Burden of non-communicable diseases in South Asia
BMJ 2004; 328 doi: https://doi.org/10.1136/bmj.328.7443.807 (Published 01 April 2004) Cite this as: BMJ 2004;328:807All rapid responses
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Reading your thorough clinical review on the “Burden of communicable
diseases in South Asia” was mildly depressing as there were no answers
suggested (though I appreciate it was an article on all forms of non-
communicable disease, and management was beyond its remit). You say that
"even at the current state of knowledge, however, the magnitude of the
problem is large enough to demand urgent attention and action".
As a United Kingdom-based trainee cardiologist, my interest in
cardiovascular disease in South Asia stemmed from an article by Thomas
Pearson in the late 1990s. The message from that piece is not greatly
diferent from yours. Since I do not practice in South Asia, I have no real
feel as to whether or not attention/action is already being taken. I ask
this in self-confessed ignorance, having read this special issue of the
BMJ from cover to cover, and not found any potential ongoing solutions to
the impending crisis (i.e., any good news). I suppose one should blame the
Editors for that?
Even way back in 1990, infectious/parasitic disorders and
cardiovascular disease were nearly equivalent as the leading causes of
death, with 9.2 million and 9.1 million deaths attributed to each category
respectively. Cardiovascular disease has of course since moved ahead.
If one believes in the "epidemiologic transition", then South Asia is
surely moving from the Age of Receding Pandemics to the Age of
Degenerative and Man-made Diseases.
With the suggestion that South Asian populations may be at especially high
risk, the projected estimates of cardiovascular disease rates in the
developing world are most likely conservative.
But you at the WHO know all this already, stretching as far back as
the 1996 "Report of the Ad Hoc Committee on Health Research Relating to
Future Intervention Options. The neglected epidemics of noncommunicable
diseases and injuries. Investing in Health Research and Development".
In the UK, we continue to have problems in controlling the pandemic.
Obesity and type II diabetes mellitus are on the rise. The UK Government
has only recently focussed on this and its relation to inactivity. It is
still usually more expensive to buy healthy foods and drinks, though
government campaigns have led to less salt being used in manufactured
foods in the UK. This does not surely bode well for South Asia.
A different approach in South Asia is needed and we all realise this.
As S M M Hossain et al say on page 830 of the same issue of the BMJ, "Most
South Asian governments have concentrated on emulating a Western style of
healthcare service, with the result that an elite few are overmedicalised
whereas the majority are neglected. However, community participation in
the development of local health services could provide a solution". We
need to involve people (before they become patients) via their
communities. We need new approaches. "Cricket has suddenly acquired huge
public health significance in South Asia", say Shafqat and Bharucha on
page 843, but how many women go to the matches? Most articles on this
subject bemoan the void of physical activity in South Asian cultures, but
is physical activity being encouraged for women in an environment and form
that is acceptable? You say "More accurate estimation of these burdens,
their risk factors, and time trends would help to better inform policy and
to monitor change in response to public health interventions". Ahmad et al
in a rapid response to your article say that "Evidence for epidemic of
coronary heart disease in India is weak" (they obviously do not believe in
the epidemiologic transition theory). This may all be true if we are going
to be perfectionists and provide an evidence-based health policy for 1
billion people, but by the time you instigate it, you may have missed the
boat.
I know that WHO has published a great deal about this. More
information on its successes so far would be interesting, such as the pick
-up rate of your "CVD-Risk Management Package" (though I appreciate this
was designed for people who ALREADY have hypetension, or another risk
factor such as diabetes or smoking). As someone who is due to commence a
Doctorate shortly focusing on UK South Asians, and who harbours a desire
to join you in this fight, I fear I will be entering the battlefield with
the battle already lost. Give me some hope!
Competing interests:
None declared
Competing interests: No competing interests
Dear Editor,
It is widely believed that India is on the verge of an epidemic of
coronary heart disease (CHD)(1). We believe this assumption to be based on
weak evidence. We found one meta-analysis, reporting a nine fold increase
in urban India (1 to 9%) and two fold increase (2 to 4%) in rural India
between the 1960s and 1990s (2). We believe these results to be
inaccurate because of the poor
quality of underlying data and because comparisons were based on studies
defining CHD differently. CHD was measured using either Minnesota coded
electrocardiograms or clinically defined using non validated translations
of the Rose angina questionnaire. The latter tends to give greater
positive results and is less valid in women (3) and South Asian
populations (4).
Our review, which is currently undergoing peer review, focused on
Minnesota coded ECGs to provide an objective measure. We reviewed 31
studies published between 1974 and 2002.
The quality of the data was generally poor as many did not fulfill
basic criteria for epidemiological research (5). Further, research was
generally concentrated on a small area around the capital, Delhi. We found
the prevalence in urban India to be higher than rural areas in males and
females. We found no clear rise in prevalence, including age specific
rates, in males over a 27 year period with some modest evidence of a rise
in females. A major expansion of research and surveillance is urgently
needed with new studies following more rigorous and standardised methods
to permit comparison over time, between locations and between and within
populations. Only then will the true extent and impact of the disease in
South Asia be known. In the meantime, claims of a massive epidemic need to
be interpreted with caution.
1. Yusuf S, Reddy S, Ounpuu S, Anand S. Global burden of
cardiovascular disease. Part II. Variations in cardiovascular disease by
specific ethnic
groups and geographic regions and prevention strategies. Circulation
2001;104:2855-64
2. Gupta R, Gupta VP. Meta-analysis of coronary heart disease
prevalence in India. Indian Heart Journal 1996;48:241-5
3. Harris RB, Weissfield LA. Gender differences in the reliability
of reporting symptoms of angina pectoris. J Clinical Epidemiol
1991;44:1071-8.
4. Fischbacher CM, Bhopal R, Unwin N, White M, Alberti KGMM. The
performance of the Rose angina questionnaire in South Asian and European
origin populations: a comparative study in Newcastle, UK. International
Journal of Epidemiology 2001;30:1009-16.
5 Bhopal R. Concepts of Epidemiology. Oxford: Oxford University
Press, 2003.p 290
Competing interests:
None declared
Competing interests: No competing interests
EDITOR--The clinical review on the infectious disease burden in South Asia makes
for informative but disturbing reading.1 The scope, priority, and goals of
a microbiology department in a developing country is different from that
of the developed world. One of the authors of this letter (SB) has had the
opportunity to work in both settings (India and the UK). This makes it
possible to suggest realistic measures that can bring about significant
changes in the way infectious disease is managed in the developing world.
Indian (practically throughout South Asia) microbiologists offer a service
based primarily within the laboratory with minimal patient contact. The
emphasis is low cost, low technology, labour-intensive diagnosis. The
expensive, high technology microbiology practised in the Western world
would not be appropriate considering the limited resources available.
However, cost-effective measures involving a change in basic attitude and
procedure could be introduced.
The current UK practice of close liaison between medical microbiologists
and the clinical team is rarely encountered in South Asia. The resulting
poor communication can lead to laboratory services that do not reflect the
clinical priorities. Provision of medical microbiology that combines a
diagnostic service with continuous clinical input with regards to optimal
specimen collection, choice of antibiotics and further management would
ensure the most effective use of limited resources. In order to provide
this service there is a need to reorient microbiology training at the
medical level as well as the technical level in the developing world.
Preventative measures via a proactive Infection Control service could also
improve cost effectiveness. Introduction of infection control nurses,
development of a comprehensive infection control policy, continuous
surveillance and feedback to clinical team and nursing staff, compulsory
notification to national surveillance centres, and close liaison with
public health would provide value for money in resource deficient
developing world. The Sri Lankan approach based on periodic in-service
training programmes of medical laboratory technologists and infection
control nurses together with establishment of a Task Force in microbiology
to identify priority areas in microbiology services2 could be adopted by
other South Asian countries.
It is important that political parties who govern the nations are
conscious of the changes that need to be brought about to ensure public
health. The challenge before the microbiologist is essentially managerial,
political and economic. It is about influencing and convincing the people
at the top so that policy changes are not just cosmetic but are viable
tools in bringing genuine socio-economic and health benefits to all
concerned.
References:
1. Zaidi AKM, Awasthi S, deSilva HJ. Burden of infectious diseases in
South Asia. BMJ 2004; 7443: 811-815.
2. Thevanesam V, Corea E. Infection control in Sri Lanka. J Hosp Infect.
2002; 52: 231-3.
Contributors: SB and TMAW were involved in writing the paper. TMAW
critically reviewed the paper suggested necessary changes in the original
manuscript. TMAW is the guarantor of the paper.
Funding: None
Competing interests: SB received his initial microbiology training in
India between 1997 and 2002.
Competing interests: No competing interests
Management of Acute myocardial infarction in a rural setting.
Ghaffar A et al enlightened the important subject which is most
concerned to developing country like India (1). The prevalence of
coronary heart disease (CAD) has progressively increased in India during
the last half century. Illiteracy, smoking , tobacco chewing in additions
to these risk factors rural population are unaware of hypertension and
diabetes resulting in reporting CAD cases in acute stage ( 2).
Observation of unexpected sudden death preceded by chest pain together
with information and news coming from urban areas has caused villagers to
become more aware of chest pain in young males (2). In one year 69
patients of AMI reported within three hours of chest pain at general
hospital Mahad. All received 1.5 million units intravenous
streptokinase(STK) by intravenous drip over one hour, the hospital to
needle time was 10-30(average 19) minutes. Reperfusion i.e. regression of
elevated ST segment in electrocardiograph (ECG) achieved within 30-60 (
average 38) minutes in 52(75.5%) and within 90 minutes in 12 cases. 5 (
7.2%) cases showed no improvement. these five cases underwent rescue
angioplasty at Mumbai. 22 cases took discharge after STK therapy and were
admitted to tertiary care hospital at Mumbai were discharged after 7 days.
Remaining 40 cases had uneventful recovery with T wave inversion in
corresponding AMI leads and were discharged at request on 4th day of
admission. All 40 cases were followed for six months without any
cardiovascular events. Other 71 cases reported with chest pain and
chronic breathlessness. Their (ECG) showed old myocardial infarction (
deep Q waves with T wave inversion). All of them gave history of had
severe chest pain 2-6(average 3.5) months before, were treated by family
doctors at village with analgesic. No body received STK.
In India medical professional is commercialized. Specialists are
flourished in big cities like Mumbai, Pune, Chennai, Delhi and Kalkatta.
There are many small intensive care units opened by converting residential
blocks. Even multistoried tertiary care hospitals registered as public
trust just to get tax free grants and import license. These hospitals
behave like a commercial health industry. At times payment capacity
decides the hospital admission and duration of stay and not the severity
of illness. In such situation patient behaves like parked taxi with
meter on. Specialists attached to tertiary care hospitals are given target
for admissions if their post is to be continued.
Because of easy availability of transport due to privatization of auto
riksha (three wheeler) in rural India. Majority of AMI patients reach
hospital in golden hours. Since the advent of thrombolysis morbidity and
mortality due to AMI has been reduced in Mahad (2).
Traffic jam in big cities delays the hospitalization , in such
situation, pre-hospital thrombolysis by paramedics or physician may
salvage the heart in golden hours and prevent subsequent morbidity and
mortality( 3). Thus a day is not away to take needle to patient rather
patient to hospital.
Diabetes, hypertension, hyerlipidemia, raised homocysteine level, lack of
exercise and cut throat competition and struggle for survival are major
risk factors resulting in high incidence of CAD in young Indians(4). Many
patients sold their piece of land, jewelry or pay heavy interest to
moneylender to reimburse the hospital payment, thus heart attack is
earth- quake for villagers and their family.
Government hospitals are ill-equipped. Often patients are diverted to
private hospitals as instruments and gadgets of intensive care is under
repair. Tortoise pace attempt to revive intensive care unit in a public
hospital. Poor patients with acute life threatening medical emergency
admitted to government hospitals. Doctors get varied experience inform of
invasive and non-invasive procedures and response to treatment, after
getting enough practical experience and qualification majority left the
government institutes and utilized their experience to earn and treat
patients admitted in a five star commercial health institutes.
Similar to Malaria, tuberculosis, filarial and dengue fever, in India
CAD is an epidemic form. It is high time that Government of India should
form a task force to combat this life threatening disease affecting young
and earning members of society.
H.S.Bawaskar
Bawaskar Hospital Mahad Dist- Raigad Maharashtra India 402301
E-mail:himmatbawaskar@rediffmail.com
Reference
1-Ghaffar A, Reddy KS and Singhi M. Burden of non-communicable diseases in
South Asia. BMJ 2004;328:807-10.
2- Bawaskar HS, Bawaskar PH. Thrombolytic therapy in acute myocardial
infarction in a rural setting. Tropical Doctor 2002,32:66-70.
3-Keeling P, Debbie H, Price L, Shaw S, and Barton A. Safety and
feasibility of prehospital thrombolysis carried out by paramedics. BMJ
2003; 327:27-28.
4- Enas AE, Yusuf S and Mehta JL. Prevalance of coronary artery disease
in Asian Indians. (Editorial). American J. Cardiology 1992;70:945-49.
Competing interests:
None declared
Competing interests: No competing interests
We read with interest the excellent clinical review ‘Burden of non
communicable diseases in South Asia’ by Abdul Ghaffar etal, BMJ Volume 328
3April 2004-04-07
Till about a century ago, the people of South Asia did hard physical
labour (fishing or farming) and ate a healthy mix of rice, vegetables and
fish. Today, regardless of age, they sit in a shop or an office six days
(and sometimes seven days) a week with hardly any exercise and mostly have
an unhealthy diet, with everything fried in ghee and oil, for the best
taste. Physical fitness activities are a ‘waste of time and money’. All
this contributes to the ‘metabolic syndrome epidemic’ with glucose
intolerance, dyslipidemia and central obesity. To add to the picture is
hypertension and smoking caused by physical inactivity, alcohol &
stress. Stress in turn is contributed heavily by the long hours and hard
work ( there are no ‘weekends’ here ; you are lucky to get a Sunday off),
poor pay and diminishing morale. The diminishing role of family support
doesn’t help in coping with stress. We hold a personal view that, people
from South Asia have smaller coronary arteries than their Western
counterparts, which puts them at a major disadvantage. These form the
short cuts to having the first coronary event.
The lucky survivor often carries on the same lifestyle. To the best
of my knowledge there are less than 10 smoking cessation clinics for the
whole of the region, which are mostly privately run. In a place where
private practice is everything, if you advise patients strictly, you run
the risk of losing the patient to the neighbouring physician .Cardiac
rehabilitation programmes are mostly unheard of. Percutaneous intervention
and bypass grafting are mainly for the few who can afford it privately.
What are the solutions? Reforms should take place at all levels.
Education should not stop after just teaching people to write and sign
their names. Only then, they will be able to NOT vote for a health
minister who doesn’t know reading and writing. English, as a medium of
instruction, should be given more importance, as, from personal
experience, we feel that is the only way to access the wide world outside.
Local systems of medicine should be given due importance , but should
also be reminded to observe the limits. I have seen many end stage
rheumatic valve disease patients, who were treated for joint pains by
Ayurvedic physicians at the age of 6 and ‘completely cured’. Yoga and
naturopathy are effective forms of alternative medicine, to reduce stress
and weight gain.
Finally, money is important, and politicians in the developed
countries, should get more funds across for basic improvements, health
education and research.
Competing interests:
None declared
Competing interests: No competing interests
For calculating the absolute number of patients with coronary heart
disease in India, extrapolation from mortality figures available from the
various Global Burden of Diseases studies can be used. According to the
Global Burden of Diseases study published by the International Institute
of Health, in 1990 coronary heart disease caused 0.62 million deaths in
men and 0.56 million deaths in women in India. In 2000 this increased to
0.85 million in men and 0.74 million in women, a sum of 1.59 million
deaths. Clinical studies show that untreated these patients die at rate of
7-8% per year. Addition of appropriate medical therapies can reduce this
death rate to 2% per year. If we consider an average mortality of 5-6% per
year, then the absolute number of heart disease patients will be 20 times
the persons dying from it. This would extrapolate to a burden of 31.8
million patients in India. This compares with 16.5 million patients in USA
and 2.7 million in the UK. Further extrapolation of this data would
suggest that there would be 1.27 million acute coronary events per year in
India at the rate of 4% events per year in the total coronary population.
Compare this with 0.63 million acute coronary events in the European union
and 0.275 million heart attacks annually in UK.
For estimation of the disease burden, the Global Burden of Diseases
Studies reported the disability adjusted life years (DALYs) lost by
various diseases in India. Perinatal conditions top the list followed by
lower respiratory infections, diarrhoeal diseases, ischaemic heart
disease, and unipolar depression. Coronary risk factors such as high blood
pressure, tobacco and cholesterol are in the top ten. This shows that
cardiovascular diseases are a major burden in this region. The World Bank
has concluded that in India DALYs lost due to ischaemic heart diseases are
projected to more than double in the next 20 years. In 1990 coronary heart
disease was responsible for 5.6 million DALYs lost in men and 4.5 million
in women. This is projected to increase to 10.5 in men and 7.7 million in
women by year 2010.
In India and many developing countries in the absence of reliable
mortality data estimates of the burden of disease have mostly been based
on population based cross-sectional surveys. Morbidity surveys involve
problems of sample design, sample size, standardization, and measurement
errors. Indian coronary disease epidemiological studies have been reviewed
earlier. In the urban population the prevalence increased from 1.05%
(Agra, 1962) and 1.04% (Delhi, 1962) to 6.60% (Chandigarh, 1968). In
recent years a consistent high prevalence of coronary heart disease has
been reported from Delhi (9.67%, 1990), Jaipur (7.8%, 1995), and Chennai
(9.0%, 2001). In semi-urban populations of Haryana and Kerala the
prevalence has increased from 3.6% (1975) to 7.4% (1993). In rural
populations the prevalence increased from 2.06% (Haryana, 1974) and 1.69%
(Vidarbha, 1988) to 2.71% (Haryana, 1989), 3.09% (Punjab, 1994), 3.46%
(Rajasthan, 1994) and 5.00% (Himachal, 2002). Rural-urban comparison shows
that while prevalence has increased two-fold in rural areas (2.06% in the
1970s to 4.14% in the 1990s) the prevalence in urban areas has increased
nine-fold (1.04% in the early 1960s to 9.45% in the mid 1990s). There is
evidence of coronary heart disease growth from rural to semi-urban and
urban areas with the highest prevalence reported from metropolitan Delhi
and Chennai. This clearly shows the importance of socio-economic factors
associated with societal transition explaining the coronary heart disease
epidemic in India. Analyses of prevalence studies in various decades in
India provide significant information regarding the absolute number of
coronary heart disease cases. Decadal variations indicate that the
prevalence has increased in urban areas from about 2% in 1960 to 6.5% in
1970, 7.0% in 1980, 9.7% in 1990 and 10.5% in 2000 while in rural areas it
increased from 2% in 1970 to 2.5% in 1980, 4% in 1990 and 4.5% in 2000. In
terms of absolute numbers there is a very steep increase in coronary heart
disease cases in both urban and rural areas. In urban populations, the
numbers have increased from 0.5 million in 1960 to 4.5 million in 1970,
5.6 million in 1980, 9.7 million in 1990 and 14.1 million in the year
2000. In rural populations the numbers have increased from 4.1 million in
1970 to 6.4 million in 1980, 11.8 million in 1990 and 15.7 million in
2000. Thus epidemiological studies show that there are at present 29.8
million coronary heart disease patients in this country. This number is
similar to derived from global burden of disease studies. As
epidemiological studies exclude many patients with silent and asymptomatic
coronary heart disease, the actual numbers may be much greater.
From the year 1995 to 2000, India has been spending about 5% of its
gross domestic product on health. Of this private expenditure on health is
about 82-83% and the general government expenditure is 17-18%.Therefore
any disease that is as widespread as coronary heart disease would entail
substantial economic burden on the population. Considering the data in the
global burden of disease study mortality statistics the number of patients
with coronary heart disease in the country is about 32 million (vide
supra). Of this about a fourth would be aware of their disease status and
therefore at any given point of time about 8 million coronary heart
disease patients would be under some form of medical care. For all these
patients, a minimum basic prescription following the ‘polypill approach’
should include a beta-blocker, ACE inhibitor, statin, aspirin, vitamin and
occasional nitrate tablets. Many patients are on more complex
pharmacotherapy. The average cost of generic forms of these drugs in India
amounts to Rs 5500 (£ 69) per year. If we consider that 8 million patients
are on this form of therapy, the total burden in terms of cost of such
therapy to the patient population would be 44 billion rupees a year (£
0.55 billion). Add a similar amount for ancillary services such as costs
of investigations and hospital visits (44 billion rupees, £ 0.55 billion).
We have determined the cost of a single acute coronary event to the
patient as Rs 5000 per event (£ 63) in terms of costs of medicines. For
1.27 million acute coronary events, the cost would be 6.5 billion rupees
(£ 80 million). About 20,000 coronary bypass surgeries and 30,000 coronary
angioplasty procedures are performed in the country every year. At the
minimum cost of Rs 100,000 per procedure (£1250), many hospitals charge
the patient more than 5-times this amount, this would add burden of
another 5 billion rupees (£ 625 million). All this adds up to 100 billion
rupees (£1.25 billion) in direct cost of therapy to the patient. A similar
amount could be spent by the healthcare system in caring for these
patients in outpatient clinics, hospitals and other institutions.
Therefore at an underestimate the economic burden of coronary heart
disease in India could be 200 billion rupees (£ 2.5 billion, $ 4.4
billion). Indirect costs should be added. Economists would consider that
this disease is contributing this much to the national product, but we
conclude that this is a waste as more than 80% of the heart attacks can be
prevented by appropriate management and prevention strategies.
REFERENCES
World Health Report 2002. Reducing risks promoting healthy life. Geneva.
WHO. 2002.
Beaglehole R, Yach D. Globalisation and the prevention and control of non-
communicable disease: the neglected chronic diseases of adults. Lancet
2003; 362:903-8.
Gupta R, Rastogi P. Burden of coronary heart disease in India. In:
Manjuran RJ. Cardiology Update. Cardiological Society of India 2003; 142-
51.
Wald NJ, Law MR. A strategy to reduce cardiovascular disease by more than
80%. BMJ 2003; 326:1419-23.
Competing interests:
None declared
Competing interests: No competing interests
Every day 2 people commit suicide in the capital city of Nepal,
Kathmandu valley. Police sources say that the rate of suicide is
increasing day by day. In year 2000/2001, there were 210 cases in Kathmandu
valley and 2000 cases in Nepal. This figure nearly doubled in 2001/2002,
with suicides raising to 380 in Kathmandu valley and 3033 in Nepal.
The Central Bureau of Statistics of Nepal conducted a census of the population
in July 2001. It reported 1492 suicides in the year preceding the census.
Suicide is seventh most common cause of death in Nepal. Asthma
and COPD related causes being at the top. Accidents and accident related
causes, are less common than suicide. The typhoid, malaria, measles,
jaundice and HIV are down below in the list2. Suicide has never been
considered as a disease of public health importance, though mortality from suicide
exceeds other causes. It has drawn considerable attention in the West while
it remains largely neglected in developing countries.
It is surprising that this edition of BMJ doesn't mention suicide at all.
1. Kantipur Daily. 16th May 2003
2. His Majesty’s Government/Nepal. Population Census 2001. National
Planning commission. Central Bureau of Statistics
Competing interests:
None declared
Competing interests: No competing interests
Ischemic heart disease (IHD) is the leading cause of death in Sri
Lanka while stroke is the third cause of death (1). Although coronary
revascularization procedures are carried out in Sri Lanka it is not
available to most patients due to the cost. For instance, a coronary by
pass grafting surgery costs around $2000 whereas the average income of a
Sri Lankan in around $3362 per annum. Pharmacotherapy is equally expensive
with an average cost of a prescription of a patient with diabetes and IHD
(containing a cocktail of drugs including statins, oral hypoglycemic
agents and an ACE inhibitor) being around $2000 per annum. Moreover,
thrombolytic drugs such as streptokinase are not available in most
hospitals in Sri Lanka, expect for the teaching hospitals and general
hospitals.
However, the coronary risk factors seem to be increasing and in 2000
the overall prevalence’s in a sub urban population were diabetes 6.5%,
hypertension 27%, hypercholesteroleamia 17.4%, obesity 18.4% and central
obesity 50.2% (2). There is a significant increase in all coronary risk
factors when compared to the prevalence 10 years ago. This difference is
seen mainly in the prevalence of central obesity and hypertension which
was 16.9% and 16.11% in the year 1990 (2). Therefore, it is evident that
diabetes and IHD will continue to be the leading cause of morbidity and
mortality in the coming years. Especially since the demographic transition
in Sri Lanka will lead to a rapid increase in numbers of older people.
What can be done to curb this epidemic of non communicable diseases?
Treatment and secondary prevention is obviously very expensive. Therefore,
it is impetrative that preventive measures should be implemented as soon
as possible. Although, Sri Lanka is a developing country plagued by a
civil war and scanty resources we have made a remarkable progress in
reducing the burden of infectious diseases. Only Sri Lanka has been able
to sustain high levels of immunization coverage among its children. All
these achievements could be attributed to the primary health care system
in Sri Lanka. Unfortunately, prevention of non communicable diseases has
not been given much emphasis in the primary health care system.
Therefore, it is vital that a program of prevention of non
communicable diseases be included in the primary health care system
emphasizing the importance of regular exercise, healthy eating habits and
most importantly cessation of smoking.
Reference:
1. Annual health bulletin 2000: 23
2. Malavige GN, de Alwis NM, Weerasooriya N, Fernando DJ, Siribaddana SH.
Increasing diabetes and vascular risk factors in a sub-urban Sri Lankan
population. Diabetes Res Clin Pract. 2002 Aug; 57(2):143-5.
Competing interests:
None declared
Competing interests: No competing interests
Newly detected provisional diabetics in the rural South India.
In developing countries like India, diabetes mellitus is emerging as
a major cause of increase in morbidity and mortality through its
microvascular complications. About half of the patients develop
complications even before their diabetes is diagnosed.1, 2 The actual
onset of type II diabetes may occur about 9 to 12 years before its
clinical diagnosis and this asymptomatic phase of hyperglycemia induced
microvascular complications is estimated to last for about 4-7 years.3
Therefore, efforts are needed to identify asymptomatic diabetic patients
from the general population. This report describes how common are newly-
detected provisional diabetics (defined as individuals with random blood
sugar > 200 mg/dl) in the rural settings.
Community based targeted screening for diabetes was carried out in
the 2 rural districts of India. All inhabitants, aged > 30 years, were
invited. Random blood glucose was measured with a glucometer (Accutrend
Alfa) by finger-prick capillary method. In 73 diabetic screening camps,
23,472 individuals were examined. Of these 23,472 subjects, known
diabetics were 4111 (17.5%; 95% CI – 17.0 – 18.0), and newly detected
provisional diabetics, 1076 (4.6%; 95% CI – 4.3 – 4.9). Random blood
glucose between > 140-199 mg% was estimated in 1157 (4.9%) and less
than 140 mg% in the remaining 17,128 (73%).
This study data shows that around ten percent of the individuals in
the rural settings are potential diabetics (RBS > 140 mg/dl).
Identifying this high-risk group is important as patients in the
undiagnosed asymptomatic phase with impaired levels have a higher
mortality rate due to myocardial infarction, stroke and large-vessel
occlusive disease than known diabetics or normoglycemics.4 These potential
diabetics are also found to be independently associated with microvascular
complications of diabetes such as retinopathy, renal disease, and
polyneuropathy.5
References
1.United Kingdom Prospective Diabetes Study. Complications in newly
diagnosed type 2 diabetic patients and their association with different
clinical and biochemical risk factors. Diabetes Res 1990;13:1-11.
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white Americans. Diabetes Metab Rev 1990;6:71-90.
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Competing interests:
None declared
Competing interests: No competing interests