HEALTH WISE

Variations of socio-cultural settings play active role

Mental conditions:

Sajitha PREMATUNGE

Kanchana from Angunakolapelessa was one of the lucky ones. "I went to many doctors and most of them prescribed medication, but nothing came of it." She had been suffering from insomnia due to a mental condition and lucky for her the National Program for Community Based Mental Health Care: Capacity Building in Management of Mood Disorders spotted her just in time. Under the program a community was formed in her village of which Kanchana became an enthusiastic and active member. "We engaged ourselves in activities like home gardening; it left us little time to think."

Now Kanchana leads a happy life self-sustained and a representative of the same community that saved her from losing herself and becoming a recluse.

Volunteer for the program, Chandrasena, observes a huge attitudinal change in the community. "We have stopped using the term `pissa' when referring to people with mental conditions." Kanchana's father Siripala explained that a person with a mental condition was usually treated with scorn and ridicule.

"Boys laugh and at times throw stones at people with mental conditions. But now they know better." Kanchana explained that her mental illness sort of acted as a blessing in disguise, if not for which she would never have joined the program, which as she explained turned her life completely around.

Fourteen per cent of global mental diseases are mood disorders. And Sri Lanka can't talk about things in isolation any more since mental health affects health. Mental disorders attribute to most physical illnesses. Recently completed National Mental Health Survey conducted by (Institute if Research and Development) IRD and commissioned by the Ministry of Health records mood disorders at 10% (suffering mainly from depression) as opposed to the 1% (Post Traumatic Stress) PTS, revealed Dr. Athula Sumathipala, during the inauguration of the National Program for Community Based Mental Health Care: Capacity Building in Management of Mood disorders. Prof. Lalitha Mendis agreed that for a country that has suffered years of terrorism as faced first hand the gruesome repercussions of the tsunami, PTS is surprisingly low. Dr. Sumathipala explained that far too much emphasis had been laid on PTS, sometimes completely disregarding other mental conditions.

Dr. Sumathipala claimed that most of the 10% do not seek psychiatric help. Dr. Neil Fernando, Acting Director of Mental Health Services, said that other reasons that the existing system has failed to cater the needs of healthcare seekers is because it is centralized, hospital based, disease oriented and the care delivered is on a one to one basis, but claimed that the much needed political initiative has always been present. "The system needs to be decentralized, community based, person oriented and care provided through community partnership", reiterated Dr. Fernando. He further explained that the program involves direct and active participation of the community.

"Doctors alone can't develop mental healthcare the government as well as nongovernmental institutions should work together."

Five hundred mental healthcare communities are scheduled to be established in grama niladhari divisions around the country, five for each MO of mental health. There are now 110 medical officers of mental health around the country. In 2002 the program was successfully initiated in Angunakolapelessa of the Southern Province.

"To provide effective mental health services, we need to extend services to the primary care level", said Dr. Fernando. The proposed national program for Community Based Mental Healthcare is designed to do just that. The main objective of the program is to provide mental healthcare through community participation. "Although we don't deal with treating mental health problems direct, the program encompasses four components of health care delivery system - promotion, prevention, treatment and rehabilitation." He said that their intention is to promote mental healthcare through knowledge accumulation, promote early detection and treatment, provide maximum care within the localities of patients, develop skills of caretakers in the community, improve attitudes, reduce stigma and discrimination and establish self help groups and encourage family networking.

Prof. Vijaya Manicavasagar, Senior Clinical Psychologist and Associate Professor, Black Dog Institute, School of Psychiatry at the University of New South Wales - one of the most active project partners - said that better diagnosis would lead to better management of disorders. "Any undiagnosed disorder will manifest. And our main objective is to raise awareness." Prof. Manicavasagar explained that the program also intends to empower clinicians to facilitate health policy changes which will lead to improvement of health services.

Their other project partners include IRD Sri Lanka, Mental Health Directorate and the Regional Director of Health Services, Sri Lanka Medical Association, College of General Practitioners Sri Lanka, World Mental Health Organization Sri Lanka, Sri Lanka Foundation Institute, Sri Lanka Ministry of Health and Open University of Sri Lanka.

The Black Dog Institute commenced disseminating knowledge in 2008 under this program. It currently provides specialized training for nurses, psychologists and other mental healthcare providers, under this program.

Dr. Varuni De Silva, Senior Lecturer, Department of Psychiatry, Faculty of Medicine, Colombo, Dr. Jayantha Jayatissa, Secretary, College of General Practitioners, Dr. Indika Karunathilaka, Senior Lecturer, Department of Medical Education, Faculty of Medicine, Colombo, Dr. Sriyani Liyanage, Medical Officer, Mental Health Focal Point, Colombo District, Ms. Chrishara Paranawithana, National Program Officer, Mental Health, WHO, Sri Lanka, Dr.

Sudath Samaraweera, Consultant Community Physician, Epidemiology Unit, Ministry of Health and Dr. Sisira Siribaddana, Consultant Physician, Project Leader, Sri Lanka Twin Registry, IRD were the first eight Sri Lankan Medical Professionals who participated in the initial Training Program.

Prof. Lalitha Mendis, immediate Past President, Sri Lanka Medical Association said that although the proposal seemed ambitious at first it was attainable due to the political will that, in fact initiated the process. "In the chain of evolution of mental health services, mental healthcare providers are an important link. And the community based approach is more economically feasible and clinically sound." Moreover the professor explained that such an approach provides an ethical basis for mental healthcare that respects the rights of the people.

"Mental health services should be accessible and available at all times." She explained that mental healthcare should take into account the variations of socio-cultural settings that are the major causes of mental conditions, in respect of districts. Knowledge of and sensitivity to wider socio-cultural and religious beliefs that operate in the lives of people is vital to mental healthcare, and reiterated the fact that skills are as important as knowledge.

Diabetes in Sri Lanka worse than in affluent countries

The following are the finds of a research conducted by the Diabetic Research Unit (DRU), Dept. of Clinical Medicine, Faculty of Medicine, Colombo.

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 or both leads to resection blood glucose level.

The disease is becoming a serious public health issue worse than that in the affluent countries; which 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 centres 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 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 over 20 years in this population. The high response rate (91%) increased the representativeness of the SLDCS data and the generalisability 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 standardisation of the prevalence make these the most up-to-date 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 diabetics 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 decades 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.

More seriously, the estimation of diabetes, pre-diabetes and overall dysglycaemia for the year 2030 would be 13.9%, 13.1% and 26.2%, respectively, for the Sri Lankan adults over 20 years of age. However, investigators believe the estimated prevalence could be much higher considering unprecedented growth obesity and overweight in the modern era.

Risk factors

*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 the five adults aged over 20 years in Sri Lanka has either diabetes or pre-diabetes. These dysglycaemic conditions are associated with urbanisation, 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.

Genetic forms

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.

Diabetes mellitus is increasingly diagnosed among young adults (16-40 years) worldwide. Various disease presentations 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 characterised 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 over G mutation in young adults with diabetes from a South Asian population. This is considered as a pioneer study on the mt3243 A over G mutation in South Asians. We found that the prevalence (0.9%) 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.

Toxic trans fatty acids in your food

D.P. Atukorale

Trans Fatty Acids (trans Fats) are a type of toxic artificial fatty acids created by technology and are foreign to human body. Trans fats are commonly found in margarine, shortening, all vegetable oils including olive oils, beef, mutton, pork, processed food like cookies, cakes crackers, full-fat dairy products, pizza, macaroni, hamburger, and fried fast food. Cooking oils (except coconut and palm oil) used for frying in your home, hotels and restaurants are full of these poisonous trans fats.

If mayonnaise and salad dressings are prepared with hydrogenated ingredients they also contain trans fats. Although trans fats are unsaturated fats, they are worse than saturated fats.As mentioned earlier trans fats are one of the undesirable products produced during hydrogenation or hardening produced in turning oils into solid shortening and margarine: Trans fats are worse than LDL (bad) cholesterol. Because these trans fats are unlike natural fatty acids which are needed for good health, our bodies are incapable of utilizing trans fats in a productive manner.

It is like pouring arrack or toddy into your petrol tank, it gums up the works. Cars are designed to run on petrol and not on arrack or toddy. The chemicals in arrack or toddy will cause the engine to freeze up. In like manner, trans fats cause our cells to `freeze up' so to speak, making them dysfunctional. The more trans fats eaten, greater the cellular destruction.

Common knowledge

Trans fats raise your LDL (bad) cholesterol and decrease the level of HDL (good) cholesterol. It is common knowledge among physicians that low HDL cholesterol is a worse risk factor than high LDL cholesterol.

IN Sri Lanka as far as I am aware, at present trans fats are not listed on any food labels. Saturated fats such as coconut oil or palm oil do not contain trans fats. During deep frying (repeated frying) amount of trans fats in vegetable oils increase. That is why doctors and nutritionists (dieticians) advise you not to use vegetable oil for repeated frying. On the other hand coconut oil can be used for repeated frying.

Where do we get trans fats? Unfortunately they are every where as a result of modern food processing. Trans fats are produced when mono-unsaturated oils (e.g. olive oil) and polyunsaturated oils (eg. corn oil. Soya oil and sunflower oil) are heated to high temperatures, in the extraction, refining and deodorizing process, vegetable oils are heated to temperatures up to 400 degrees F (200 degrees C) for extended periods of time. This converts normal unsaturated fatty acids into poisonous trans fats. Between 15-19 per cent of the fatty acids in liquid vegetable oils are trans fats.

Solid fats

Vegetable oils are often hydrogenated to turn them into solid fats. In the process of hydrogenation, higher temperatures and longer exposure times create a far greater number of trans fats. Shortening and margarine are hydrogenated oils. On average they may contain 35 per cent trans fats, but some brands may run as high as 48 per cent.

These are probably the most toxic fats ever known says Walter Willet MD, Professor of epidemiology and nutrition at Harvard School of Public Health. He says `trans fatty acids are 2 to 3 times as bad as saturated fats in term of what they do to blood lipids' (Harman D et al, 1976 Journal of American Geriatrics Society 24 (7) 301).

Trans fats can contribute to atherosclerosis. Many researchers believe that trans fats have a greater influence on the development of cardiovascular disease than any other dietary fat (Willet W C et al 1993, Lancet 341 (8845) 581.

The New England Journal of Medicine reported the results of a 14 years study of more than 80,000 nurses. (New England Journal of Medicine, Nov. 20, 1997). The research documented 939 heart attacks among the participants. Among the women who consume the largest amounts of trans fats, the chance of suffering a heart attack was 53 per cent higher than among those at the low end of trans fat consumption. The researchers from Harvard School of Public Health and Brigham and Women's Hospital in Boston who conducted the study said that this suggested that limiting consumption of trans fats would be more effective in avoiding heart attacks than reducing overall fat intake. About 10 per cent of fat in the typical Western diet is trans fat.

Link

According to Mary Enig PhD, there is a link between trans fat and diabetes. Trans fats have been linked with a variety of adverse health effects which include cancer, multiple sclerosis, diverticulitis complications of diabetes and other degenerative diseases.

Hydrogenated oil is a product of technology and may be the most destructive food additive currently in common use. If you are eating margarine, shortening, hydrogenated oil, then you are consuming trans fats.

Next week: Processed vegetable oils