At least 2 million Lankans over 20 years are pre-diabetics, many unaware they have the disease:

Fight NCD with lifestyle changes

By Carol Aloysius

Non Communicable Diseases (NCDs) are on a high roller affecting millions of people mostly in their fifties in every part of the world including Sri Lanka. Diabetes which occupies the second highest slot in the long line of NCDs at ten percent, is estimated to afflict at least two million persons (men and women) in Sri Lanka over 20 years of age. Long considered the ‘Mother of all diseases’, diabetes, if not detected and treated in time, can lead to many other serious illnesses such as Ischaemic heart disease and hypertension as well as stroke and kidney failure which eventually cause the body system to be severely compromised and could end with premature death.

The most disturbing aspect of this disease is that these conditions are often without any symptoms and consequently, thousands of persons are walking around without knowing they even have the disease. Studies indicate that one third of pre-diabetics are unaware of their risk status and health officials have warned the numbers could surge to as high as 25% in the near future due to our aging population.

The Health Ministry has for years battled against this debilitating disease but wide prevalence indicates that something is amiss and that the previous focus on the curative aspect needs to be shifted to preventing it. The Health Ministry’s goal is for Sri Lanka to be NCD free by 2030. Considering the present obstacles facing health officials, the big question is, will this goal be achievable?

The Sunday Observer talked to two experts from NIROGI Lanka Project which together with the approval of the Ministry of Health are trying out a new approach to fighting diabetes-with lifestyle changes involving community participation.

Excerpts from interviews with Professor of Surgery, Faculty of Medicine, University of Colombo Dr Chandrika Wijeyaratne and Senior Lecturer and public health expert in NCD, Department of Community Medicine Dr A Carukshi Arambepola …

Q:In the past decade Non Communicable Diseases ( NCDs like diabetes, cardiac, hypertension, kidney failure and cancer, have soared in Sri Lanka. Although we have official data, it is said the unofficial rates are very much higher. What in your opinion is the estimated number of persons with NCDs in Sri Lanka? What is the difference between ten years ago and now?

A. With respect to diabetes the number of adults over the age of 20 years afflicted is around 10% of our population – therefore estimated as at least 2 million persons (both men and women).

No doubt this proportion will rise with increasing age in that about 25% of people have diabetes or pre-diabetes. These conditions are often without any symptoms. The local data suggests that approximately one third of them are unaware of their risk status.

With reference to high blood pressure this is even greater in that almost 40% of our adult population is affected.

Currently Ischemic heart disease is the leading cause of mortality in hospitals in Sri Lanka. Hospital admissions due to diabetes and related complications have shown a rise from 86 to 226 per 100,000 over the past two decades.

Q: For example?

A. For example, when a small proportion of people with end stage kidney disease twenty years ago had diabetes, in the current day this figure is closer to about ¾ths. Chronic NCDs accounted for 71% of all deaths in Sri Lanka, compared with 18% due to injuries, and 11% due to communicable diseases, and maternal and prenatal conditions.

Moreover, trend analysis suggests that NCD mortality rates have been rapidly increasing during the past decade (Register General, 2008).

Q:What are the main causes for this steep rise of NCDs despite interventions by the Health Ministry and various NGOs?

A. The root causes are unhealthy lifestyle i.e. food and drink rich in starch, salt, sugar and fats with low consumption of vegetables and fruit coupled with insufficient physical activity that encourage obesity. In parallel, tobacco and alcohol consumption makes these vulnerable persons at greater risks of cardiovascular disease, chronic lung disease, diabetes, and cancer – the commonest chronic NCDs.

Q: As you have pointed out many of these NCDs are preventable. Yet they continue to persist. Why? Are they all life style related?

A. There are few risk factors shared among all major chronic NCDs. Those are unhealthy diet, lack of physical activity, tobacco and alcohol consumption.

All of them are life style related. Main causes for the current NCD epidemic is due to changing lifestyles, consuming more fast food and unhealthy diets, tendency for consumption of more alcohol and tobacco, living in polluted environments etc.

According to recent research about 80% of adults do not consume adequate amount of fruits and vegetables. Saturated fat consumption, which is an important risk factor for cardiovascular disease is also high. Dietary intake of salt (10g/day) and sugar (60g/day) is also high in Sri Lankan diet when compared to WHO recommendation.

Prevalence of current smokers and alcohol consumers among adult male are 22.8% and 26% respectively.

Q: What about physical exercises?

A. Only a small proportion is engaged in regular physical exercises, which is also a very important factor in reducing NCD risk factors.

Q: I understand Nirogi Lanka project of the SLMA is currently promoting a new approach with the help of the Health Ministry, to tackle this problem using community involvement as a base, to change lifestyles. How can life style changes help control NCDs? Can they also prevent them?

A. Prevention is better than cure. Prevention works at all three following levels;

a) Primary prevention is focused on activities we do to prevent the onset of NCDs. This is mainly by addressing the four risk factors that cause NCDs.

b) Secondary prevention is carried out mainly for people who have already got NCDs, in order to prevent /delay any multi-organ complications of the disease (sometimes fatal and serious) that may affect the quality of life and life span.

c) Tertiary prevention is carried out among those who have already developed the complications of NCD to enable patients to lead a near normal life, which includes rehabilitation and disability limitation.

Q: Which of them is most effective?

A: Of the three prevention types, the most cost effective is primary prevention as people are not yet ill and the main strategy used is by promoting a healthy lifestyle. By addressing the lifestyle, we can keep the four risk actors of NCDs under control (healthy diet, physical activity, no smoking, no alcohol). Strategies used for this purpose are simple, low cost, rewarding and enjoyable. It can change individuals and thereby change their families and finally communities or workforces. However, changing lifestyle is not an easy task, it could be done by educating people on healthy lifestyles and by empowering them to take control of their lives to bring out a change in their lives.

Of the two, the more sustainable approach is by empowering people to take correct decisions on their own lifestyle. Here, we mainly focus on addressing the factors that underlying the risk factors, and changing for the better through continuous measurement and reflective practice. One important message is to come up with culturally appropriate and practical solutions so that they are all doable. Primordial prevention is another aspect to primary prevention that includes activities that stops risk factors before they establish in an environment. A good example would be prevention of gestational diabetes in mother so that the risk of her offspring getting diabetes in future is minimal.

Q: Dr Wijeyaratne, you have worked in hospitals abroad and been exposed to various innovative approaches to general health including NCD. Tell us about some of those experiences and how far they can be used in Sri Lanka.

A. Patient self management through education by teams of doctors, nurses, midwives and counselors, where the emphasis is on patients being in charge of and accountable for their own health and well being

Q: What are the implications of rising NCDs on families?

A.The government of Sri Lanka has identified that the prevention and control of chronic NCDs as a priority issue in the national health agenda and the National Health Master Plan 2007-2016 as these diseases lower the quality of life, impair the economic growth of the country and place a heavy and rising demand on families and national budgets.

Currently treatment of NCDs accounts for nearly 90% of the total disease burden..

Q: Gaps?

A. There is a gap in service provision of public health facilities due to continuous resource gap, frequent unavailability of essential drugs and other diagnostic testing.

Out of pocket expenditure will create an extra burden on the patients particularly on poor.

Premature death and disability from these conditions (< age of 65 years) translates to poor work performance and productivity.

Individual patients and their families face catastrophic expenditure with sudden life threatening events that require coronary stents and surgery, stroke disability and rehabilitation, kidney dialysis and transplantation and complex cancer treatments.

Q: Your message to the public?

A. Live your life to the fullest by adopting healthy habits of home cooked food with adequate vegetables and fruits and by avoiding sweetened beverage, engage in regular physical activity, stop tobacco and alcohol and remain mindful at all times.

This will steer you and the generations ahead onto a healthy path.

Community based programs conducted by Dr Carukshi Arambepola and Prof Chandrika Wijeyaratne