The Indiscriminative Disease- Diabetes

By Yolanthika Ellepola

Research Assistant, Institute of Policy Studies of Sri Lanka

Diabetes which was once historically predominant in the developed world and confined to the affluent has become a worldwide pandemic with two thirds of the global diabetic population living in the developing world.  With pronounced demographic, epidemiologic and socioeconomic change, some argue that Asia is emerging as an epicentre of this epidemic.  Asians are known to have an increased disposition of Type 2 diabetes and in fact are more susceptible to developing the disease compared with native white Caucasians.  These characteristics imply that Asians have a high disposition of Insulin resistance and at a lesser degree of obesity than people of European decent. The International Diabetes Federation estimates that young adults diagnosed with diabetes will reach 380 million by 2025, with over half of them living in Asia provoking an enormous health burden.  The early onset of Type 2 diabetes pose grave concern since complications may appear to arise early in adult life.  Until recently, Type 1 diabetes (also known as Juvenile diabetes) a condition prevalent among children in China, Japan and the Pacific Islands indicate that more than 70%of them were diagnosed with Type 2 diabetes. Similarly, the incidents of Type 2 diabetes in Chinese adults tripled from 1.0% to 3.2% between 1980 and 1996 while the incidence of the disease in Korea, Indonesia and Thailand magnified three to five folds during the past 30 years.  In particular to the Indian sub-continent, a projected increase of 40% is likely to be observed between 2000 and 2030.

Although the rise of diabetes at an early life has attracted much attention and comprehensive reviews on the incidence of the disease have been conducted in Sri Lanka. Limited studies to date have explored the impact of this disease on the patient, their families and on the economy.  The focal point of this article is to deliberate this particular research gap.

Diabetes in Sri Lanka

Despite Sri Lanka’s rapid epidemiological and demographic transitions, the dichotomy faced in one segment of the population is under nutrition including Anaemia, Vitamin A deficiency and protein energy malnutrition whilst  on the other, Non- Communicable Diseases (NCDs) such as cancer, hypertension and cardiovascular diseases. The stereotypical notion that diabetes  is dominant in the developed world and restricted to the urban rich in developing nations has markedly changed.  At a comparatively lesser extent, diabetes is observed in rural Sri Lanka. Research conducted by Katulanda and colleagues in 2012uncovered that the incidence of diabetes stood at 18.6% in the Western Province and 6.8% in the Uva Province.

Today, more than 100 daily deaths are stemmed from diabetes and cardiovascular disease with 1 in 5 Sri Lankan persons either diabetic or in in danger of developing diabetes.  Research findings highlight that 24% of adolescents aged between 10-14 years are at risk of developing Type 2 diabetes. Scientists at King’s College London and the National Diabetes Centre (Sri Lanka) have found evidence of a high number of risk factors for type 2 diabetes among the young population. The study further highlighted that diabetes among young Sri Lankan adults ranged between 13-14%. Most significant risk factor detected among the 10-40 age group was physical inactivity which had a prevalence of 45%, while the prevalence of central obesity accounted for 38% with more males than females prone to this risk factor.  Central obesity among those in the 15-19 age group was 22.1% with greater female preponderance of the disease.  Diabetes is thus attributed to  lifestyle transitions coupled with the desire to ape Western lifestyles.

Disease Burden of Diabetes on the Households

Although reliable data on the direct medical costs of diabetes are unavailable for Sri Lanka, it is known that low-income groups are likely to incur a higher proportion of their income on diabetes care.  The medical costs incurred by a person with diabetes are two to fivefold higher than those incurred by people without diabetes and it is  estimated that 85–95% of all health care costs are borne by individuals and their families from household income. The lowest income groups bear the greatest burden, paying a larger proportion of household income toward diabetes care.

Given that 1 in 5 Sri Lankans are diabetic or pre-diabetic, the year-on-year increase in this proportion is greater in impoverished groups, worsening with duration of diabetes, presence of complications, hospitalization and surgical therapy.  The consequences of socioeconomic and urban–rural gradients are that they are associated with divergence in disease outcomes. Relatively more affluent residents’ experiences of diabetes  is more costly, yet manageable whereas those in  rural dwellings endure late recognition and rapidly progressive, often fatal or disabling disease.

Ripple Effects of Diabetes

Diabetes has adverse consequences on both the patient and on the immediate family.  Direct psychological impacts due to a loss of a limb or deterioration in sight threaten family ties and subsequently impose a degree of stress on the patient and family members.  Inability to participate in social activities, dependence on others in performing daily activities and the struggles of learning to cope with changes further aggravate the stress inflicted upon the family. A study conducted in India revealed that diabetes exerts a psychological burden on the patient with 27%of respondents felt discriminated against, 12% diagnosed with depression and 52%  experience diabetes-related stress.The survey further highlighted that 19% of the respondents perceived notable diabetes related burden on the family.

The enormous social and cultural pressures within the community further stifle efforts to manage diabetes.  Patients choose to compromise their diet and treatment regimen to comply with their community etiquette and avoid social stigma surrounding their condition.  The stigma attached to diabetes among young unmarried individuals is considerably greater.  Diabetes in this age category is viewed as a sign of inadequacy which could seriously impair marriage prospects in a social system of arranged marriages.  Immediate families of patients often contribute to this stigma by encouraging them not to disclose their condition. 

Under-resourced Health Sector

Though the healthcare system is based on the principle of state responsibility for free health care, diabetes care is not explicitly part of the roles and responsibilities assigned to health personnel in the rural health care set-up, nor in pre and in-service training of personnel. Although reliable statistics are scarce, the public health system is under-utilised for all types of care, due to reasons of location, unreliable functioning of health facilities and increased indirect expenditures involved. Rural hospitals often lack screening and access to check-ups which often lead to diabetes discovered at a later stage when severe complications have risen.  Ironically, qualified practitioners tend to congregate in urban areas, while private providers in rural areas are likely to be less than fully qualified. While hospitalisation, surgery, medication and laboratory tests are the major drivers of cost, clinical practices driven by profit can substantially increase costs in the absence of well-defined management practices and clinical goal-setting. Educational activities for diabetic patients are non-existent.  Lack of time, cultural and economic constraints, unavailability of treatment, under trained healthcare providers in poor resource settings are barriers that challenge effective management of diabetes prevention and control.

Policy Implications

In the awakening of lifestyle changes resulting from economic development, diabetes has slithered into the lives of many Sri Lankans seizing their productive years.  It is thus timely that priority action could address the needs of people with or at risk of diabetes. Diabetes regrettably affects families, communities and the wider economy.  Thus, possible involvement to mitigate the impact is of urgent need.  Engaging all sections and levels of society in planning and implementing a national diabetes programme is vital to achieving the greatest support, penetration and impact.

The Sri Lankan health care system unfortunately, lacks a sense of urgency with regard to the threat posed by diabetic complications. The increased incidences of diabetes and at a younger age imply the great risk of a future explosion in the occurrence of diabetes related diseases. The ability of the Sri Lankan health services to cope with such an eventuality is reliant on the establishment of a complete tertiary care infrastructure and clear treatment guidelines. Early detection, prevention and treatment of diabetic complications can be especially beneficial in terms of patient quality of life and cost-effectiveness.  Measure that could reduce hospitalization will reduce the major expenditure associated with advanced diabetes. Several studies have estimated that cost savings accounting to 75% can be made by re-focusing the provision of care toward an outpatient basis.

Investments in infrastructure must be accompanied by investments in education. Success in reducing the incidence of diabetes, and hence the burden of disease on the Sri Lankan economy will be dependent on the extent to which healthcare professionals,  patients and their families fully comprehend the trickle down effect of diabetes and accept the fact that diabetes is  preventable and controllable. The key to this accomplishment is through educating health care professionals who have direct contact with the patients and those health care professionals involved in diabetes care. Although aspects related to diet and amount of physical activity undertaken will be influenced by the interplay of various sectoral policies and forces, adherence to diet restrictions will depend on the sustained availability of inexpensive dietary substitutes in the market, their affordability and accessibility on a continuous basis to the patient.  These will require re-aligning of national policies for food procurement, pricing and marketing, to ensure lower prices, and improved access to healthy foods.  Population-based strategies for health promotion and risk reduction, along with surveillance of trends in disease and risk factors are equally important components of public health approach for diabetes  prevention control.  It is therefore vitally important that policy makers are made aware of not only the potential cost of diabetes, but also of the vast savings that could be made in the long run  provided corrective measures are employed.