Non communicable but dangerous

With 25% Sri Lankan adults overweight, diabetes is a spectre hovering over the lives of 1 in 3 over the age of 40:

by Carol Aloysius

The spectre of diabetes has stalked adult populations across continents for years. Today younger people including children, are pre-diabetic or diabetic, and at risk of developing serious complications early in life. Recent statistics indicate 15% of Sri Lankan children are obese, while obesity among adults has also increased three-fold in the past two decades with over 25% Lankan adults being overweight.

Professor in Reproductive Medicine, Dept. of Obstetrics & Gynaecology, Faculty of Medicine, University of Colombo, Dr Chandrika N. Wijeyaratne shares with the Sunday Observer, current insights into the disease based on her own hands-on experience in the field.

Excerpts...

Q: Diabetes Mellitus is one of the commonest diseases in Sri Lanka. Yet many are unaware they have the disease? Why?

A: The reason most affected persons remain unaware of increased blood sugar is because they do not experience any symptom until the blood glucose becomes very high. Diabetes afflicts around 1 in 10 adults over 20 years of age and almost 1 in 3 among those above 40 years of age.

Q: How do you develop high blood sugar?

A: High blood sugar results from a relative lack of the hormone insulin that drives the blood glucose into cells. The commonest reason is a resistance of the body cells to the action of insulin that is caused by unhealthy lifestyle and physical inactivity leading to excess body fat. This is called Type 2 diabetes. When there is a cellular level resistance to insulin, the pancreas that produces insulin has to work 'overtime' to achieve an increased insulin production. Eventually the pancreas becomes tired out and exhausted causing insulin deficiency. When the body develops insulin resistance the blood sugar tends to increase, particularly by excess production of glucose by the liver. In parallel the blood cholesterol and fats (lipids) increase with a tendency to develop high blood pressure.

High blood sugar has been observed to occur among Lankans at a younger age. If a person in the late 20s develops type 2 diabetes, and it remains undetected and uncontrolled, he could develop complications of the disease before the age of 40 years.

The less common variety of Type 1 diabetes is often seen in the young where there is destruction of the insulin producing cells of the pancreas. This group of people often develop symptoms of passing large amounts of urine with excess thirst, severe weight loss despite a good appetite and may even be rushed to hospital with 'diabetic coma' caused by acid like substances called ketone bodies produced by an increased breakdown of body fat for energy. Diabetic ketoacidosis is life threatening and requires emergency hospital treatment.

Q: Is diabetes inherited?

A: No doubt there is a genetic tendency to develop diabetes when your family members are diabetic. But the primary and major underlying cause of the common variety of Type 2 diabetes is an unhealthy lifestyle and unhealthy environment causing excess body fat, particularly around the waist.

Q: What are 'unhealthy lifestyles'?

A: Consuming excess unhealthy food with tobacco and alcohol abuse, coupled with physical inactivity, contribute to weight gain, high blood pressure, and the gradual damage to all blood vessels. Overweight and obese persons don't become so overnight. Often the foundation is laid in the mother's womb and during childhood, due to the wrong belief that a 'chubby child' is healthier. This is absolutely wrong.

Q: Those most at risk?

A: Adolescents are at increased risk of developing insulin resistance, especially during puberty. Children and young adults who consume excess fast food, fizzy sugar laden drinks and spend long hours at the computer or watching TV are at greater risk of becoming obese. This results in pre-diabetes, which is just a single step ahead of developing diabetes. Increasing age or a stressful event like surgery, trauma or pregnancy can tip the balance and speed up the development of diabetes in these high risk individuals. There are certain drugs such as steroids that also increase this conversion to diabetes.

Q: How do you detect Diabetes?

A: Blood glucose testing is the modern day diagnostic. To confirm diabetes you must check fasting blood sugar on two occasions to ensure it remains high. The ideal method of testing is blood drawn into a syringe, the plasma separated in the laboratory and tested for sugar. This is accurate and cheap although its takes some time to know your result. However, the glucometre is a handy tool to check your capillary whole blood with a tiny drop of blood obtained by a needle prick of the finger tip. Capillary blood glucose is about 15% less in value than plasma glucose.

The gold standard test to confirm pre-diabetes or diabetes is the 75g oral glucose tolerance test (OGTT). This requires overnight fasting of 8 hours and involves testing fasting blood glucose (FBG) and the 2 hour post glucose BG. In pre-diabetes the FBG exceeds 100 and is less than 126 mg/dL or the 2 hour BG is between 140 and 200 mg/dL. To confirm diabetes the FBG has to exceed 125 mg/dL or the 2hour value over 200 mg/dL. Performing the OGTT requires resources and is laboratory based. Therefore we often rely on FBG or random blood glucose (RBG) on two separate occasions; RBG in excess of 200 mg/dL suggesting diabetes. Another, but expensive test is the blood HbA1c% that reflects your average blood sugar in the previous 3 months - the lifetime of a red blood cell. In a normal non diabetic individual this test value should be less than 6%.

Q: What organs are most affected by diabetes?

A: The triad of high blood sugar, high blood pressure and elevated lipids leads to premature atheroma or fat filled blockage of blood vessels that feed vital organs. Such complete blockage of blood flow to the heart and brain cause heart attacks and strokes respectively (Macro vascular disease). The smaller blood vessels of the kidney, nerves and eye are affected by persistent high blood sugar that causes Micro-vascular disease. The net result includes kidney failure, numb feet with loss of protective sensation that increases risk of foot injury and infection leading to leg amputation, sexual dysfunction and blindness. So although high blood sugar causes few symptoms, it has it has great potential to damage almost every organ of the body leading to premature disability and death.

Q: Typical symptoms of diabetes?

A: The patient will lose weight, feel excessively tired, and develop leg cramps at night. However these symptoms are never reliable. You must check the BG and ensure how your control is.

Q: Is diabetes curable?

A: Diabetes is incurable. However, you can control it and lead a normal life. Type 1 diabetics can be offered a 'cure' through islet cell transplants - although an insulin pump - a little machine fixed to your skin, which checks your glucose level and titrates the insulin dose is quite close. Both are expensive options. On the other hand, as Type 2 diabetes is a lifestyle disease, if you reduce weight, you can overcome your degree of diabetes to quite substantially. Additionally metformin with lifestyle changes for the pre-diabetic can delay the conversion to full blown diabetes.

Q: Many pregnant women are now being diagnosed with gestational diabetes. How do you control their diabetes prior to delivery?

A: The Family Health Bureau has formalised a system of screening for every pregnant mother at the field clinic in early pregnancy to ensure she has no previously undetected diabetes. Pregnancy is like a stress test and can unmask pre-diabetes in the mother due to major changes in hormones. Having high blood glucose in the mother means this excess glucose crosses the placenta to transfer to the foetus. Excess glucose can cause problems for the unborn - from birth defects in those exposed to high glucose at conception. All organs are formed in the first three months. So good BG control throughout the day of a mother can protect the baby. Gestational or pregnancy induced diabetes that occurs around the 5th month of pregnancy often cause the baby to become overweight. An overweight foetus is not healthy. In the short term the obstetricians have to tackle problems of excess water around the baby, problems with safe delivery, still births and high blood pressure in the mother. It is not that the foetus becomes diabetic but excess glucose is unhealthy.

Q: Is gestational diabetes temporary?

A: Diabetes in most mothers becomes nonexistent after the birth of the baby. However, if mothers are not careful and gain excess weight they can slowly progress to diabetes within 3-5 years from childbirth. So we recommend all affected mothers adopt a healthy lifestyle and check BMI, blood glucose and blood pressure at least annually and most certainly before their next pregnancy. The health authorities have prioritized universal screening of pregnant mothers, which is highly commendable.

Q: What facilities are available for screening, treating diabetes free of charge?

A: The Ministry of Health has set up screening facilities in over 750 healthy lifestyle centres island-wide for early detection of high-risk individuals. Additionally there are mobile services. They can be accessed free through their respective local hospital or doctor.

Q: Recent advances in diabetic detection, prevention and treatment globally and in Sri Lanka?

A: The World Health Organisation has spelt out an essential package for the control and prevention of non communicable diseases including diabetes. It includes an essential drug list and the basic technology, for screening and treatment of affected persons on a consistent basis.