|Year : 2019 | Volume
| Issue : 1 | Page : 37-40
Characteristics of insulin registry patients with Type 1 diabetes in Sri Lanka
Mahendra Arunashanthi Wijesuriya1, Jessica Lynn Sandy2, Chamari Lalani Warnapura1, Angela C Middlehurst3, Graham D Ogle3
1 National Diabetes Centre, Sri Lanka
2 International Diabetes Federation Life for a Child Program, Glebe, NSW 2037, Australia
3 International Diabetes Federation Life for a Child Program; Diabetes NSW and ACT, Glebe, NSW 2037, Australia
|Date of Web Publication||21-Nov-2018|
Dr. Jessica Lynn Sandy
International Diabetes Federation Life for a Child, Diabetes NSW and Act, 26 Arundel St., Glebe NSW 2037
Source of Support: None, Conflict of Interest: None
Background: There is a paucity of literature on epidemiology of type 1 diabetes (T1D) in Sri Lanka. This study reviews the characteristics of patients registered in an insulin bank programme in Sri Lanka. Materials and Methods: Data were collected and analysed from records of all 672 patients diagnosed with T1D registered in the insulin bank with dates of the diagnosis ranging from 1971 to 2016. Results: Of the 672 patients, age at the diagnosis ranged from the day of birth to 44 years. The majority of patients, 526 (78.3%) were diagnosed before 15 years of age, with 7 (1.0%) cases diagnosed before 6 months. Females accounted for 56.8% of cases. The ethnic distribution of T1D in the study population was consistent with the overall population. Conclusion: This study gives some insight into the epidemiological features of T1D in young people in Sri Lanka. The peak age at the diagnosis is similar to studies in the western countries. This study also demonstrated a slight female predominance and a small but significant number of cases diagnosed in infancy. Further epidemiological and clinical research would help guide organisation of care and distribution of resources in the management of T1D in Sri Lanka.
Keywords: Children, diabetes mellitus, developing countries, Sri Lanka
|How to cite this article:|
Wijesuriya MA, Sandy JL, Warnapura CL, Middlehurst AC, Ogle GD. Characteristics of insulin registry patients with Type 1 diabetes in Sri Lanka. J Diabetol 2019;10:37-40
| Introduction|| |
Type 1 diabetes (T1D) occurs globally,, and recognition and skilled management are essential for reducing morbidity and mortality. Understanding of epidemiological patterns of T1D within a particular country is important for provision of care, resource allocation and training of health professionals. While studies suggest a high prevalence of type 2 diabetes in Sri Lanka, ranging between 12% and 20% of adults,,, we are unaware of any published data on T1D in Sri Lanka.
The incidence of T1D is increasing in many countries including Asia., For example, the annual increase in incidence in both Uzbekistan and South Korean is 5.6% per year., However, there are no definitive data from South Asia on the rate of increase. The International Diabetes Federation (IDF) Atlas More Details estimates an annual incidence of T1D in Sri Lanka of 3/100,000 children under the age of 15 years and a prevalence of 18.2/100,000; however, this is based on only one study by Kalra et al. from Karnal in India.
This paper is a short communication that provides some insight into the characteristics of T1D patients in Sri Lanka by providing information on epidemiological characteristics of the population cared for by the Diabetes Association of Sri Lanka's Insulin Bank, established in 1971. Insulin is provided through local fundraising and also support from the IDF Life for a Child Programme.
| Materials and Methods|| |
Data were collected on all 672 patients accessing the Insulin Bank at the Diabetes Association of Sri Lanka in Colombo, who were diagnosed with T1D from 1971 to February 2016. Between 1971 and 1988, only 14 patients were enrolled, and then enrolment numbers increased in 1989. The diagnosis of T1D was a clinician assessment based on the presentation, age, clinical features and immediate requirement for insulin with no suggestion of type 2 diabetes or another type of diabetes being responsible. Patients were referred predominantly by their treating physicians who were aware of the support provided by the Insulin Bank. Others self-referred after hearing about the programme through from their school, the media or by word of mouth.
Data were collected by the physicians prescribing and distributing insulin. Information collected included demographic data such as gender, date of birth, date of diagnosis, ethnicity and province.
The only information used was previously collected information available from clinical records, and this study was approved by an ethics review by the Diabetes Association of Sri Lanka.
Data were managed, and descriptive statistics were performed in Microsoft Excel 2011 version 14.6.7.
| Results|| |
A total of 672 patients were registered with the Insulin Bank. Age at the diagnosis ranged from the day of birth to 44 years of age, with the highest incidence in the 10–14 years age range and a peak at 11 years [Figure 1] and [Figure 2]. Over three-quarters, 78.3% (n = 526) were diagnosed before the age of 15 years. The majority (56.8%, n = 382) of the total patient population was female, with the most marked female predominance noted in the 5–9 years and 10–14 years age ranges. The only age group where female diagnoses were less common than male diagnoses was in the under 5-year age group.
|Figure 1: (Histogram) Age of the diagnosis of type 1 diabetes in Sri Lankan Insulin Bank|
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|Figure 2: (Colour histogram) Type 1 diabetes age and gender at the diagnosis in Sri Lankan Insulin Bank|
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The most common ethnicity was Sinhalese (85.3%, n = 573), followed by Moor (7.3%, n = 49), Sri Lankan Tamil (5.81%, n = 39) and Indian Tamil (1.04%, n = 7). This is consistent with population data where the respective figures are 82.0% (Sinhalese), 7.1% (Sri Lankan Moor), 4.3% (Sri Lankan Tamil) and 5.1% (Indian Tamil). Other ethnicities, including Burgher, made up <1% of the total study population.
The most common district of inhabitance was Colombo (27.8%, n = 187) followed by Gampaha (n = 92, 13.7%) and Kalutara (n = 57, 8.5%).
There were seven cases diagnosed before 6 months of age, representing 1.0% of the study population. Of these, five were male. Two of these patients are known to have died; one with no further details known, and one who was thought to have had neonatal diabetes (diagnosed at 1 month of age) and who died at 18 months of age due to cardiac failure. Of the other five cases, one was diagnosed shortly after birth with no family history of diabetes and is known to be alive 30 years later. Another was diagnosed with Wolcott–Rallinson syndrome in the context of consanguinity. There is no follow-up information on the other three cases.
| Discussion|| |
The IDF Atlas estimation of the incidence of T1D in children <15 years in Sri Lanka is based on only one study in one region of India., This study estimated an incidence of 3/100,000/year and a prevalence of 18.2/100,000. In contrast, an incidence of up to 10.5/100,000/year was seen in an urban population in India. One study from Southern India in the early 1990s also saw a delayed peak of the diagnosis in the rural areas and those with lower family income, with peak age of onset being 18 years compared to 11 years for those in the urban areas and those with higher income, which may be in part due to delayed or missed diagnosis and may partially explain the lower prevalence noted in childhood in the rural areas.
Worldwide trends suggest a higher incidence of T1D in late childhood, with higher numbers of diagnoses seen in those 9–14 years or 10–15 years (depending on the study parameters), as compared to younger age groups.,, This was also seen in our study population, where the peak range age of the diagnosis was between 10 and 14 years. Our data also suggested no variation in incidence due to the ethnic background when compared to census data; however, interpretation of this is limited by incomplete ascertainment.
According to the DIAMOND research, there tends to be a female predominance in low-incidence countries, and these trends are reversed in high-incidence countries. Studies based in India have seen a higher prevalence in males.,,, Our patient population was predominantly female despite a higher total population of males under 15 years of age in Sri Lanka. The reason for female predominance in T1D in low-incidence countries is likely multifactorial; fathers with T1D are more likely to survive and pass on genes than mothers with T1D, and fathers' genes are more likely to cause T1D in a female offspring and are possibly more diabetogenic than similar genes in mothers (that are more likely to cause T1D in male offspring).,,
An important finding in this study is the seven cases diagnosed before 6 months of age. T1D is extremely rare before the age of 6 months. Monogenic diabetes can present early in life, and some may not require insulin, so it is, therefore, important to identify monogenic and other forms of diabetes to better understand and manage diabetes in certain patient populations. Genetic testing is indicated where possible in these cases to further guide management of these patients.
There are some limitations to this study. First, the Insulin Bank does not service all young people with insulin-dependent diabetes in Sri Lanka, and secondary ascertainment was not possible from another data source. Therefore, an incidence or prevalence cannot be determined from this data. There is a very high likelihood that a significant number of patients are not being treated by this service and are thus not included in this dataset. Patients were not randomly selected, as they were either referred by doctors or heard about the service from school, media or word of mouth. This could lead to selection bias, with those able to afford alternative options less likely to access a free insulin bank or those geographically isolated less able to access the insulin bank.
Second, there were no antibody or C-peptide results available for this study population, and the diagnosis of T1D was clinical, based on the need for insulin at the diagnosis. There is thus a possibility that there are a few patients with type 2 diabetes in this dataset, especially in the older age groups; however, this number is estimated to be low. In addition, there may be some patients with diabetes secondary to thalassemia, and others known to be of different aetiologies, such as neonatal diabetes; however, again this number is very small.
Given the country-to-country variation in the quoted prevalence of T1D and the fact that some studies were published some years ago, it is likely that the true incidence of T1D in Sri Lanka differs from the current estimates. As discussed above, this study was unable to estimate incidence because ascertainment was incomplete and also likely varied over the follow-up period. To better understand the burden of T1D in Sri Lanka, a more accurate approximation is required, preferably based on a regional or nationwide register with high ascertainment (ideally with two ascertainment sources and use of a capture–recapture method). However, the information provided by this paper provides a useful initial understanding of the epidemiology of diabetes in Sri Lanka.
| Conclusion|| |
This study gives insight into the age and gender distribution of T1D in Sri Lanka; most notably that the peak age at the diagnosis is 10–14 years, similar to other countries, and that a small but significant number of patients are diagnosed very early in life and may have monogenic causes. Further research is needed to estimate the prevalence and incidence of T1D in Sri Lanka, as well as to clarify the types of monogenic and other forms of diabetes that may be occurring. Additional insight into the epidemiology of T1D in Sri Lanka would optimise health-care delivery for those with T1D through informing resource allocation and patient and physician training and education.
The authors would like to thank Daniëlle van der Kaay for help with initial data collection.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]