Healthwatch

SLMA calls for media cooperation

Diabetes in Sri Lanka worse than in affluent countries:

Sri Lanka Medical Association on Wednesday (March 18) called for the cooperation of both the print and the electronic media to resolve the impending epidemic of diabetes in the country, which is at the moment is affecting 10.3 per cent of the population.

The SLMA President Prof. Rizvi Sheriff in association with Prof Chandrika Wijeratne, Prasad Katulanda, Prof. David R Matthews and Dr. Preethi Wijegunawardena made this call for media cooperation at a press briefing he had at SLMA auditorium at Wijerama Mawatha Colombo prior to the inauguration of the SLMA 122nd Annual Sessions at the Cinnamon Grand Hotel Colombo.

He said he was making this call for media cooperation because in preventive health they play the major role than the doctors; as such carrying incorrect health messages to the people they harm the health of the society and themselves, as they are part of the society themselves.

At this press briefing which was on non communicable diseases, which is rising up in the country, the panel of speakers spoke on different aspects of the problem. Healthwatch will carry them separately within the next two weeks.

Following is a brief release given to the press on this problem at the conference.

******************

Diabetes mellitus is a multifactorial, chronic, progressive disease that arises when the pancreas does not produce enough insulin, or when the body cannot effectively use the insulin produced. Failure of insulin secretion, insulin action or both leads to raised blood glucose level.

The disease burden of diabetes in Sri Lanka is becoming a serious public health issue worse than that in the affluent countries; this is believed to be due to the ethnic susceptibility of the South Asians for type 2 diabetes mellitus, the rapidly aging population and socioeconomic transition that is happening in Sri Lanka.

Very limited research has been carried out in the area of type 2 diabetes in our country when compared to western countries. Indeed, there is no well equipped and dedicated research centers with multidisciplinary clinical and research teams for type 2 diabetes and related conditions like the obesity, cardiovascular diseases and metabolic syndrome in Sri Lanka. One of the primary goals of Diabetic Research Unit (DRU), Department of Clinical Medicine, Faculty of Medicine, Colombo is to fill this gap.

No countrywide surveillance system

There had been no countrywide surveillance system for non-communicable diseases in Sri Lanka and the prevalence of diabetes had been determined by epidemiological surveys. Nevertheless, accurate prevalence data are vital to guide resource allocation for curative and preventive measures.

The first step of the DRU was to determine the nationally representative prevalence of diabetes (of all types) and pre-diabetes for the adult population in Sri Lanka.

The DRU research team with collaboration of Oxford Centre for Diabetes Endocrinology and Metabolism, UK; conducted a large cross-sectional study called The Sri Lanka Diabetes and Cardiovascular Study (SLDCS).

This study was carried out in all provinces of Sri Lanka except North and East. Five thousand individuals were recruited from 100 random ‘Grama Sewaka Kottasha’ islandwide. This is the widest epidemiological study conducted in Sri Lanka, which is the main strength of our study.

It also is the first comprehensive national level study on diabetes and pre-diabetes in Sri Lanka that measured the prevalence of diabetes, pre-diabetes for all age groups more than 20 years in this population.

The high response rate (91 per cent) increased the representativeness of the SLDCS data and the generalizability of the results to the Sri Lankan population.

The high standards in data collection, sample processing, storage, central laboratory analysis and data management along with the standardization of the prevalence make these the most up-to-data and reliable data for Sri Lanka that can be used for national and international comparisons.

Main findings

1) National diabetes prevalence is 10.3% in all adults (Among males 9.8%, females 10.9%)

2) National pre-diabetes prevalence is 11.5% in all adults

3) In Sri Lanka 36% of all diabetic subjects were previously undiagnosed

4) In urban populations the diabetic prevalence was 16.4% and rural population, it is 8.7%.

5) The total number of diabetes in Sri Lanka would be over 1.3 million, pre-diabetes 1.5 million.

6) The diabetes prevalence was as low as 2.5% in 1993 in Sri Lanka. During last one and half decade the prevalence of diabetes has rocketed to 10.3% in 2006. Surely, it is rising year by year.

According to the most recent data, Sri Lanka is among the countries with the highest diabetes prevalence rates in the world.

PRE-DIABETES

Impaired Glucose Tolerance (IGT) and Impaired Fasting Glucose (IFG) have been identified as two intermediate stages of glucose intolerance in the progression to diabetes mellitus and it is defined together as ‘pre-diabetes’.

Determination of the prevalence of pre-diabetes is important for public health policy as those affected are at a higher risk of both diabetes and cardiovascular disease.

More seriously, the estimation of diabetes, pre-diabetes and overall dysglycaemia for the year 2030 would be 13.9 percent, 13.1 percent and 26.2 percent, respectively, for the Sri Lankan adults, more than 20 years of age.

However, investigators believe the estimated prevalence could be much higher considering unprecedented growth of obesity and overweight in the modern era.

Risk factors of diabetes in Sri Lankan population are

* Physical inactivity
* Increasing age (old age)
* Family history of diabetes in 1st degree relatives
* Obesity
* Living in urban areas
* Overseas employment
* Past history of gestational diabetes mellitus
* Hypertension
* Abnormal blood lipids

Summary

One in five adults aged more than 20 years in Sri Lanka has either diabetes or pre-diabetes. These dysglycaemic conditions are associated with urbanization, physical inactivity, obesity and changes in lifestyle and those affected have higher cardiovascular risk such as heart attacks and strokes.

The high prevalence of pre-diabetes and the rapid socio-demographic transition of this population indicate the potential for a further rise in diabetes in Sri Lanka.

The diabetes epidemic will lead to a high incidence of cardiovascular disease and diabetes-related chronic complications, overwhelming the limited healthcare resources in the country. The researchers strongly suggest urgent public health interventions to handle this health catastrophe.

A higher prevalence of diabetes has been reported in both endogenous and migrant South Asians around the world, with a high level of familial segregation. Although a genetic predisposition may be an underlying factor for the increased predisposition, genetic studies on large South Asian populations are rare.

Genetic forms of diabetes in Sri Lanka

Diabetes mellitus is increasingly diagnosed among young adults (16-14 years) worldwide. Various disease presentation and causes of diabetes in this age group poses diagnostic and therapeutic challenges to doctors.

Surprisingly, the clinical spectrum of diabetes has not been adequately characterize among young adult South Asians, amongst whom diabetes has emerged as an important public health problem.

The research team of DRU has performed the largest ever study assessing the prevalence of the mt3243A>G mutation in young adults with diabetes from a South Asian population. This is considered as a pioneer study on the mt3243A>G mutation in South Asians.

We found that the prevalence (0.9 percent) is comparable with non-South Asian population and that in addition to a maternal family history of diabetes and/or deafness, additional clinical characteristics and audiogram findings could be taken into account before referring patients for genetic testing.

As a part of the Sri Lanka Young Diabetes Study, we found that type 2 diabetes is more common in Sri Lanka compared to European young adults. Which occur mainly due to obesity and physical inactivity.

It is evident that DRU has produced significant amount of research date to support diabetic community globally.

DRU has become a leading and outstanding diabetic research institution in the Sri Lanka. Moreover, DRU collaborates with the world’s leading research institutions including Oxford Centre for Diabetes, UK to provide answer to key issues affecting diabetes patients particularly in South Asians.

In addition, a large number of younger scientists have received priceless research experience both locally and internationally through DRU.

Cancer: Hope at the end of tunnel

Script and picture Sachitra Mahendra

Cancer sees no age when it takes over a victim, for Dr. Tiam’s youngest patient is about two years old and the oldest patient is 75.

Dr Ang Peng Tiam earns reputation as one of the best cancer specialists in the Southeast Asian region. He currently serves as a Consultant Medical Oncologist at Mount Elizabeth Hospital, Singapore, where he was recently sharing his specialty with a foreign delegation.

This C word has the natural tendency to give people the creeps sometimes creating the worse misconception that it is a terminal disease. The disease can be cured or at least controlled, Dr. Tiam emphasizes, on two grounds: early but accurate detection and best but proper treatments.

The patients in late stages should be given treatments that lengthen their lifespan assuring them a serene death.

“Confidence is ultra important. It is the bridge between the doctor and the patient. Most of the tumours can be wiped away, and we can make the patient’s life long. I always point that people have no reason get scared of this disease.”

Majority of Dr Tiam’s patients come from Malaysia and Indonesia, while he gets a good number of patients from Hong Kong, Philippines, Thailand and Myanmar as well.

He is well respected for his expertise in oncology, study of tumours, which is essential in cancer treatment. He frequents foreign seminars on cancer to freshen up his expertise.

No consultations

Many come to him for his opinions both physically and over the phone.

“Consultations do not cost me anything, so I don’t charge people for consultations. But I cannot see everyone all the time, and I know some patients would not want to ask certain things, either because they are scared, embarrassed or just confused. So I wrote a book called ‘Doctor I have cancer. Can you Help me?’”

Patients like to hear things. Mostly positive, but that’s not always a possibility. But there should be words of comfort to lift their sunken spirits. The book that runs for 120 pages is consisted of 10 chapters with interesting stories of cancer survivors in Dr. Tiam’s life.

RECORDS AS EXAMPLES

“All doctors understand the fears that our patients have. We do not and should not brush such fears aside.”

Dr Tiam has his own strategies of winning his patients’ confidence. He keeps a database of every patient. In case a patient does not believe that their doctor has seen enough of worse cases and fared well with them, Dr. Tiam has the records as examples.

Controlling cancer can sometimes sound costly. One of his patients wanted to stop medication because it was too expensive.

The doctor had to accept the terms, and he did. Within a few months her left breast’s tumour made a comeback causing the lady to get back to medication however expensive it turned out to be.

When Dr Tiam started specializing oncology back in 1990s, there were only five experts in the whole Singapore. “It’s a subject that keeps on changing. We have a good number of drugs with minimal side effects. Its exciting nature itself brings me satisfaction. First we study the natural history. Then comes the treatment methods, which is the deciding factor.”

Oncologist’s work role starts with the diagnosis that confirms positive cancer. They have to stage the disease to survey how far the disease has spread to decide on the treatment option.

Some stages require radiation surgery which means the oncologist has to work hand in hand with the surgeon and radiotherapist. Dr Tiam has come across the three commonest kinds of cancer: breast, lung and gastrointestinal cancer.

His line of work may seem full of despair to somebody. “Being optimistic is an essential requirement for an oncologist,” says the doctor, “if you get frustrated over seeing some of your patients dying of cancer and in worse stages, then you are in the wrong position.

I always enjoy looking after cancer patients, because I always believe on cure. And if I feel it’s really too much some day, I’ll quit this job for a teaching position or research.”

KNACK FOR RESEARCH

Dr Tiam came back to Singapore in 1991 completing his overseas training to found and head the Medical Oncology Deparment at the Singapore General Hospital (SGH).

He has the natural knack for research, although he hardly has time for any now. He was honoured for his medical contributions in 1996 which was to be followed by many of the genre.

Even at 50s, Dr Ang Peng Tiam looks very much younger with his face always smiling full of hope. Whoever sees him will be left with the memory that will keep on haunting: cancer - no worries about exceptions - can be cured, and we are not alone fighting against the ‘dreadful disease’.

A new chronic kidney disease

A new entity of Chronic Kidney Disease of Unknown cause was emerging. In the last 10 years practising physicians and nephrologists have noticed the increasing morbidity and mortality attributable to CKD.

No evidence of the cause was evident in the History, Examination or Investigation.

This illness was first noticed in Anuradhapura in the NWP and now see in NCP and Uva. WHO has named it CKDu. The Ministry of Health’s first reaction was to setup special renal clinics in several areas. Doctors from Kandy & University of Peradeniya worked in these clinics.

In some areas like Padaviya CKDu was more prevalent. These areas also had CKD associated with Diabetes, Hypertension & Urological disease but the CKDu was clearly different. It was reported that Anuradhapura medical ward mortality pattern was changing fast.

It was a disease starting in the young adult and slowly progressing to ESRF in 10-15 years. There was little anaemia or HPT. Kidneys were stunted on Ultrasound scan. Chronic Interstitial Nephritis was the predominant pathology, in the few cases renal biopsy was undertaken Dr. Tilak Abeysekare and Dr. Nimmi Athureliya gave leadership to these early studies and served to create the needed awareness.

It is now accepted as a Public Health Problem and available evidence suggests an exposure to environment toxins. Many researchers based in the Hill capital have suggested possible aetiological agents based on their studies. Examples are ...

Excess fluoride in water
Heavy metal Cadmium/Aluminium
Organophosphate contamination
Contaminants in fertilizer

These studies have been done by enthusiastic scientists to find a quick solution to a growing problem affecting largely poor farmers with much media hype. Some were convinced that their theory is confirmed by their results. The WHO Team felt a more organized study needed to be undertaken.

It was evident that the studies lacked direction towards finding a cause. We must commend the leadership given by the MOH and WHO who got all stakeholders together to work out a phased out plan with promise of adequate funding.

The WHO local, regional and Geneva offices all joined the Hon Minister’s call and the Epidemiology Unit is giving operational leadership. This National Research Programme for CKDu is now under scientific leadership of Prof Shanti Mendis. To be continued

Doctors’ Wives Association in community help program

Mr. & Mrs. Esther Turner from Australia recently came to Sri Lanka with a package of gifts of books, school bags, clothing and writing material for the poor, the poor children identified by the Doctors’ Wives Association.

Sri Lanka headed by Chrissy Aloysius in their-educational and healthy uplift of the needy children programme.

In the picture: Mrs. Turner from North Wales handing over a gift pack of toys and medicines to a child affected with cerebral palcy in one of the poor families in Moratuwa.

Pix by medical student, Chitra Anthony

Laughter the best medicine

A youngster was thinking about getting married. So he wrote to his father, the Editor of a newspaper for advice. The father wrote back thus.

“I can’t tell you how happy. I am to hear about your impending marriage. You’ll find marriage the most wonderful state of bliss and happiness that one can get. “As I look across the table at your dear mother, I realise with great pride how full and wonderful our years together have been. “Get married by all means. You have our blessings. It will be the happiest day in your life”.

PS - “Your mother just left the room. Stay single you idiot !”

Sent by N.S. Liyanage, Kaluthara.

Letters: Re-engineering your body

A new era in medicine is coming. And it is just in time for a culture that worships youth and beauty, and that has witnessed a pride of scientific and technological triumphs.

We don’t just hope to stay young and vital, healthy and happy, forever - we expect it. What is surprising is how far medical science has come towards meeting these expectations. Now there are treatments to repair or replace tissues and organs, therapies that compensate for defective genes, devices that stand in for failing body parts, and treatments to keep us thin and wrinkle free.

From Readers Digest October 2005 issue had this interesting piece

Sent by Sharmen Jayasekara, Raddolugama.