By Dr. Dineshani Hettiarachchi
As we have approached the end of Diabetes Awareness Month, The Sunday Morning Brunch spoke to Prof. Prasad Katulanda, a pioneer in diabetes research in Sri Lanka as well as internationally. He is a Consultant Endocrinologist and a Professor at the Department of Clinical Medicine, Faculty of Medicine, University of Colombo.
He was also awarded the prestigious Colombo Medical Congress 2022 oration this year where he spoke about the ‘Diabetes epidemic of Sri Lanka and the University of Colombo Faculty of Medicine’s response’. This is a fitting title to reflect this year’s theme, which is on managing diabetes by building your healthcare team.
Diabetes has now become a regularly used term and owing to its prevalence it has become an important public health problem in Sri Lanka. This is a disease that occurs when our blood sugar is high (hyperglycemia). If untreated, it can lead to many health problems and affect many organ systems including eyes, kidneys, nerves, and heart, and is also linked to some types of cancers.
Trends in the prevalence of diabetes have shown an upward trajectory. Prof. Katulanda recalls that diabetes was not considered an important public health problem in Sri Lanka before 2000, noting that one of the earliest available local studies conducted in 1990 indicated a diabetes prevalence of 2.5%.
However, subsequent studies showed a rising trend which was also noticed by the medical practitioners in the country. This increase was not reflected in the data published by international organisations as these organisations used non-Sri Lankan studies to extrapolate for the island due to the unavailability of well-conducted large-scale studies. As a result, sufficient attention was not paid by the relevant stakeholders to face the rising trend in diabetes. There were several needs in the public health response to this hidden epidemic, stated Prof. Katulanda.
Public health responses to combat diabetes
The epidemic and its underlying factors had to be demonstrated by purposeful large-scale comprehensive epidemiological studies to provide a clear picture nationally and internationally for better resource allocation and public health interventions.
Therefore, additional research had to be promoted by encouraging other researchers through collaborative research and capacity building, including training and mentoring of young researchers. Based on the new insights gained through research, public health interventions needed to be launched.
This included community-based prevention programmes through mass health education initiatives and formulation of culturally based dietary and physical exercise interventions. In addition, further research to identify potential solutions based on traditional treatment methods had to be explored, which would also provide economic gains to the country.
The Sri Lanka Diabetes and Cardiovascular Study (SLDCS) which was initiated in 2005 demonstrated that one in 10 adults in Sri Lanka had diabetes and about one-third was undiagnosed. This new evidence led to the immediate correction of the WHO and IDF data and as a result, the public health sector was alerted to respond promptly.
The Ministry of Health took initiatives to establish the Non-Communicable Disease (NCD) Unit at the Ministry of Health which has become an NCD bureau and subsequently a formal national NCD policy was also initiated by the Government. The Diabetes Research Unit at the Department of Clinical Medicine was recognised as the premier research unit for diabetes and NCDs in Sri Lanka.
In addition, many researchers began to collaborate with the Diabetes Research Unit at the University of Colombo, Faculty of Medicine (DRU-UCFM) team with more enthusiasm for diabetes and NCD research. Many professional and academic bodies formed action committees and task forces to face the diabetes challenge together.
Diabetes in South Asians
The importance of physical activity and obesity as risk factors for diabetes was not only re-established in our population but was elegantly described by two August Researchers Prof. Ranil Jayawardena and Dr. Chathuranga Ranasinghe, who not only joined the UCFM but became pioneers in the fields of nutrition and physical exercise.
This demonstration of the obesity epidemic and its relationship with the diabetes epidemic contributed to the international efforts to reclassify obesity in South Asians. Simultaneously the interrelationship between physical activity and obesity through its distribution according to different provinces and ethnic groups helped the understanding of the importance of physical activity in the prevention of diabetes in South Asians, stated Prof. Katulanda.
During the first decade of the new millennium, scientists had a conviction that South Asians harboured separate genetic markers that accounted for the higher risk for type 2 diabetes in this population. Several international groups were working in parallel to find answers. The UCFM team joined the Oxford-UK team and contributed to this effort, including the largest Genome-Wide Association Scan (GWAS) on South Asian diabetics.
However, it has not yet been possible to clearly explain the apparent genetic risk of South Asians for type 2 diabetes and it is postulated that it may go beyond simple genetic mechanisms. There may be other factors such as epigenetics or gene-gene or gene-environment interactions that may play a role and this is being investigated at present.
The DRU-UCFM team was responsible for bringing forth some important research findings on diabetes in South Asians. Thereafter, several renowned international research groups actively collaborated with it, which resulted in new initiatives to find solutions to the South Asian diabetes and NCD epidemics.
The Oxford diabetes and metabolic research group, the Monash-Melbourne Australian group led by Prof. Brian Oldenburg and the Imperial UK group led by Prof. John Chambers were among the main collaborators of the DRU-UCFM team.
A new area of research on investigating the effects of cinnamon on diabetes and dyslipidemia in collaboration with Prof. Priyadarshani Galappaththi of the Pharmacology Department and co-supervised by Prof. Godwin Constantine helped to identify the potential use of Ceylon Cinnamon in diabetes and dyslipidemia. Two international patents were granted for Ceylon Cinnamon to the UCFM researchers.
Asian Collaboration for Excellence in Noncommunicable Disease Research (ASCEND) Programme initiated by Prof. Brian Oldenburg with a multinational team from India, Sri Lanka, Bangladesh, and Pakistan helped train several dozens of young researchers in diabetes and NCD research. It became a huge success story in capacity building efforts, stated Prof. Katulanda.
Many of these researchers completed research degrees and have become pioneers in diabetes and NCD action as health administrators in the Ministry of Health (one ASCEND alumnus became the NCD director) and academies.
Finding solutions to diabetes and NCDs among South Asians living in South Asia as well as in the rest of the world has become a global health priority. The Global Health Research Unit is a collaborative group of eminent global researchers coming together from India, Pakistan, Bangladesh, Sri Lanka, and the UK as a consortium to find solutions to the South Asian NCD problem.
The DRU-UCFM team was invited to be part of this consortium which has undertaken important research on the prevention of type 2 diabetes in South Asians, community interventions through health promotion, and many other aspects.
When you are a researcher, many opportunities arise to undertake research out of the usual research agendas according to the novel challenges and changing trends, recalled Prof. Katulanda.
“The Covid-19 pandemic posed many challenges to us as researchers. We made use of this opportunity to undertake several important research projects relevant to the Covid pandemic, especially concerning diabetes and NCDs and Sri Lanka.
“In addition, as part of research mentoring and promotion among the postgraduate clinical trainees, we have undertaken clinical research to find answers to some important clinical questions especially relevant to our population, undertaking real-life experiments on novel diabetes therapeutics. Research on mobile health and falls among patients with diabetes has led to doctoral degrees through these programmes.”
Prof. Katulanda concluded that through a planned concerted research programme over nearly two decades, the DRU-UCFM had been able to make a very significant national impact to describe and understand the diabetes epidemic and find solutions to the diabetes epidemic in Sri Lanka. “During this journey, we have been able to contribute to the development of several researchers of international repute through doctoral degree programmes,” Prof. Katulanda said.
The efforts of the DRU-UCFM team have helped to improve the research standing of the University of Colombo and the country through many high-impact publications.
(The abstract of the oration is published in the Proceedings of the University of Colombo Colombo Medical Congress 2022 and in the Ceylon Journal of Medical Sciences)
(The writer is a family physician with a special interest in rare genetic diseases and regenerative medicine currently working as a lecturer at the Department of Anatomy, Faculty of Medicine, University of Colombo, Sri Lanka)
Consultant Endocrinologist/Diabetologist and University of Colombo Faculty of Medicine Department of Clinical Medicine Vidya Jyothi Prof. Prasad Katulanda
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