Diabetes, heart problems , hypertension have trebled over the recent years. In the efforts made to combat this unhealthy trend, not many know the important role played by Endocrinologists.
Endocrinologist, NHSL, Dr Noel Somasundaram , a specialist in the field for many years, spoke to the Sunday Observer to give us more insights into this very significant role .
Excerpts...
Q. You are a qualified, well known health professional specializing in Endocrinology. Not many people are familiar with this field . So tell us what is Endocrinology?
A. The body is controlled by hormones from birth to death. These hormones are produced by endocrine organs such as, the master gland in the brain Pituitary and the other glands throughout the body such as, the Thyroid gland that produce thyroxine hormones that control each and every cell of the body, parathyroid glands behind the thyroid that produce Parathormone that controls calcium and bone, adrenal glands that control glucose, electrolytes and the flight response and reaction to stress through several hormones such as, cortisol, aldosterone and adrenaline, the reproductive function is controlled by the gonads (Testes in males and Ovaries in females) and finally, within the Pancreas there are several hormones such as, insulin and glucagon that control the glucose levels and the metabolic function of the body. In addition there are many other hormones from the gut that control energy metabolism and the weight and molecular response of the body and brain. Endocrinology is the specialty that investigates and treats problems in these mechanism or glands.
Q. What is the role of an Endocrinologist in ensuring that our body organs work well?
A. Each of the mechanisms of the body should work normally and in sync, for normal body functions to occur. When there is an abnormality such as, underachieve gland or overactive gland or a tumour in the gland, then there has to be a process of evaluation and investigation that is rational, cost effective and evidence based. The Endocrinologist’s job is to ensure that these processes are followed and the patient is reassured or advised on the correct treatment that is required.
Q. Who is the first point of contact for a person with suspected hormonal issues?
A. When the bodily functions mentioned above do not develop and function normally, an endocrine problem is suspected, and the GP is usually the first to consult.
Q. Once identified what is done to restore his/her hormonal balance?
A. The endocrinologist will see whether a test is needed based on the symptoms and signs, and decide on any further action.
Q. How does the endocrinologist diagnose? What are the tests ?
A. Based on the symptoms and signs a plan of investigations and management of the condition is done. Almost every hormonal system and its control at different levels can be done. The common test is an investigation of thyroid and its control mechanisms. Thyroid is controlled by the master gland pituitary via the production of Thyroid Stimulating Hormone (TSH) which in turn stimulates the thyroid to produce thyroxine hormones (T4 and T3). There are antibodies that may cause some of the common thyroid diseases such as Thyroid peroxidase antibody or Thyroid Stimulating Antibody. Scans such as ultrasound scan of thyroid or CT scan may be taken based on the need. A fine needle aspiration is done to evaluate a thyroid nodule if required. Thyroid scintigraphy is done to evaluate certain thyroid conditions or thyroid cancer.
Thyroglobulin is a test done to follow up thyroid cancer. Genetic studies from fine needle aspiration may be done to evaluate for malignancy when it is not very clear. So, there are numerous tests available. The question is what is the most appropriate and cost effective test for the patient. In each of the hormone systems a similar approach is used.
Q. How valid and accurate are they? Is there scientific evidence?
A. Some tests are specific and sensitive but not foolproof. In each of the tests are variations based on numerous factors such as, at what time of the day and what age and in which gender is it done? Pregnancy could change certain tests and the hormones may also change according to the age reproductive stage, or other illnesses. Medications may change hormonal tests and cross react with tests. All these have to be taken into account when interpreting the tests.
Q. Do they follow some guidelines?
A. There are international and Sri Lankan guidelines but, a careful consideration of the individual is needed to be able to interpret the tests. The laboratory also should take standardization techniques and follow quality control to be able to give reliable and accurate test results. It is important to follow a quality control in laboratories, in order to produce accurate results.
Q. What are the most common conditions you see in your field?
A. The commonest endocrine disorder is thyroid disorders, found in 10% of the population. These include a goiter (enlarged thyroid), hypothyroidism (underactive thyroid), thyroiditis (inflammation of thyroid due to autoimmunity). Thyroid cancer is among the top ten cancers in Sri Lanka.
The commonest metabolic problems are obesity and overweight, osteoporosis and diabetes mellitus. Two thirds of Colombo dwellers are overweight or obese. Osteoporosis is found in 50% of women older than 50 years. Diabetes mellitus is found in 10% of Sri Lankans but the urban populations have a prevalence more than 20%.
Q. Are they all related to hormonal issues?
A. There are many reasons why a gland or metabolic process would be dysfunctional. Sometimes it is genetic but commonly it is environmental , such as obesity/ overweight, diabetes mellitus where rapidly changing lifestyle is the key factor.
Q. What are the most widespread NCDs in Sri Lanka? What has caused them?
A. The key Non Communicable Diseases (NCDs) obesity/overweight, high blood pressure, high cholesterol and diabetes mellitus have common origins. They are partly but not entirely genetic but are mainly due to rapid change in lifestyles. About 29% of Sri Lankan population is overweight, 25% have high blood pressure or high cholesterol and 10% have diabetes mellitus. They are often found together as they are caused by the same factors.
Q. Can diabetes develop overnight?
A. Diabetes is a long term process in one sense developing from the womb itself. If you have inherited the genes that predispose to diabetes then the risk of diabetes is 20-30% higher. If the mother was overweight or underweight or had diabetes mellitus during pregnancy, the fetus is programmed with those poor characteristics making the child vulnerable. This is called fetal programming and the children have a higher risk of developing obesity and diabetes. Our lifestyle determines our risk.
Q. Diabetes has also been described as a very dangerous diseases. Why?
A. Diabetes is merely a symptom of what is going on. Due to insulin resistance and inflammation many changes and damages occur throughout the body leading to microvascular damage (small blood vessels in the body being damaged) leading to eye, kidney and nerve problems. Unless a careful control of risk is undertaken the individual will develop end stage diseases such as heart failure, kidney failure, blindness and loss of limbs or even death.
Q. What are the symptoms of suspected diabetes ?
A. Sadly diabetes is not a condition of blood glucose alone. Most of the time we diagnose diabetes when a serious complication such as heart attack has already developed. It is called a silent killer due to these reasons. Therefore relying on symptoms for diagnosis or to check whether diabetes is under control is foolish and is pretty dangerous. Most people can live with very high glucose levels without knowing that the glucose is high. Sri Lankan government recommends a routine check of every individual above 35 to check with a fasting plasma glucose level to identify whether they have diabetes. In adults younger than 35 a test is required if they are overweight or have a family member with diabetes.
Q. Of the tests to diagnose a patient which is the most important?
A. For diagnosis of diabetes a fasting plasma glucose is the firsts step. If it is less than 100 mg/dl then a repeat test 3 years later can be done. In addition change of lifestyle is required in those who are normal to make sure that the risk of diabetes is lowered by appropriate lifestyle changes such as loss of weight, regular physical activity and changing to healthy diet plans. If fasting blood glucose is more than 126 mg/dl then diabetes has developed and other tests such as cholesterol and further evaluation of blood pressure and body weight has to be done. At this time discussion with the doctor about treatment options have to be made. In those who have a value of 100-125 mg/dl a HbA1C test will help to differentiate between pre diabetes and already existing diabetes.
Q. What does this test tell us?
A. HbA1c is a test that estimates the heamoglobin in the blood that is altered by blood glucose. It is a test of long term exposure to glucose and is also a reflection of what happened over the previous three months. It is a good estimate of diabetes control and should be kept as low as possible. In those who have diabetes HbA1C is an important determinant of development of complications. An ideal target is a level under 6.5%.
Q. How is it done? Which method is the best and most accurate?
A. It is done by a technique called high performance liquid chromatography (HPLC) and estimates the various hemoglobin fractions and gives an estimate of glycosylation of hemoglobin in the red cells. A standardized form of HPLC method should be undertaken by laboratories in order to interpret the test correctly. Most major laboratories in the country do the correct and recommended technique.
Q. What should be the ideal level?
A. To prevent complications blood glucose should be kept at near normal levels throughout life. In those with diabetes a before meal level close to 100 mg/dl is recommended. A post meal level close to 140 mg/dl is ideal but in those who cannot achieve this safely doctors may personalize targets based on safety with a careful consideration of the risk associated with uncontrolled diabetes.
A good marker of control is a HbA1C test done every three months to ensure that persistent attainment of glucose control had been achieved for the previous three months. In most individuals over 40 years, use of a statin to prevent heart attack is recommended even if the cholesterol is normal.
Q. You just completed a marathon islandwide Walk and Run for Diabetes last week, which began in the North and East and then from Kandy to Colombo. How many adults and youth took part in it? I understand several medical professionals also joined it for the first time. Your comments?
A. Sri Lanka Diabetes and Cardiovascular initiative is a project that works with the public, volunteers, schools and health institutions to create awareness, change lifestyles and offer free screening to public in government run ‘Healthy Lifestyle Centers’ (HLC). There are more than 800 HLCs in the country. The ‘Walk for Diabetes’ is a partnership with the Lions International and Lions District 306 C1 to create awareness among the public. The ‘Run for Life’ is an international program that urges children and young adults to ‘Run’ for fun and as part of a balanced healthy life.
Q. Why was it launched? What were the services given to the public on the way as diabetic checks? Were they free of charge?
A. The whole program brings to light the dangers facing Sri Lankans and we urge everyone young and old to take this risk seriously. We need to actively pursue a physically active life and eat healthy. Everything done during the project was free of charge. Physical examination as well blood tests were offered along the way and experts offered personalized advice and counselling.
Q. Looking back, did it accomplish your goal and vision? What were they?
A. We wanted to create awareness among public and this was achieved. We wanted the media to focus attention and despite the election and cabinet change the media gave time and coverage for the event and its message to the people. We thank the media institutions for this.
Q. Did it have the blessings of the Ministry of Health? Did the private sector hospitals also have a role?
A. The Minster of Health and Nutrition himself walked part of the distance to show the people the importance of issues that were highlighted during the walk and run.
Q. Will you continue it or will this be a one off activity?
A. We have had annual walks throughout the country for the past 10 years and this was the first time we did it across the country. We would certainly do it again and we need the support of everyone to keep doing it.
Q. What exercises do you recommend to prevent NCDs?
A. Not just diabetes but most NCDs including some cancers can be prevented by changing lifestyle and maintaining correct weight. The risk of diabetes is lower in those physically active. We recommend that from childhood individuals are intentionally physically active. The exercise can be anything. It could be productive exercise such as farming or leisure activities such as climbing, exploring, swimming. What is required is to be physically active. There are many benefits of being physically active even in the elderly.
Q. Diet? There is an ideal food plate being recommended by WHO. What is the recommended diet per person according to age and immunity?
A. Sri Lanka also has adopted a food plate model for its population. Sri Lankans consume too much carbohydrate and too little vegetable and protein. Sri Lankan model plate recommends that for all meals less than half to be starch and the rest to be vegetable and protein. Too much carbohydrate leads to obesity and inflammation. Consuming more vegetable and protein improves general well being and helps maintain weight and glucose.
Q. Diabetes among children and adolescents is on the rise . How do we stop this trend?
A. This is very alarming and we recommend that parents take note of these starting from weaning food. Offering mixed meals to children rather than artificial foods as weaning food helps children to learn to eat a healthy meal. Parents should realize that in the form of treats we offer harmful food to children. The current culture of too much studying and too little physical activity breeds a batch of children who are vulnerable to illnesses.
Q. Finally, some useful tips for parents and students as an endocrinologist?
A. We have to go back to our roots and make life as natural as possible. Processed food, inactivity, too many chemicals have made us vulnerable and unhealthy.
Going back and rediscovering natural goodness of food and enjoying physical activity outdoor will give us a better quality of life. A wholesome life should be offered to children and this should start from the cradle.