With the persistent rise in what is considered The Mother of All diseases as it affects almost every part of the human body more than any other diseases/s, the theme is both relevant and timely especially since many patients with diabetes don’t even know they have this disease which stalks them silently and relentlessly till it reaches its severest stages.
The Sunday Observer spoke to Professor and Head, Department of Clinical Medicine, University of Colombo and Consultant Endocrinologist and Diabetologist, National Hospital of Sri Lanka, Vidya Jyothi Prasad Katulanda to share his views on why and how Diabetes is caused, who are most vulnerable to it, and most importantly to offer readers simple rules on how to prevent its early onset and reduce lifelong adverse effects .
Excerpts
Q: Diabetes is still widely prevalent worldwide including Sri Lanka. While ongoing efforts by medical authorities to halt its spread have reportedly led to a decrease in numbers, how would you rank diabetes in Sri Lanka today?
A: Globally over 500 million people are affected with diabetes. Overall, this is about one in 10 adults having diabetes across the world. Although the medical fraternity and the health authorities are battling the diabetes epidemic, the numbers are going up. If we take Sri Lanka about 15 years ago 10 percent of the adult population had diabetes. According to the latest studies done in the Colombo District, about one-third of the adult population has diabetes. Another one-third has pre-diabetes. Therefore, if we extrapolate our present data with that of 15 years ago about 16 percent of people in Sri Lanka may have diabetes. This amounts to one in six adults having diabetes.
Q: What is the last study done islandwide on the incidence of diabetes?
A: The last study at the national level is about 15 years old. A study done in the Western Province called the Sri Lanka Non-Communicable Disease Survey showed the figures I have mentioned above. We urgently need a national level more comprehensive diabetes study.
Q: According to the studies, which areas in the country are worst affected and what may be the reasons?
A: The highest prevalence of diabetes is in the Western Province. This may follow the pattern of urbanisation and other Districts with high prevalence are Kandy, Galle, Kurunegala. One study has also shown Jaffna to have high diabetes prevalence. This is because the people are more obese and sedentary due to higher income and the increased level of urbanisation leading to overcrowding. All these factors have collectively contributed to an increased level of use of sugar, high calorie foods and people leading more sedentary lives.
Q: Which categories of people according to age and gender are most at risk of getting diabetes?
A: As in other parts of the world, the older people have a higher prevalence of diabetes. This is partly because there are many older people who had got diabetes many years ago. However, we see an alarmingly high incidence of diabetes in the younger and middle-aged groups. This is people are more at risk of getting diabetes as they are more obese.
Q: How do you categorise those who haven’t got the disease, but are at risk of developing Pre-diabetics?
A: Type 2 diabetes does not happen overnight. Those who are at risk go through an intermediate stage which can be identified by the blood glucose levels (Fasting between 100 – 126mg/dl and after a meal or glucose test between 140 – 200mg/dl). These individuals are considered to have pre-diabetes. In addition, studies have shown that they are at risk of heart attacks as well. They are more at risk of diabetes than normal people. However, those who have risk factors such as family history, obesity, sedentary lifestyles, less sleep, as well as other risk factors may also be at risk although they may not have got pre-diabetes at present.
Q: What about pregnant women?
A: Diabetes is very important for women as diabetes in pregnancy is associated with complications for both the mother and the baby both before and after delivery. Women who develop pregnancy associated diabetes are at high risk of developing diabetes later.
Q: In a previous interview with us, you said that 50 percent of people don’t even know they have the disease until it has progressed to an advanced stage. According to your present experience at the NHSL, have these figures come down in recent years?
A: Diabetes may go un-identified for many years. That is why we call it the Silent Killer. In Sri Lanka, people with undiagnosed diabetes have slightly come down compared to other countries due to increased awareness of diabetes and due to increased facilities to check for diabetes.
Q: Diabetes has often been called the Mother of all Diseases. Why? What happens to the body when you get diabetes?
A: Diabetes is called a multisystem disease as it affects almost all other organ systems in the body. Uncontrolled diabetes damages the small blood vessels (microvascular complications) in the eyes (retinopathy), kidneys (nephropathy) and the nerves (neuropathy). These complications can lead to blindness, kidney failure and nerve dysfunction. There are multiple issues due to nerve dysfunction. Since you may lose sensation in your feet, you may get injuries without your knowledge which even results in amputation of legs. The autonomic nerve dysfunction can cause faintness, vomiting, diarrhoea and erectile dysfunction.
Q: Are there methods to identify diabetes early?
A: Initially people with diabetes may not have signs and symptoms. When blood glucose levels start rising, you will start to feel dizzy, weak and sleepy. You may develop symptoms of diabetes such as increasing thirst, needing to pass a lot of urine and weight loss. Some people may also get wound infections, boils and fungal infections in the genital organs and areas. Therefore, people with these symptoms should do a diabetes test without delay.
Q: What is the natural history of diabetes?
A: Diabetes complications happen if the patients have inadequate control of diabetes or have other risk factors like high cholesterol, smoking or family history. However, if the disease had been undiagnosed for several years, patients may present these complications even at the time of diagnosis. The process of cholesterol building inside blood vessels which is called atherosclerosis that ultimately leads to heart disease, stroke and peripheral vascular disease, starts quite early in patients with diabetes even at the stages of pre-diabetes. In patients with type 2 diabetes, high blood glucose is toxic to small blood vessels especially in kidneys , nerves and eyes and complications in poorly controlled patients start about 10 years after the diagnosis.
Q: The Government has decided to give high priority to Non Communicable Diseases (NCDs). How will this affect the diabetes problem?
A: The Government has set up the Non-Communicable Disease Unit and the Non-Communicable Disease Bureau and is making progress in diabetes care over the last decade with the help of doctors, especially endocrinologists and physicians. Setting up healthy lifestyle centres also is a good initiative. People should make use of these facilities. While this will improve care of patients with diabetes, more aggressive efforts on prevention at national level are needed to stem the tide.
Q: Why?
A: Prevention of diabetes and other Non Communicable Diseases (NCDs) is much more important than treatment. This is because treating diabetes and other NCDs as well as their complications are costly and a huge burden to the country and society especially in a situation like today. For most of the treatments and screening tests we need to spend our limited foreign currency.
Q: What are your suggestions to face the diabetes epidemic?
A: Prevention of diabetes should be brought into the national health and development agenda. There are many ways this can be done using resources as prevention of diabetes and NCDs needs to be done through a comprehensive, integrated and multisectoral program. Awareness raising among children on prevention should start in the schools with the involvement of the Education Ministry. The Health Ministry in collaboration with the Media Ministry should launch a public education program. Such a program should get the support of all professional bodies, media sector NGOs and the civil society. Support of all sectors including the agricultural and food industry should be sought to make available more healthy food options and discourage promotion and use of unhealthy foods. Town planning, local government bodies and the sports sector should be involved in promoting physical activities and making healthy environments conducive for physical activity and sports.
Q: What are the most important things people should do?
A: Everyone should eat healthy meals controlling carbohydrates and calories to suit their level of physical activity and to prevent obesity. Green vegetables and green fruits should be encouraged in the meals. Everyone should undertake some form of physical activity. Adults on average should have a minimum of 150 minutes of aerobic physical activity spread over 3 to 5 days. Children should have at least one hour of physical activity per day. People need to focus on body image and try to maintain a healthy BMI (preferably less than 23) and an ideal waistline (men less than 90cm and women less than 80cm).
Q: What part do healthy diets help in reducing diabetes risks?
A: Diets low in refined sugar and carbohydrates, and high in green vegetables, green fruits, with some amount of nuts and fish have been shown to reduce diabetes risk.
Q: When should people start to follow healthy lifestyles?
A: Healthy lifestyles should start from childhood and should follow till we die to be free of diabetes and NCDs. There are no age limits for a healthy lifestyle.
Q: Many people have started using glucometers. How does this machine work and how accurate is the reading?
A: In the glucometers a small drop of capillary blood is used to check glucose. In the test strip, a chemical reaction takes place when the blood drop is applied, and this is detected by the glucometer. However, glucometers are not recommended for diagnostic purposes. For diagnosis, a formal laboratory test for blood glucose or glycosylated haemoglobin is generally recommended.
Q: What is the best time to get this test?
A: Glucometer testing times should depend on for what purpose this is used. Usually, early morning before bed tea and before meals would give an idea of overall blood glucose control. If there is a need for more stringent control like in pregnancy, we need to do both before and after meals. If it is needed to detect high or low blood glucose, blood glucose needs to be checked at such an instance. So people with diabetes should do even a random test if they get low or high glucose symptoms.
Low glucose symptoms are feeling dizzy, faintish, hungry, sweaty, palpitations and even clouding of consciousness. When glucose is high the patients may feel thirsty, need to pass urine frequently and also feel dizzy.
Q: What is the HbA1c Report? And what is its use?
A: Red blood cells survive about three months in the body. Some amount of haemoglobin is bound to glucose molecules, and this is proportionate to the level of glucose. Glycosylate Haemoglobin (HBA1C) is a test that gives an idea of the average blood glucose over a period of the preceding three months. It was initially used to determine overall blood glucose control. However, now it is used as a diagnostic test.
Q: Some important Do’s and Don’t’s to follow for healthy diabetes free life styles?
A: Cut down on sugar, sugar added beverages and sweets. Limit carbohydrates, especially refined carbs to maintain healthy weight, especially if you are a person involved with a job that does not involve much physical activity. Increase consumption of green vegetables and green fruits. Engage in regular physical activity. Stop smoking. Limit alcohol if you are using or don’t start if you don’t use and sleep at least six hours or more daily.
Q: Any new strategies in the management of diabetes?
A: Type 2 diabetes was considered traditionally a chronic disease that cannot be reversed. Some new studies have shown that type 2 diabetes can be reversed especially during the initial years with very tight control and losing body weight. When body fat level is reduced by weight loss the fat stored in the liver and pancreas is removed. This leads to reduction of insulin resistance and improved insulin production by beta cells of the pancreas.
Q: Your message to the public?
A: If you have not got diabetes, determine to prevent it or delay onset as much as possible. If you have got diabetes, try to reverse it or get the best possible control to prevent complications. If you have symptoms of diabetes, immediately check your blood glucose levels. It is a good habit to check blood glucose at least once a year if you are above 35 years and at an even younger age, especially if there is a history of young onset diabetes in the family.