Preventing diabetes - key to safe motherhood

By Carol Aloysius

Diabetes is on a sharp upward curve in Sri Lanka, with one in 10 over 20 years and one in four adults over 40 years having type 2 diabetes.

While all those afflicted by the disease are at high risk of developing other non communicable diseases such as hypertension and cardiovascular disease, women are more at risk than generally thought. Diabetes in a pregnant woman affects both the mother’s health and that of her unborn child. The key to preventing it is by adopting healthy lifestyles starting at an early age leading to healthy mothers.

Professor of Reproductive medicine, Dept. of Obstetrics and Gynaecology, Faculty of Medicine, University of Colombo and Hony. Consultant physician and endocrinologist De Soyza Maternity Hospital, Dr CHANDRIKA WIJEYERATNE talks to the Sunday Observer on how diabetes can be prevented and why women play a key role in ensuring a healthy nation. 

Excerpts

Q. Diabetes is one of the commonest non communicable diseases in the world and in Sri Lanka. Your comments?

A. Diabetes has shown an exponential increase in its occurrence in the past two decades. Sri Lanka, although a lower middle income country has experienced similar changes in the increase of diabetes mellitus and risk factors for cardiovascular disease very similar to high income countries. One in ten of Sri Lankans over the age of 20 years and one in four of adults over the age of 40 years have type 2 diabetes.

Q. How do you describe diabetes? What causes it?

A. The commoner variety - type 2 diabetes mellitus is a situation where your insulin hormone produced by the pancreas cannot act on cells to help glucose to enter into the cell for it to function properly. This is due to a resistance of the insulin receptors. The cause of this resistance is excess body fat or adipose tissue. 

The resulting high blood glucose affects the function of blood vessels throughout the body. The larger blood vessels tend to get blocked by atheroma (fat deposits) that can cause heart attacks, strokes and poor circulation to the feet. 

Affection of small vessel function can cause diabetic kidney failure, eye disease, erectile dysfunction and nerve dysfunction.

However, the majority of people with type 2 diabetes do not experience any symptoms, until the organ function gets affected. It is estimated that one third of Sri Lankans with diabetes are unaware of this affection. 

Q. Can it be inherited?

A. Diabetes does run in families. A recent study in the urban setting showed that one in ten households have diabetes. The great majority of these are due to unhealthy lifestyles.

Q. What are the different types of diabetes?

A. The three major types

1) Type 1 diabetes - which is a lack of production of insulin by the pancreas that causes extreme thirst, excess passage of urine and a risk of diabetic coma (ketoacidosis.)

 2) Type 2 - is the adult onset type due to insulin resistance and the commonest variety.

 3) Gestational diabetes - is diabetes that occurs during pregnancy, caused by the major hormone changes that unmasks diabetes.

Q. Who are most at risk? Men? Women? Youth? Elderly?

A. An increasing number of women are reported to develop type 2 diabetes due to unhealthy lifestyles. In the great majority, this can be prevented if young individuals at risk adopt healthy lifestyles In the very elderly, when the organs shrink they can develop a relative lack of insulin.

Q. Which age group is highest at risk in Sri Lanka? Why?

A. Those beyond the age of 40 - midlife - are the greatest numbers detected each year. The reason is less organ reserve with greatest risk of insulin resistance due to increased fat tissue in the body.

Q. How do you diagnose diabetes?

A. Blood glucose testing is the best method of detection. Following an overnight fast of 8-12 hours if your fasting blood glucose is less than 100 mg/dl you are unlikely to have diabetes.

If your FBG is greater than 126 mg/dl on two occasions this confirms that you have diabetes. Those with FBG between 100 and 125 have impaired fasting glucose (pre-diabetes) that can also be prevented from turning into full blown diabetes by a change from unhealthy to healthy lifestyle. The gold standard test is the 75g oral glucose tolerance test (OGTT) which can confirm pre-diabetes and diabetes.

Q. Is diabetes reversible?

A. It can be controlled and kept in check. There is no permanent cure for type 2 diabetes.

Diabetes in mothers

Q. Today, we see an increasing number of young women including young mothers being diagnosed with diabetes, some of them for the first time when they come to a maternity clinic. Your comments?

A. The greater majority of young women develop diabetes during pregnancy. This is called gestational diabetes (GDM) and afflicts about 1 in 10 mothers-to-be.

They develop GDM because of a greater potential to develop diabetes later in life due to excess body fat and family risks.

Pregnancy unmasks this risk due to the major hormonal changes that arise from the growing placenta. These hormones act usually arise around the 5th of pregnancy and after by acting against the mother’s insulin and thereby the pregnant mum develops high blood sugar during pregnancy.

However, due to their unhealthy lifestyles, young women who have developed diabetes may be unaware of this when they conceive.

This is actually pre-pregnant diabetes and has worse complications due to the high blood sugar being present from conception itself.

High blood glucose in the mother in the first three months of pregnancy can cause abnormalities in the developing foetus that can be prevented by recognising the woman’s diabetes and controlling this to normal blood glucose targets

Q. Is gestational diabetes reversible? Will it disappear after a while?

A. Gestational diabetes will get worse during the pregnancy if undetected and uncontrolled.

Then the high maternal blood glucose can cause ill effects on the unborn baby with a higher risk of foetal death or complications around birth. Additionally the mother can develop high blood pressure.

However, with the delivery of the placenta, the hormones that rake up the mother’s blood glucose subside in her system, and the GDM can revert back to normal.

But if the mother does not lose weight and adopt a healthy lifestyle she is at greater risk of developing GDM in a subsequent pregnancy or even develops type 2 diabetes even without being pregnant.

Q. How is gestational diabetes managed?

A. We recommend a healthy meal plan and physical activity and monitor the blood glucose.

The mother needs to have normal blood glucose appropriate for pregnancy throughout the day and throughout her pregnancy. The blood glucose values are much lower than those stated earlier.

The reason for this is there is a proportion of blood glucose that passes on to the foetus for which we need to make an allowance.

Therefore we maintain a pregnant woman’s blood glucose at less than 90 mg/ dl before a meal and less than 120 mg/dl 2 hours after a meal.

Q. Is insulin safe for pregnant mothers?

A. Insulin is very safe for mum and baby. However, the tablet metformin is being increasingly used for those with major insulin resistance.

Q. What are the health complications if the mother is untreated for 1) the mother 2) the baby?

A. The mother is at greater risk of developing high blood pressure in pregnancy that has its own set of major complications.

This can be prevented to quite an extent by early detection and good control of blood sugars.

Poorly controlled diabetes means the unborn baby gets excess glucose from the mother that is toxic to baby. The baby becomes unhealthy with excess body fat or in some cases poor foetal growth that can place the foetus at great risk of death or complications.

Q. Statistics on the number of diabetic mothers in Sri Lanka?

A. Approximately 400,000 women get pregnant per year and 10 percent of them have diabetes - that is approximately 40,000

Q. Have the numbers of diabetic mothers treated by you declined or gone up in the past 10 years? Why? 

A. No it keeps increasing at a younger age. Preventing diabetes starts from childhood and adolescence.

It requires a life cycle approach. Mothers can prevent getting diabetes by adopting healthy lifestyles and screening themselves prior to conception.

Q. At what age is a girl most vulnerable to developing diabetes?

A. Puberty makes one vulnerable to insulin resistance due to the excess fat deposition.

Thereafter pregnancy is the next phase when insulin resistance can set in with the growth of the placenta.

Q. Can a baby develop diabetes in the womb if her mother is diabetic, or eats too many sugary foods while pregnant?

A. The excess sugar that is passed on to the unborn child does not cause diabetes but causes excess body fat. Such girls and boys have a greater risk of obesity from a very young age. 

Q. Has new research on diabetes especially in relation to pregnant mothers young mothers provided a breakthrough in treating them?

A. Prevention is the best form of treatment through healthy lifestyles - diet and physical activity

Q. I understand that the Sri Lanka Medical Association is setting up a special service to save mothers from developing diabetes and other non communicable illnesses. Your comments? 

A. The SLMA has established a large project to assist the Ministry of Health named Nirogi Lanka with funding from the World Diabetes Foundation.

In its second phase, we have introduced the concept of Nirogi Maatha (healthy mother). 

The Ministry of Health has a super track record of attaining excellent maternal and child health services by a low cost equitable field service that ensures the great majority of pregnant women are registered early in pregnancy for ante-natal care and also follow up the babies.

The Family Health Bureau is the focal point for coordinating this valuable service. We work along with Family Health Bureau which coordinates this service, to ensure that every pregnant woman is screened by blood sugar testing for GDM and follows an appropriate diet and physical activity from pre-conception to post pregnancy and lactation.

Mothers with GDM need long term support to prevent developing future diabetes. Our theme is ‘healthy mothers result in healthy families and societies’.

Q. Advice to women in general and pregnant woman particularly, on preventing, controlling and treating diabetes?

A. Adopt healthy lifestyles. View pregnancy as a normal but valuable phase of your life.

Unhealthy diet is calorie dense with excess starch, sugars, fats and excess salt– that often come from fast foods and drinks. Brisk exercise such as walking at least for 30 minutes a day 5 days of the week, can keep you free from most non communicable diseases including diabetes.

Taking pre-pregnancy folic acid and ensuring you have taken your rubella vaccine is also your responsibility.

Finally, plan your pregnancy and your family, to create a healthy nation.

Overcoming kidney disease vital for a healthy nation

by Dr A.T.W. Guneratne

It is a well known fact that there is a significant increase in the incidence of cancer, liver and kidney failure, allergic reactions, nervous system disorders, and sterility. One common cause for this is the toxic chemicals we are consuming with food and water.

Large scale vegetable growers use weed killers, insecticides, fungicides and large amounts of chemical fertilisers to optimise their crop. Some vegetable growers do not use insecticides to the vegetables they consume, as they know that it is bad for their health.

The most insecticide sprayed vegetables are apparently the upcountry grown. e.g. cabbage, leeks, tomatoes, beans etc.

There is no control in the use of insecticides; some farmers may not know the consequences of consuming insecticide contaminated vegetables. Agro chemicals should not be sprayed at least two weeks before harvesting. Sometimes the concentration of agro chemicals used exceeds the recommended levels as given in the instruction leaflet.

Some insecticides, fungicides and chemical fertilisers have toxic heavy metals as impurities e.g. Arsenic, cadmium, lead. The authorities concerned should analyse all agrochemicals used in agriculture and ban the import of toxic ones. Some have already been banned. If vegetables are kept soaked in water for 1-2 hours and washed well before cooking most of the surface agro chemicals will be removed.

Ideally it is best to grow your own vegetables and green leaves at home. Lack of space may be a limiting factor, but if you are really keen you could grow vegetables and green leaves in pots or large polythene bags. I have seen how vegetables are grown on roof tops.

While flowers are being grown some space may be reserved for vegetables and green leaves. Compost which could be produced in your home or bought from a fertiliser store and cow dung available in bags in fertiliser stores are all what is needed with sun light and water to start your vegetable garden. You will be very happy to see your home garden thrive and in addition to have poison free vegetables and green leaves. In addition you will save on the money spent on vegetables.

In foreign countries there is a good demand for organic food. Even in Sri Lanka there are a few organic food outlets. Organic vegetables are produced without chemical fertiliser and agrochemicals, but they are expensive as yields are less, but there is a growing demand. Organic tea is also available in Sri Lanka but is mainly exported.

Fruits

In large scale commercial fruit cultivations, agrochemicals and artificial fertilisers are used similar to large scale vegetable cultivations. Fruit sellers use chemicals to enhance fruit ripening and also to protect fruits from insects.

Frequent checking of fruit cultivations and testing for chemicals in large fruit distributors, prohibiting the sale of toxic fruit ripening chemicals and educating farmers and fruit distributors will reduce the toxic chemicals in fruits.

If fruits could be bought from home gardens or you grow your own, it will be the ideal solution.

Paddy cultivation

To increase yields paddy cultivators use agrochemicals, large amounts of artificial manure and insecticides which are sprayed close to harvesting. The rice we consume must be analysed to exclude toxic chemicals. Imagine the plight we would be in if the rice we eat is poisoning us.

Large amounts of weed killers and chemical fertilisers are used in the tea estates; as such, tea has to be analysed for chemical toxicity. In large poultry and dairy farms both in Sri Lanka and abroad vitamins, antibiotics, nutritional supplements and hormones are given to enhance the production of eggs and milk. Some of these enter eggs and milk which could cause harmful effects on the consumers. The ideal would be to obtain eggs ( gam biththara ) from small scale egg producers.

In some of the fast food outlets certain chemicals are added to increase taste and smell. Some of them may cause allergy while others may be carcinogenic. Some small food outlets wrap the food in newspapers. The printing dye in newspapers are toxic to the human body, food should never be wrapped in newspapers. There may be traces of toxic chemicals in the food we eat and the water we drink, but the human body could get rid of these if the intake is not excessive to overwhelm these organs. With old age the function of these organs decreases, therefore most organ failures occur in old age.

Could we stop using agrochemicals and artificial fertiliser in agriculture and other food related industries? This is not possible as the yields will drop and it will not be profitable to do agriculture. We must encourage farmers to use more compost manure, reduce artificial manure, control and reduce agrochemical use, produce high yielding varieties of paddy, vegetables, tea etc. Already a number of high yielding verities are being used.

Chronic Kidney Disease (CKD)

It well a known fact that a large number of farmers in the North Central Province have died of CKD and that there are large numbers having this disease. It has been observed that this disease is gradually spreading to the adjacent areas. According to estimates the population at risk is about 2.8 million. Though a specific cause is not known, it is believed to be multi-factorial in origin. The water in most of the affected areas is polluted with agrochemicals and toxic heavy metals, arsenic, cadmium, lead and fluoride. There is no cure for chronic renal failure, dialysis is a temporary mode of treatment, renal transplant s are the only possible long term treatment, but only a limited number of transplants could be done and are very expensive. The only solution is to prevent the development of CKD.

Prevention of CKD

CKD is due to the consumption of polluted water and food. Agrochemicals and artificial fertiliser in excessive amounts contaminate wells, streams rivers, irrigation tanks and also the soil. The farmers must be educated regarding the problem faced by them. All sources of drinking water must be checked to find out whether they are fit for drinking. A centrally purified pipe borne water supply is the ideal which the government has started, but it will take a long time and lot of money to do so. Rain water harvesting is a practical, relatively inexpensive way to obtain clean drinking water.

People in the affected areas should be encouraged and helped to construct the tanks to collect rain water. Polluted water could be purified by a method known as reverse osmosis, which is a relatively cheap way of providing clean water from polluted brackish water.

People in the north central province and adjacent areas should be educated regarding the causation of CK and how to prevent it.

Foreign aid agencies, NGOs, and village level organisations such as Sarvodaya should be mobilised as an emergency, as there is not much time. If the present trend continues, in five to 10 years there may be a shortage of farmers and our paddy cultivation will be adversely affected and we may have to get down farmers from foreign countries to work our fields.

The authorities must coordinate and mobilise all relevant ministries and organisations and provide adequate funds to prevent a disaster in the near future.

The writer is a Consultant Paediatrician