Population Analysis for Diabetes Mellitus
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According to Figure 1 the variation of the mean fasting blood glucose in males and females from the period 1980 - 2008 is shown below.
Source: WHO - NCD Country Profiles, 2011
An upward trend in DM prevalence (Katulanda, et al., 2006) was reported among urban population who adopt westernized life style patterns and have higher income, compared with rural population involved in agriculture, low income levels and higher physical active life style. (Katulanda, et al., 2011, Mendis, et al., 1994, Katulanda, et al., 2008, Illangasekera, et al., 1993). However some studies indicate high DM prevalence rates in rural populations. (Illangasekera, et al., 1993 Illangasekera, et al., 2004)Whilst most studies suggest a preponderance in males (King H, et al., 1993, Wijewardene, et al., 2005), others have reported a female preponderance. (Fernando, et al., 1994, Katulanda, et al., 2008, Wijewardene, et al., 2005).
Perceptible gradient in DM prevalence can be explained by increasing urbanization (Fernando, et al., 1994), adoption of modern, westernized lifestyles (Fernando, et al., 1994, Katulanda, et al., 2006, Malavige, et al., 2002, Illangasekera, et al., 1993), changes in demographic profile (Fernando, et al., 1994), changes in diet (Fernando, et al., 1994, Illangasekera, et al., 1993), physical inactivity (Illangasekera, et al., 1993) and increasing life expectancy (Fernando, et al., 1994).A positive correlation was reported between DM and obesity/excess body weight with obesity considered as a risk factor in diabetic patients compared with non-diabetic patients. (Katulanda, et al., 2008, Fernando, et al., 1994, Wijewardene, et al., 2005, Global status report on NCDs, 2010, Boden-Albala B, et al., 2008) Furthermore, an inferred association of DM in ageing population (Fernando, et al., 1994, Wijewardene, et al., 2005, Katulanda, et al., 2008) and family history (Mendis, et al., 1994, Katulanda, et al., 2008) were observed though some studies were inconclusive with regard to DM and ageing population. (Fernando, et al., 1994)
Low prevalence rates of undiagnosed diabetic patients were observed in urban compared with elevated rates in rural areas (Katulanda, et al., 2008, Fernando, et al., 1994, Malavige, et al., 2002) which could be attributed to the lack of adequate screening facilities (Fernando, et al., 1994), poor standard of medical care (Arulanandan, et al., 2008) and limitations, inaccuracies in the sampling techniques (Mendis, et al., 1994).Data concerning the low prevalence rates in females have not been reported although the low prevalence from hospital-based studies was attributed to the low attendance of females. (Fernando, et al., 1994)
A wide range of DM in provinces ranging from 6.8% - 18.6%, highest in Western with lowest mean per-capita daily energy consumption including mean activity, and lowest in Uva province with highest energy consumption and elevated physical activity level was evident. Higher prevalences of DM showed a significant (P<0.001) positive association with mean BMI, higher mean income, mean waist circumference and low levels of physical activity (Met-minutes) however mean-per capita daily energy consumption showed a negative correlation. This study highlighted the importance of increased physical activity (>600 Met-minutes), decreased levels of energy consumption and suggested the protective role of increased physical activity despite high energy consumption towards prevention of DM (Katulanda, et al., 2011).
The highest prevalence of DM; 22.1% was reported in Sri Lankan Tamil ethnicity (urban -58.8%) followed by 21.4% in Sri Lankan Moor (urban - 28.9%). The Sinhalese depicted a prevalence rate of 11.9% (urban - 15.8%) with the lowest 3.2% in Indian Tamils (urban - 3.7%). A positive correlation of higher mean waist circumference, BMI, mean family income and higher levels of physical inactivity were implicated for the elevated DM prevalence among the ethnic groups. This study indicates that disparities in lifestyle and socioeconomic factors may have contributed to the differing levels in obesity observed in sub-ethnic groups within a major ethnic group to the variation in DM rates. (Katulanda, et al., 2011)
Most of the available studies in Sri Lanka was limited to a single geographical region, defined population and do not enumerate the true prevalence of DM (Wijewardene, et al., 2005). However some comprehensive studies involving many geographical regions were evident (Wijewardene, et al., 2005, Katulanda, et al., 2009, Katulanda , et al., 2011, Tran, et al., 2011).
However the reported ethnic-specific prevalence patterns may not reflect the true prevalence of the minority ethnic groups (Sri Lankan Tamil, Indian Tamil and Sri Lankan Moor) due to the study population assessed being predominantly from Sinhalese populated areas. Moreover the civil conflict may have been a contributory factor for the lack of studies including the Northern and Eastern regions from Sri Lanka resulting in an under-representation of Tamil (Mendis, et al., 1994) and Sri Lankan Moor ethnic groups as the preponderance being located in these two provinces. (Katulanda, et al., 2011)
A comparison of studies from other populations in the world with Sri Lanka is obfuscated by varying age distribution and different sampling techniques (Illangasekera, et al., 1993) including criteria used to assess DM and pre-diabetes; American Diabetic Association (ADA) guidelines, 1997 (Malavige, et al., 2002, Katulanda, et al., 2008), WHO criteria, 1985 (Fernando, et al., 1994) and WHO criteria, 1999 (Katulanda, et al., 2008).Moreover the magnitude of DM may differ between the ethnic groups and regions. In the majority of reported studies, ethnicity related epidemiological data concerning the indigenous population are lacking. Further cross-sectional studies (Katulanda, et al., 2008, Mendis, et al., 1994) highlighting the indigenous population, ethnic and regional variations are therefore necessary to examine the magnitude of diabetes epidemic in Sri Lanka.
The mortality rates from hypertensive disease (1974 - 1986) declined 1977 - 1980 (males:11.5%- 10.3% and females: 7.4% - 7.3%) however a gradual increase (males:10.3%-13.0% and females: 7.3% - 8.3%) was evident from 1980 - 1986. A male preponderance and an elevation in the male/female mortality ratio (1.4-1.6) for cardiovascular disease (CVD) was reported and differed from most Western countries. (Mendis, et al., 1996) Figure 1 highlights a progressive increase in mean systolic blood pressure levels in both males and females in Sri Lanka from the period 1980 - 2008.
Source: WHO - NCD Country Profiles, 2011
A majority of studies from Sri Lanka are limited to selected population groups and/or confined to certain regions with only a few comparisons between different geographical areas (provinces) (Wijewardena, et al., 2005, Katulanda, et al., 2009) and thus do not represent the true burden of hypertension. (Wijewardena, et al., 2005). Moreover, most studies conducted used different criteria in measuring the blood pressure levels (Wijewardena, et al., 2005, Malavige, et al., 2002, Fernando, et al., 1993) and only a few consistent data available on the prevalence of hypertension risk factor (Mohideen, et al., 1985, Mendis, et al., 1994).
High prevalence for hypertension was observed in urban areas (Katulanda, et al., 2009). However, one study mentioned a higher rate from a rural population (Mendis, et al., 1994). Most studies reported a male preponderance (Fernando, et al., 1994, Mendis, et al., 1991, Weerasuriya, et al., 1998, Katulanda, et al., 2009) whilst some indicated preponderance in females (Wijewardene, et al., 2005).
Adoption of atherogenic dietary habits, change in life style patterns (traditional to Westernized lifestyle), process of transition (rural to urban), socio-demographic changes (ageing population, education levels, family history) may be associated for the elevation in high blood pressure. (Fernando, et al., 1994, Fernando, et al., 1993, Malavige, et al., 2002, Mendis, et al., 1994, Tennakoon, et al., 2010, Mendis, et al., 1987, Katulanda, et al., 2009)
Factors underlying low prevalence in rural areas include lack of resources; screening facilities, under-diagnosis of hypertension and inaccuracies in documentation of mortality. (Mendis, et al., 1996, Mohideen, et al., 1985, Malavige, et al., 2002, Arulanandan, et al., 2008)
The highest prevalence was reported from Uva province (agriculture based) followed by the Western province (urban). The reason for this is not mentioned. A low prevalence of hypertension was reported from the Southern province with comparison to other provinces, implicating regional differences exist in the prevalence of hypertension. (Wijewardena, et al., 2005)
Potential shortcomings in study design include under-representation of ethnic minorities (Sri Lankan Tamil) from Northern and Eastern provinces(Mendis, et al., 1994).Population-based studies involving significant number of individuals from the different ethnic groups and between many geographical areas are needed to evaluate the true prevalence. The high prevalence of hypertension as evident from the above studies signifies a major health problem which requires urgent measures to be taken for its prevention, control and in improving primary and secondary health care.
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