Inequalities in the prevalence of diabetes mellitus and its risk factors in Sri Lanka: a lower middle income country.

BACKGROUND: Explorations into quantifying the inequalities for diabetes mellitus (DM) and its risk factors are scarce in low and lower middle income countries (LICs/LMICs). The aims of this study were to assess the inequalities of DM and its risk factors in a suburban district of Sri Lanka. METHODS: A sample of 1300 participants, (aged 35-64 years) randomly selected using a stratified multi-stage cluster sampling method, were studied employing a cross sectional descriptive design. The socioeconomic indicators (SEIs) of the individual were education level and occupational category, and at the household level, the household income, social status level and area deprivation level. DM was diagnosed if the fasting plasma glucose was ≥126 and a body mass index (BMI) of > 27.5 kg/m2 was considered high. Asian cut-off values were used for high waist circumference (WC). Validated tools were used to assess the diet and level of physical activity. The slope index of inequality (SII), relative index of inequality (RII) and concentration index (CI) were used to assess inequalities. RESULTS: The prevalence of DM and its risk factors (at individual or household level) showed no consistent relationship with the three measures of inequality (SII, RII and CI) of the different indices of socio economic status (education, occupation, household income, social status index or area unsatisfactory basic needs index). The prevalence of diabetes showed a more consistent pro-rich distribution in females compared to males. Of the risk factors in males and females, the most consistent and significant pro-rich relationship was for high BMI and WC. In males, the significant positive relationship with high BMI for SII ranged from 0.18 to 0.35, and RII from 1.56 to 2.25. For high WC, the values were: SII from 0.13 to 0.27 and RII from 1.9 to 3.97. In females the significant positive relationship with high BMI in SII ranged from 0.13 to 0.29, and RII from 2.3 to 4.98. For high WC the values were: SII from 028 to 0.4 and RII 1.99 to 2.39. Of the other risk factors, inadequate fruit intake showed a consistent significant pro-poor distribution only in males using SII (- 0.25 to - 0.36) and in both sexes using CI. Smoking also showed a pro-poor distribution in males especially using individual measures of socio-economic status (i.e. education and occupation). CONCLUSIONS: The results show a variable relationship between socioeconomic status and prevalence of diabetes and its risk factors. The inequalities in the prevalence of diabetes and risk factors vary depending on gender and the measures used. The study suggests that measures to prevent diabetes should focus on targeting specific factors based on sex and socioeconomic status. The priority target areas for interventions should include prevention of obesity (BMI and central obesity) specifically in more affluent females. Males who have a low level of education and in non-skilled occupations should be especially targeted to reduce smoking and increase fruit intake.

A survey on socioeconomic determinants of diabetes mellitus management in a lower middle income setting.

BACKGROUND: Information on socioeconomic determinants in the management of diabetes mellitus is scarce in lower middle income countries. The aim of this study is to describe the socioeconomic determinants of management and complications of diabetes mellitus in a lower middle income setting. METHODS: Cross sectional descriptive study on a stratified random sample of 1300 individuals was conducted by an interviewer administered questionnaire, clinical examinations and blood investigations. A single fasting venous blood sugar of ≥126 mg/dl was considered diagnostic of new diabetics and poor control of diabetes mellitus as HbA1C > 6.5 %. RESULTS: There were 202 (14.7 %) with diabetes mellitus. Poor control was seen in 130 (90.7 %) while 71 (49.6 %) were not on regular treatment. Highest proportions of poor control and not on regular medication were observed in estate sector, poorest social status category and poorest geographical area. The annual HbA1C, microalbuminuria, retinal and neuropathy examination were performed in less than 6.0 %. Social gradient not observed in the management lapses. Most (76.6 %) had accessed private sector while those in estate (58.1 %) accessed the state system. The microvascular complications of retinopathy, neuropathy and microalbuminuria observed in 11.1 %, 79.3 % and 54.5 % respectively. Among the macrovascular diseases, angina, ischaemic heart disease and peripheral arterial disease seen in 15.5 %, 15.7 % and 5.5 % respectively. These complications do not show a social gradient. CONCLUSIONS: Diabetes mellitus patients, irrespective of their socioeconomic status, are poorly managed and have high rates of complications. Most depend on the private healthcare system with overall poor access to care in the estate sector.

A cross sectional survey on social, cultural and economic determinants of obesity in a low middle income setting.

INTRODUCTION: Obesity is an increasing problem in South Asian countries and Sri Lanka is no exception. The socioeconomic determinants of obesity in Sri Lanka, and in neighbouring countries are inadequately described. Aim was to describe social, cultural and economic determinants of obesity in a representative sample from Kalutara District in Sri Lanka. METHODS: This was a cross sectional descriptive study conducted among adults aged 35-64 years. A representative sample was selected using stratified random cluster sampling method from urban, rural and plantation sectors of Kalutara District. Data were collected using a pre-tested questionnaire. A body mass index of 23.01 kg/m(2)-27.50 kg/m(2) was considered as overweight and ≥27.51 kg/m(2) as obese. Waist circumference (WC) of ≥ 90 cm and ≥80 cm was regarded as high for men and women respectively. Significance of prevalence of obesity categories across different socio-economic strata was determined by chi square test for trend. RESULTS: Of 1234 adults who were screened, age and sex adjusted prevalence of overweight, obesity and abdominal obesity (high WC) were 33.2% (male 27.3%/female 38.7%), 14.3% (male 9.2%/female 19.2%) and 33.6% (male 17.7%/female 49.0%) respectively. The Muslims had the highest prevalence of all three obesity categories. Sector, education, social status quintiles and area level deprivation categories show a non linear social gradient while income shows a linear social gradient in all obesity categories, mean BMI and mean WC. The differences observed for mean BMI and mean WC between the lowest and highest socioeconomic groups were statistically significant. CONCLUSION: There is a social gradient in all three obesity categories with higher prevalence observed in the more educated, urban, high income and high social status segments of society. The higher socioeconomic groups are still at a higher risk of all types of obesity despite other public health indicators such as maternal and infant mortality displaying an established social gradient.

Migration of Sri Lankan medical specialists.

BACKGROUND: The migration of health-care workers contributes to the shortage of health-care workers in many developing countries. This paper aims to describe the migration of medical specialists from Sri Lanka and to discuss the successes and failures of strategies to retain them. METHODS: This paper presents data on all trainees who have left Sri Lanka for postgraduate training through the Post Graduate Institute of Medicine, University of Colombo, from April 1980 to June 2009. In addition, confidential interviews were conducted with 30 specialists who returned following foreign training within the last 5 years and 5 specialists who opted to migrate to foreign countries. RESULTS: From a total of 1,915 specialists who left Sri Lanka for training, 215 (11%) have not returned or have left the country without completing the specified bond period. The majority (53%) migrated to Australia. Of the specialists who left before completion of the bond period, 148 (68.8%) have settled or have started settling the bond. All participants identified foreign training as beneficial for their career. The top reasons for staying in Sri Lanka were: job security, income from private practice, proximity to family and a culturally appropriate environment. The top reasons for migration were: better quality of life, having to work in rural parts of Sri Lanka, career development and social security. CONCLUSIONS: This paper attempts to discuss the reasons for the low rates of emigration of specialists from Sri Lanka. Determining the reasons for retaining these specialists may be useful in designing health systems and postgraduate programs in developing countries with high rates of emigration of specialists.

Use of illicit substances among schoolchildren in colombo district, Sri Lanka.

OBJECTIVE: This study aimed to understand the usage patterns and correlates of illicit drug use among schoolchildren in Colombo district, Sri Lanka. METHODS: A cross-sectional study was carried out among grade 10 and 12 students using a self-administered questionnaire. RESULTS: From the 6000 students selected, 5353(89.22%) responded. Betel chewing with tobacco was seen in 28.48% males and 10.44% females. Substances such as Barbul, Madana Modaka, and cough syrups that are not established as illicit drugs were used as psychoactive substances. Ingredients of some of these compounds are not fully understood or regulated. Prevalence of cannabis use was 3.85% in males and 0.24% in females. Studying nonscience subjects for Advanced Level, doing sports, low academic performance, and peer smoking significantly increased the odds of using one or more substances (P < .05). CONCLUSIONS: Many types of illicit substances were used by schoolchildren. More strategies to prevent further aggravation of these behaviors are needed. Constituents of some compounds are not understood and need further evaluation. Recognized high-risk groups can be targets for preventive and cessation programs.

Social, cultural and economical determinants of diabetes mellitus in Kalutara district, Sri Lanka: a cross sectional descriptive study.

INTRODUCTION: Sri Lanka is a country that is expected to face a high burden of diabetes mellitus (DM). There is a paucity of data on social and demographic determinants of DM, especially in the plantation sector. AIMS: To describe social and economic correlates and inequalities of DM in Kalutara District. METHODS: A cross sectional descriptive study was carried out among adults over the age of 35 years. A sample of 1300 individuals was selected using stratified random cluster sampling method from 65 Grama Niladari Divisions (GND), which were representative of urban, rural and plantation sectors. Twenty households were randomly selected from each division and one adult was randomly selected from each household. Data were collected using a pre-tested questionnaire. Fasting plasma blood sugar of ≥126mg/dl was used to define DM. Significance of prevalence of diseases and risk factors across different socio-economic strata were determined by chi square test for trend. RESULTS: Of 1234 adults who were screened (628 males), 202 (14.7%) had DM. Higher DM proportions (16.1%) were seen in the highest income quintile and in those educated up to Advanced Levels (AL) and above (17.3%). Prevalence in the urban, rural and plantation sectors were 23.6%, 15.5% and 8.5% respectively. Prevalence among Sinhalese, Tamils and Muslims were 14.4%, 29.0% and 20.0% respectively. There was a gradient in prevalence according to the unsatisfactory basic needs index of the GND with the highest proportion (20.7%) observed in the richest GND. The highest social status quintile demonstrated the highest proportion (17.4%) with diabetes mellitus. CONCLUSION: There is a higher prevalence of diabetes mellitus in the more affluent and educated segments of society. There is also a higher prevalence among urban compared to rural and estates. Sri Lanka is in an early stage of the epidemic where the wealthy people are at a higher risk of DM.

The eye in dengue fever, a rarely appreciated aspect of dengue expanded syndrome: a case report.

BACKGROUND: Dengue fever is a mosquito-borne illness prevalent mainly in the tropics. It is feared for causing the dengue hemorrhagic spectrum of the disease leading to significant morbidity and mortality. Its rarer manifestations are categorized as the expanded dengue syndrome, and though being recognized, they are not fully appreciated and understood. The involvement of the eye in dengue fever is one such phenomenon. CASE PRESENTATION: A 27-year-old South-Asian woman presented on day 2 of dengue fever, without capillary leakage, for further management. Despite developing hepatitis, she had an otherwise uncomplicated progression of the illness because she did not develop capillary leakage. On day 8 of the illness, she had the lowest platelet count and developed bilateral blurred vision. Examination revealed that only gross movements were detected in the left eye, and the right eye had a visual acuity of 6/9. She was diagnosed with foveolitis in the right eye and central serous chorioretinopathy in the left eye, along with hemorrhages in both eyes. These were confirmed by funduscopy, fluorescein angiography, optical coherence tomography, and macular scans. She received systemic and intravitreal steroids and was assessed regularly. After 6 months of observation, her visual acuity was 6/6 in the right eye and 6/9 in the left eye, which remained the same thereafter. DISCUSSION: The exact mechanism of eye involvement in dengue viral infection is poorly understood. Multiple causes have been suspected and include viral factors, immune mediation, capillary leakage, stress, and hemorrhage. Eye involvement is classically seen at the lowest platelet count and when the count begins to rise. Though symptoms are nonpathognomonic, blurring of vision is the commonest complaint, but the range of presentation is extensive and variable. Ophthalmological assessment and funduscopy are very useful in addition to advanced assessments. There is no clear consensus on management; suggestions range from conservative care to aggressive steroid therapy with immune modulation and even ophthalmological intervention. Recovery can be full or partial with a variable time scale. CONCLUSION: The extensive spectrum of possible visual symptoms should prompt the clinician to suspect any visual complaint as potential dengue eye involvement. Guided studies and screening are needed to better understand the true incidence of eye involvement in dengue fever.

Prevalence, patterns, and associations of dyslipidemia among Sri Lankan adults-Sri Lanka Diabetes and Cardiovascular Study in 2005-2006.

BACKGROUND: Dyslipidemia is a major risk factor for cardiovascular disease. Prevalence patterns and determinants of dyslipidemia in Sri Lanka are unkown. OBJECTIVES: We aimed to determine the prevalence and correlates of dyslipidemia among Sri Lankan adults. METHODS: A nationally representative sample was recruited by multistage random cluster sampling in Sri Lanka Diabetes and Cardiovascular Study, a cross-sectional study. Data collected by an interviewer-administered questionnaire, physical examination, anthropometric measurements lipid analysis from take 12-hour fasting blood samples were used. RESULTS: Among 4451 participants 60.5% were women and mean age was 46 years. Mean (standard deviation) total cholesterol (TC), high-density lipoprotein cholesterol (HDLC), low-density lipoprotein cholesterol (LDLC), triglycerides (TGs), and TC/HDLC levels were 206.7 mg/dL (±43.5), 46.8 mg/dL (±10.6), 135.5 mg/dL (±37.6), 121.7 mg/dL (±66.8), and 4.6 (±1.1), respectively. Women had higher mean TC, HDLC, LDLC, and TG values compared to men across all age groups. Mean TC, LDLC, and TGs increased with age in both genders; 77.4% of participants had some form of dyslipidemia. Low HDLC was the commonest type (49.6%) of dyslipidemia. Increasing age, female sex, living in urban sector, high body mass index, central obesity, diabetes, hypertension, insufficient physical activity, and smoking were associated with having some form of dyslipidemia. CONCLUSION: Three in four Sri Lankan adults have some form of dyslipidemia. Physical inactivity, obesity, hypertension, and diabetes are the leading modifiable risk factors.

Genetic associations of inflammatory bowel disease in a South Asian population.

AIM: To estimate prevalence and phenotypic associations of selected inflammatory bowel disease (IBD)-associated genetic variants among Sri Lankan patients. METHODS: A case study of histologically confirmed ulcerative colitis (UC) or Crohn's disease (CD) patients with ≥ 1 year disease duration, who were compared to unrelated, gender-matched, healthy individuals as controls, was conducted at four major centers in Sri Lanka. Phenotypic data of the cases were obtained and all participants were genotyped for 16 selected genetic variants: IL12B:rs1045431, IL23R:rs11805303, ARPC2:rs12612347, IRGM:rs13361189, IL26/IL22:rs1558744, CDH1:rs1728785, IL10:rs3024505, FCGR2A:rs3737240, PTGER4:rs4613763, IL17REL/PIM3:rs5771069, HNF4a:rs6017342, STAT3:rs744166, SMURF1:rs7809799, LAMB1:rs886774, HLA-DRB5, DQA1, DRB1, DRA:rs9268853, MST1, UBA7, and APEH:rs9822268. The genotypes of all variants were in Hardy-Weinberg Equilibrium (P > 10-3). To account for multiple hypothesis testing, P-values < 0.003 were considered significant. RESULTS: A total of 415 patients and 465 controls were recruited. Out of the single nucleotide polymorphisms (SNPs) tested, the majority were not associated with IBD in Sri Lankans. Significant positive associations were noted between rs886774 (LAMB1-gene) and UC (odds ratio (OR) = 1.42, P = 0.001). UC patients with rs886774 had mild disease (OR = 1.66, P < 0.001) and remained in remission (OR = 1.48, P < 0.001). A positive association was noted between rs10045431 (IL 12B gene) and upper gastrointestinal involvement in CD (OR = 4.76, P = 0.002). CONCLUSION: This confirms the heterogeneity of allelic mutations in South Asians compared to Caucasians. Most SNPs and disease associations reported here have not been described in South Asians.

Tobacco smoking among school children in Colombo district, Sri Lanka.

Tobacco smoking is an important problem among schoolchildren. The authors studied the patterns of tobacco smoking among schoolchildren in Colombo, Sri Lanka, using a self-administered questionnaire. Multistaged stratified random sampling was used to select 6000 students. Response rate was 90.7% (5446), out of which 53.4% were males. Prevalence rates for males and females, respectively, were as follows: having smoked at least 1 complete cigarette: 27.0% and 13.3%, smoked more than 100 cigarettes: 2.3% and 0.3%, daily smoking: 1.8% and 0.2%. Mean age of starting to smoke was 14.16 years. The tobacco products most used were cigarettes (91.5%) and bidis (3.8%). In univariate analysis, male gender, parental smoking, studying non-science subjects, peer smoking, and participating in sports were significantly associated with smoking of at least 1 complete cigarette (P < .05). In multivariate analysis, the most significant correlates were having close friends (odds ratio = 3.29, confidence interval = 2.47-4.37) or parents who smoked (odds ratio = 1.86, confidence interval = 1.28-2.71). Female smoking has increased from previously reported values. These high-risk groups can be targets for preventive programs.