The Silent Epi­demic

Text Mangai Balasegaram Pho­tos Jesper West­ley

Asian Geographic - - Heritage -

The

wound was still raw, but the agony of the am­pu­ta­tion was not just in the phys­i­cal pain for Mo­hamad Zid­dig. Ly­ing on his hos­pi­tal bed at the Anu­rad­ha­pura Teach­ing Hos­pi­tal in Sri Lanka, a sin­gle leg pro­trud­ing from the folds of his striped sarong, the 57-year-old said lit­tle. A heavy si­lence hung over the rel­a­tives cir­cling his bed.

Two months ago, he ar­rived at the hos­pi­tal with a foot ul­cer. Now he had lost an en­tire leg to a dis­ease he’d never heard of. A farmer and a bread­win­ner, his fu­ture was now un­cer­tain. His de­spair was pal­pa­ble. His son dis­closed the fam­ily had come to lift his spir­its, but they too were con­cerned. Tend­ing the crops and get­ting fol­low-up care would be a chal­lenge.

In a bed nearby to Mo­hamad’s, an­other fam­ily tragedy was un­fold­ing.

Padma Dis­sanayake, 54, sur­veyed the su­tured stump be­low her knee de­spon­dently. At least she had sup­port from her hus­band – he had sav­ings from his for­mer job as a driver in Dubai, and he would carry her around. They had no wheel­chair. But liv­ing in an area where care was limited, the fu­ture looked un­cer­tain. Di­a­betes could in time rob her of her de­te­ri­o­rat­ing sight.

Else­where in the packed ward, there were other casualties to di­a­betes: am­putees miss­ing toes or feet; nasty foot ul­cers.

Sri Lanka’s three decade-long civil war is long over, but an­other alarm­ing threat to life and limb has emerged – type 2 di­a­betes. It is a key cause of am­pu­ta­tions, as well as blind­ness, nerve dam­age, skin ul­cers, heart dis­ease and chronic kid­ney fail­ure.

Genes play a part. Stud­ies show that Asians have a higher risk of de­vel­op­ing di­a­betes than Cau­casians. Asian pop­u­la­tions are also de­vel­op­ing the dis­ease at younger ages than Western pop­u­la­tions.

Di­a­betes is nor­mally linked with obe­sity, yet a rel­a­tively slim-look­ing Asian may be at a higher risk than an over­weight Cau­casian. This is be­cause Asians de­velop di­a­betes at a lower body mass in­dex (weight-to-height ra­tio), says the Asian Di­a­betes Preven­tion Ini­tia­tive. Asians, es­pe­cially South Asians, have less mus­cle and more fat, which in­creases in­sulin re­sis­tance. Body fat dis­tri­bu­tion also mat­ters. Asians tend to carry more fat around the belly, which is more metabol­i­cally ac­tive, rais­ing the risk of di­a­betes. Thus, waist cir­cum­fer­ence – which should not ex­ceed 90 cen­time­tres for men and 80 cen­time­tres for women – is of­ten mea­sured.

Lack of nu­tri­tion dur­ing preg­nancy can re­sult in the baby’s cells be­ing “pro­grammed” to sur­vive on fewer nu­tri­ents, which raises a risk for di­a­betes when food is plen­ti­ful later. Chil­dren born in poverty or a famine may thus be at higher risk. Poor nu­tri­tion for the mother – such as too much sugar and fat – can also cause prob­lems and raise the risk of di­a­betes later. Trag­i­cally, the vast ma­jor­ity of these di­a­betes cases are pre­ventable and treat­able. Most coun­tries have now launched ini­tia­tives to improve diet and ex­er­cise, says Dr Hu, yet im­ple­men­ta­tion across dif­fer­ent groups and geo­graphic ar­eas is not uni­form. “There is still a long way to go.”

The World Di­a­betes Foun­da­tion (WDF), a lead­ing fun­der for di­a­betes preven­tion and care in the de­vel­op­ing world, has seen a rise in the num­ber of project ap­pli­ca­tions in Asia in re­cent years, driven by the in­creas­ing bur­den posed by the dis­ease. Since 2002, WDF has pro­vided more than USD52 mil­lion to 189 projects across Asia.

It is fund­ing the first phase of a com­pre­hen­sive, cost-ef­fec­tive model to pre­vent and man­age di­a­betes in Sri Lanka. This in­volves screen­ing some 20,000

In fo­cus

Com­pli­ca­tions can be pre­vented or de­layed by early di­ag­no­sis and cost-ef­fec­tive mea­sures, such as ed­u­ca­tion about diet and re­minder sys­tems. Pro­fes­sor Dr Ju­liana Chan from the Chi­nese Uni­ver­sity of Hong Kong ad­vo­cates struc­tured team-based care, as well as af­ford­able drugs and in­sur­ance cover.

She cites the case of twin sis­ters who both de­vel­oped di­a­betes at 35. Ini­tially, both re­fused treat­ment. But after a few years, one twin was per­suaded to have treat­ment. Now 50, she is well and ex­pected to live un­til 80 or be­yond. Her sis­ter, how­ever, re­cently died of kid­ney fail­ure and stroke, after years of frag­mented care and a lack of so­cial sup­port.

“The key ques­tion is: why are we pay­ing mil­lions of dol­lars to give some­body a few years of life while on dial­y­sis, or a few months of life when they get can­cer, but we don’t of­fer af­ford­able choices to peo­ple with di­a­betes to keep them away from hos­pi­tals and pre­serve their qual­ity of life?” says Pro­fes­sor Chan.

With limited re­sources, in­no­va­tion may be key. In Hong Kong, the Joint Asia Di­a­betes Eval­u­a­tion pro­gramme is an elec­tronic plat­form that pro­vides treat­ment tar­gets and re­minders and in­volves pa­tients. “We need mul­ti­ple strate­gies so that these peo­ple are seen at the right time by the right peo­ple in the right set­ting,” Chan says. ag

MANGAI BALASEGARAM is a jour­nal­ist and health spe­cial­ist based in Kuala Lumpur who has worked for Thes­tar in Malaysia, the BBC, and the World Health Or­ga­ni­za­tion.

JESPER WEST­LEY pro­vided ad­di­tional re­port­ing from Sri Lanka. He is cur­rently work­ing on a book project about the bur­den of di­a­betes in the de­vel­op­ing world. He is based in Copen­hagen, Den­mark.

Sup­port for this story was pro­vided by the World Di­a­betes Foun­da­tion, which funds more than 500 di­a­betes projects in 115 coun­tries. www.world­di­a­betes­foun­da­tion.org

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