is illiterate. The infant mortality rate in Afghanistan is 157 per 1,000 births — the second-highest rate of any country in the world. Afghanistan also has a shockingly low life expectancy of less than 45 years. (Afghanistan is variously lumped into both the Middle East and South Asian regions.)
All told, it’s not difficult to understand that well-balanced meals are hard to come by for the average person in South Asia. Dr. Rajesh Patel, a dermatologist in India who also specializes in hair loss issues, explains the impact of a poor diet.
“In terms of diet and hair loss, the [South Asia] population has a variety of things working against them,” says Patel. “Impoverished areas notoriously have poor diet and lack of nutrition, which leads to a number of diseases and overall poor health. Of course with a lack of nutrients come things like iron and protein deficiency, which can be linked to hair loss.”
Added Dr. Patel: “In the wealthy, who have the means to obtain satisfactory nutrition, we simply do not see as much thinning hair and hair loss. This observation goes to further highlight the connection between a poor diet and problems of the hair.”
The persistence of the caste system in India and other areas creates a large distinction between the wealthy and the poor. In recent years, however, a growing middle class has emerged, and with it we should see an increase in proper nutrition. Some studies have shown that as many as 40 million people are added to the middle class each year in India. In fact, it is estimated that most of India’s population will be in the middle class within 15 years — yet more evidence of the success of the 1991 economic liberalization.
The great irony: Wealth may still bring poor nutrition
That said, the results of a greater distribution of wealth are not instantaneous and are not always what is expected.
“There is an emerging middle class in the area who have taken toward a more Americanized diet of junk food,” says Patel. “As we all know, junk food is generally high in calories and sugars and provides very little nutritional value. This emergence of bad diet, coupled with things such as stress and smoking, causes damage to the skin and hair.”
On a global level, the fast-food market grows about 5 percent each year; in India, however, the growth of the fast-food market for the past decade has been 40 percent annually. McDonald’s, Pizza Hut, Domino’s Pizza and Subway all have a strong presence in India, with approximately 40 new McDonald’s restaurants opening each year.
On the other end of the food-culture spectrum, widespread vegetarianism and traditional fasting might also lead to hair loss issues and other health concerns when not approached with a concern for complete and complementary nutrients.
“India has a large population of vegetarians and the lack of iron consumed by vegetarians may be a cause of hair loss and other health problems,” says Dr. Patel, although it should be noted that there are conflicting conclusions in the medical community about whether vegetarianism and hair loss are related.
According to many reports, the meat industry in India, Pakistan and other areas of the region is steadily growing and people are expected to eat more meat in upcoming years. The fact that meat is one of the best sources of iron and other vitamins should, in theory, increase the overall health of the general population — and that includes a reduction in hair loss issues. But as is the case with almost all matters of nutrition and health, there can be too little and too much meat consumption. Red meat contains protein, zinc and B12 vitamins, all essential to overall healthy hair. But in excess, too much animal protein can lead to an overabundance of omega-6 fatty acids from meat against omega-3 fatty acids, more typically found in cold-water fish and leafy green vegetables. This imbalance is believed by many to be a different cause of hair loss and unhealthy skin. The presence of hormones and antibiotics in livestock raised under factory farming conditions and still present in meat products consumed by humans is alleged by some to cause hair loss as well.
In South Asia, spices are present in a majority of the regional cuisines. For instance, curry dishes typically contain a number of exotic spices. Patel indicates that these spices play a largely unknown role in the overall nutritional value of local foods.
“We have evidence that spices such as haldi [turmeric] and methi leaves [fenugreek] have health benefits, although the spice industry is so large and so unregulated in South Asia that the exact health benefits or potential harm is difficult to assess,” he says.
An accurate predictive model for the future of hair loss in South Asia may be found in Japan. Japanese historians routinely point to the end of World War II as being the turning point in regard to hair loss. Prior to that point, hair loss issues were said to be rare in Japan. However, following the Westernization of Japan in terms of food, culinary customs and population intermingling, hair loss is said to have become a much more widespread phenomenon in the country.
Stress from poverty, stress from affluence
While good nutrition is a requisite for healthy hair, doctors who specialize in hair are seeing more and more parallels between stress and hair loss issues.
“The damning effects of stress on hair are just now starting to be completely understood,” said Dr. Mahendra. “Theories are now backed up by medical case studies. If a person lives with stress for a long period of time, no matter if male or female, premature thinning hair is very likely to be noticed. In fact, the more stress a person is under, the more hair loss issues that individual can expect.”
Mahendra explains the science behind stress and hair loss: “When your body feels stress, it goes into survival mode and neglects the needs of areas considered nonvital, such as hair. As a result, some of your hair will go into a semiresting phase. While in that phase, hair becomes thinner and may even fall out. This process is slow but becomes pronounced over time in those people facing unmitigated stressors.” (Note that this type of hair loss is usually not permanent, as growth returns when the stress subsides.)
Other types of hair loss can be associated with stress. With alopecia areata, white blood cells attack the hair follicle, causing the hair to fall out. Several factors are believed to cause this condition, including excessive stress combined with heredity. Another condition, telogen effluvium, is characterized by large areas of hair going into dormancy and subsequently shed in a relatively short period of time. Telogen effluvium is likely caused by the shock of emotional issues, physical trauma, chronic illness and severe psychological stress, and it ceases (hair growth resumes) when those factors cease.
In poverty-ridden areas, we also see an increase in some infections that can cause hair loss. Scalp infections, such as black piedra, are often found in South Asia. Piedra is a fungal infection characterized by hard nodules on the hair fibers. Although the source of the infection is sometimes unknown, it is believed to be transmitted from person-to-person and often found in more impoverished regions. Other fungal infections, such as ringworm, can also invade the scalp and lead to hair loss. These infections can be treated with topical or oral medication, but the medications are not readily available in many areas and are largely unaffordable by the majority of the population.
The stress of poverty leaves many families fighting just to live another day. However, it’s not just the poor who are experiencing excessive stress in South Asia.
“As more economic opportunities have become available, a new kind of stress has emerged,” says Dr. Patel. “It’s not the stress of just feeding your family for many men anymore — it’s the stress of starting your own business, finding funding, managing a staff, and all that goes with monetary success. Certainly, there is an increase in the middle class … even an increase in the number of millionaires in society. But money doesn’t make the stress go away — in fact, it can cause more of it.”
