The battle against Non communicable diseases [NCDs] will be in the spotlight at the 3rd High-Level Meeting as part of the United Nations General Assembly on NCD’s in September 27, 2018. It is hoped that progressive, evidence-based methods towards achieving Sustainable Development Goals by the year 2030 will be accepted by over 50 Heads of States for accelerated implementation. Diabetes, often considered the mother illness of most NCDs, will be tabled for discussion to reduce the global burden of disease. What is needed immediately is a strong political commitment to ensure the meaningful prevention and support of people living with or at risk for diabetes in the response.
Incidence and prevalence is progressively rising in type 2 diabetes (T2DM). A few decades ago it was clearly defined that type 1 diabetes is mainly seen in the under 20’s age group and T2DM in the over 40’s. However, now we see the age of onset of T2DM younger, more so in low- and middle-income countries such as Sri Lanka.
We have already established the aetiology of T2DM. One hypothesis could be that younger onset is due to nutrition in-utero being inadequate and consequently the presetting of insulin resistance. In an undernourished child growing in the womb, the compromised nutrition is directed to the maintenance of life through the supply to the brain at the expense of the rest of the body. This usually occurs through a process of insulin resistance so that organs like the liver and musculature remain underdeveloped up to the point of birth. Low birth weight that results in children of this category are thought to be more prone to the development of T2DM in later life. Postnatal enhanced degree of feeding makes them gain weight exponentially mainly through deposition of fat. This produces early onset of T2DM due to pre- setting of insulin resistance.
In these nutritionally compromised individuals the musculature is underdeveloped and hinders adequate exercise which escalates weight gain. As the spread of the T2DM in the world is mainly in the low- and middle-income group, this could be a very important factor that can be corrected through adjustment of maternal nutrition in the stages of preconception and pregnancy. This highlights the value of the “girl child” and its nutrition through the ‘life circle approach’. This makes it essential for pregnancy to occur at an optimal period between 20 and 40 years so that full development and nutrition is more likely to be guaranteed at this time. Early pregnancy is best avoided less than 20 years of age and the girls should be preferentially treated where nutrition is concerned.
According to the Sri Lankan Demographic and Health Survey 2006/2007 data, low birth weight occurs in approximately 17% of new births while prevalence of dysglycaemia occurs in approximately 21.8% of the population.
Interaction of all aetiological factors namely foetal origins, lifestyles, stress and genetics have a major impact of the onset of the pathology.⁴ Modern lifestyles of sedentary and unhealthy fast food, addictions due to increased stress in children and adults, rapid urbanization leading to increased air pollution and unsafe water acts as a catalyst decreasing the age of onset of illness. In addition, inadequate nutrition predisposes people with T2DM to the development of depression as they have been deprived of a desire to fulfill their nutritional requirements in early life. State of undernutrition in-utero leads to a stressful situation before birth and a tendency to develop endogenous depression in later life.
To illustrate, I quote a true-life situation where a young girl living in Colombo, Sri Lanka was diagnosed with T2DM at the tender age of 9 years. She was found to have a high glucose level on a routine screening and was treated as T1DM. She had a low birth weight and nutrition compromised in-utero. She was found to be obese and showed signs of insulin resistance such as acanthosis nigricans where her insulin was gradually reduced and eventually stopped. At present, she is managed well on oral hypoglycaemic agents and a modified lifestyle.
The resultant pandemic of T2DM can only be halted through proactive measures of primary prevention highlighting wellbeing of young females in our society.