The surge in diabetes among the Lankan population and its serious impacts on the health of the afflicted has led to a re-evaluation of the current approach to diabetes treatment. According to a predictor on diabetes in 2005, 1 in 10 women in 2005 were said to have diabetes while the number shot to 1 in every 7 women in 2016.
The health impacts on our bodies are horrifying. The chief victim of uncontrolled blood sugar is the blood vessels of our body. The large blood vessels (macrovascular) when clogged with fat laden deposits of atheroma cause heart attacks, strokes, and gangrene (tissue death) of toes with a high risk of foot / leg amputations. The large number of small blood vessels when afflicted by the poorly controlled blood sugar (microvascular) cause kidney failure, blindness and loss of nerve function that make one’s feet numb and at risk of chronic injury and ulceration due to the lack of protective sensation. Apart from that, diabetes in pregnancy not only puts the mother at high risk of developing the dangerous high blood pressure of pregnancy (pre-eclampsia), unhealthy placentae can cause poor fetal growth and underweight babies.
The Sunday Observer spoke to President, Sri Lanka Medical Council and Professor of Reproductive Health, Prof Chandrika Wijeyaratne, who has been in the forefront fighting the diabetes menace in Sri Lanka, especially, among women for the past three decades to tell us how to detect early symptoms of the disease, and most importantly how to prevent its deadly impacts on our health and the future generations of this country.
Excerpts….
Q. World Diabetes Day was observed recently under the theme, ‘Healthy Women- Healthy Nation’ with the Health Ministry led by the President announcing that several innovative programs were in the offing towards that end. As a Professor in Reproductive Medicine and a wide experience in dealing with women’s health, do you see this as a step in the right direction?
 Prof Chandrika Wijeyaratne |
A. This is indeed the correct direction. However, I would like to emphasize that much has already been done in Sri Lanka, given that we have a highly effective Maternal and Child Health program led by the Family Health Bureau. In reality, Sri Lanka has been well ahead of the world theme assigned for this year and is regarded as a model of care, all credit going to the local leaders in Women’s Health.
Women and diabetes is a special problem. Women have often been overlooked and ill addressed. Women with diabetes are in fact at greater risk of bad outcomes, than normal women. I raised this awareness about 6 years ago in Lucknow, India, and it caught on like wildfire.
Q. With regard to this year’s theme, how is diabetes specifically a health risk for women? And why?
A. Women are as vulnerable or even more, than men. That is what real time local data evolving over the past 2 decades show. Women from early years (such as in their late 20s) have been shown to have overweight and obesity, which is a frightening trend. The main reasons for this are behavioural and environmental causes. Unhealthy diet in the form of food and sugar laden beverages (including tea), and a woefully inadequate level of physical activity, make women more vulnerable to excess body fat. In the background of the Asian risk, of developing from an early age in life due to unhealthy fat and insulin resistance, pregnancy is a stress test for diabetes. Hence, when pregnancy occurs in the background of a high body fat status – the development of diabetes in pregnancy risk is extremely high. Our published local data at community level – in 2006 and in 2016 show a dangerously increasing trend of this phenomenon – gestational diabetes.
Q. Is there a specific age when women are most at risk of getting the disease? Why?
A. Although the general belief is that when one crosses the age of 40 the risk of developing diabetes increases, it is clear that our population from their late teens is at risk of developing pre-diabetes and diabetes. Female hormone oestrogen is also linked to excess body fat, where, greater the body fat the higher the levels of hormone. The annual conversion rates to diabetes are pretty high for some groups, particularly, young women with irregular periods and excess body hair with immature eggs in the ovary (called Polycystic Ovary Syndrome - PCOS). The condition of PCOS is also a lifestyle disease – the more active a life one leads and the more cautious one is on eating and drinking healthy, the less risk of these hormonal problems. There is good evidence worldwide to show this link.
Q. Diabetes has surged worldwide in recent years. It has been said, at present, over 199 million live with diabetes and the total projected to increase by 2040 will be 300 million. What has caused this dramatic increase? It is said, diabetes is the 9th leading cause of death globally causing over 2 million deaths annually. What is the percentage of women with diabetes in Sri Lanka?
A. Our recent data shows that diabetes in pregnancy – which is the main predictor of future diabetes in women, has increased from 1 in 10 women in 2005 to 1 in every 7 women in 2016. Mind you, this is at field level in semi urban settings. Among older non-pregnant women the affliction of women with diabetes matches or overtakes those of men. So, my guess is that we must be having at least 2 million adult women with diabetes and overt pre-diabetes at this time.
Q. What is the most common form of diabetes found in Sri Lanka which is widespread among women? Is it true that women with type 2 diabetes are likely to develop ischemic heart disease?
A. The majority of men and women in Sri Lanka have type 2 diabetes due to excess body fat and insulin resistance. Diabetes has no gender bias. The main focus on diabetes is because it is considered the ‘mother of all diseases’. The chief victim of uncontrolled blood sugar is the blood vessels of our body. The large blood vessels (macrovascular) when clogged with fat laden deposits of atheroma cause heart attacks, strokes, and gangrene (tissue death) of toes with a high risk of foot / leg amputation.
The large number of small blood vessels when afflicted by the poorly controlled blood sugar (microvascular) cause kidney failure, blindness and loss of nerve function that make one’s feet numb and at risk of chronic injury and ulceration due to the lack of protective sensation.
Q. Some women develop diabetes during pregnancy. Is this a permanent condition? What are the chances of gestational diabetes recurring later in life? After how long a period from the time of delivery?
A. Pregnancy is a window period to look into the future health of the mother. In the majority of women (about 90%) the diabetes state resolves when the offending placenta is delivered at birth. However, our recent study in Gampaha showed that 1 in 10 women with gestational diabetes remained diabetic at the standard 2 month post-partum check. This is a very disturbing trend. About 10 years ago when I recalled Sri Lankan women with GDM who had reverted to normal soon after childbirth, about 3 years after - we found 50% of them had diabetes or pre-diabetes. These women were only in their early 30s. More recently when we followed up the same women in Gampaha and re-checked them after a year, a large proportion of them (although they tested normal soon after childbirth) had abnormal blood sugar. So GDM is indeed a high risk and predictor of future diabetes from early life.
Q. It has been said that one in six births are affected by diabetes in pregnancy. What is the impact of gestatational diabetes on the newborn?
A. That is correct. The massive hormonal changes of pregnancy occur due to the growing placenta producing hormones. Additionally, the pregnant woman prioritizes her body energy to be converted into glucose to nourish her growing baby at all times. So her insulin resistance starts rising in an exponential manner. If the pregnant woman has a pre-existing insulin resistance and thereby an exhausted pancreas with the potential to develop insulin deficiency early in life, she develops high blood sugar and requires insulin for correction. If unnoticed and uncorrected, the high blood sugar leads to excess fat laden in the baby’s body and causes many complications including, sudden fetal death due to fluctuating blood sugar and salts. The mother is also at high risk of developing the dangerous high blood pressure of pregnancy (pre-eclampsia), caused by disease of her placental blood vessels. These can prove life threatening. Such unhealthy placentae can cause poor fetal growth and underweight babies. When the newborn’s supply of excess blood sugar from the mother is cut off with the clamping of the umbilical cord, the excess insulin from the baby’s pancreas that occurred while in the womb, causes a paradoxical low blood sugar and places the newborn at risk of brain damage.
Q. Although Diabetes Mellitus ranks among the leading causes for morbidity and mortality in Sri Lanka, many are unaware they have the disease? Your comments?
A. Diabetes often has no symptoms. A recent Lankan survey of 25,000 households to study adults by self-reporting their diseases found that high blood pressure afflicts one-third and diabetes one fifth. The vast majority who reported they have no disease had not checked themselves. Unless one checks oneself regularly you never know you have a severe disease.
Q. Are hypertension, heart disease and other pre conditions contributory factors to getting diabetes? Or vice versa?
A. Diabetes is the mother of all these diseases.
Q. Can one die of diabetes? What is the mortality rate among Lankans in general and Lankan women in particular?
A. You often do not die from high blood sugar. But the complications I stated before cause death. This causes about 7% of premature deaths (below the age of 65 years). My greater concern is the long months and years of poor quality of life from the complications of diabetes. This is called Disability Adjusted Life Years (DALYs)- and this is extraordinarily high for diabetes with an annual increase of over 3% in Sri Lanka.
Q. A growing number of Lankan children have also been found to be pre diabetic. What is the reason?
A. As I said, the rubber stamping is done in your mother’s womb and thereafter the environment encourages unhealthy lifestyle and excess body fat. Society needs to address the fact that a fat child is not a healthy child and avoid this situation at all costs. This is health promotion, the way forward.
Q. What are the health impacts on such children? Will the girl child be more at risk?
A. No doubt, the girl child with excess body fat is at risk of her hormones getting into a state of great imbalance. Puberty is a stage in life when one is at greater risk of insulin resistance. Hence, the hormonal imbalance causes irregular periods and the insulin resistance causes darkening of skin folds – particularly, around the neck, called, acanthosis nigricans. Mothers often think this is a rash. It is only a reminder that snacks, biscuits and sweet drinks given to your daughter must be stopped!
Q. Are sweetened drinks also to blame for this diabetic epidemic? Many fruit and milk drinks are available freely in the open market. Despite advertisement bans on them that have been gazetted, they are also sold at school sports meets and sports tournaments with enticing labels claiming they can enhance performance and children’s IQ. Your comments?
A. Agreed. Our country lacks a civic sense among the advertisers, food producers and consumers- particularly, in schools. We have been lobbying for this for the past 13 years and I can write a book about this. In one single word – I am SAD.
Q. What are the recent interventions to prevent diabetes in women that have been introduced by the Health Ministry. What facilities are available for screening, treating diabetes free of charge?
A. The Nirogi Maatha project of the Sri Lanka Medical Association advocated since 2012, saw to fruition a government commitment for Universal Screening for pregnant women using blood sugar and not urine sugar. This is a major step forward. The mother’s card has included in it since 2007 the blood sugar value and BMI of the mother at booking – that is in over 95% within the first trimester. Sri Lanka has all the essential ingredients to overcome this problem by proper system management and public cooperation and commitment.
Q. I understand, all pregnant women are being screened for diabetes on a routine basis and if any of them are found to have diabetes, they are treated in the hospital to control their diabetes before delivery. Could you explain more about this scheme? Has it brought a positive feedback?
A. In the professorial unit of the De Soysa Hospital for Women we have had a combined clinic run by endocrinologist and obstetrician for women with diabetes, held twice a week. We commenced issuing human insulin free of charge to take home and ensure good control of blood sugar since the early 1990s.
We have also initiated in Nirogi Maatha a mother baby pair review long term. This is challenging- as women, after childbirth tend to slip back into an unhealthy lifestyle and avoid coming back to get themselves checked. This is our greatest challenge and need the support of the media. Here again the food and milk industry play a negative role through unhealthy advertisements.
Q. What are the gaps you see in the current programs to prevent diabetes? Are the 750 Lifestyle centres being well patronized ? Or is there a need for more awareness raising?
A. The Healthy Lifestyle centres are well equipped, but wrongly located for the busy working and seemingly healthy population.
Nirogi Lanka experience in the community, workplaces and schools of over 7 years is an eye opener. An annual bash or walk is now insufficient. Every day must be diabetes prevention day in Sri Lanka.
Q. Your message to parents, the public and women in particular on preventing diabetes ?
A. Sri Lanka’s health is in your hands.