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Shifting paradigms in diabetes care

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Today is World Diabetes Day

The prevalence of diabetes worldwide has nearly doubled since the 1980s. Globally about 422 million people have diabetes according to the World Health Organization and the majority of them live in low and middle-income countries. Around 1.5 million deaths are directly attributed to diabetes each year. A century after the discovery of insulin, millions of people with diabetes around the world still cannot access the care they need.

In this setting the theme for World Diabetes Day 2021-23 has been declared- ‘Access to Diabetes Care.’ The management of diabetes has today taken a shift involving a more holistic approach, points out Consultant Endocrinologist at the Sri Jayewardenepura General Hospital, Dr. Dimuthu Muthukuda. In an interview with the Sunday Island, she throws light on these shifting paradigms which are aimed at enhancing the quality of life of those with diabetes.

by Randima Attygalle

Q: How relevant is this year’s theme ‘Access to Diabetes care’ in a Sri Lankan context?

A: Since the discovery of insulin in 1921, there had been many strides forward in terms of the varieties of insulin – both oral and injectable. Today there are both national and international guidelines pertaining to diabetes care. Despite these, people with diabetes all over the world are challenged in accessing diabetic care. We are at a satisfactory level in delivering diabetic care within our freely accessible and well-structured health care system. Our limiting factor is the non-availability of the ideal device for insulin delivery which is the insulin pen. What we have in the state health sector for cost reasons is still the syringe and the needle. However, we are constantly improving our services for increased accessibility.

Q: What is the current ‘diabetes picture’ here at home?

A: In terms of the numbers, our situation is quite alarming. Recent studies show that the prevalence of diabetes in suburban areas of the island is about 20%. The situation in the rest of the South East Asian countries is no better. The major triggers of diabetes in our part of the world are obesity and being overweight. Today obesity has reached pandemic proportions and is as dangerous as COVID. Worse, there is a sizeable proportion of school children with diabetes.

The accumulation of fat in the abdomen which is called ‘abdominal or central obesity’ is common among South East Asians. This reflects the tendency for a person to develop diabetes. The other major risk factor is insulin resistance. This condition is closely linked to obesity and diabetes and this inter-connectivity leads to a very vicious cycle.

A few decades ago when we talked of a person with diabetes, it was a middle-aged or an older person that we visualized. This is no longer the case. Today many children, adolescents and young adults are diabetics.

Q: What are the most common types of diabetes?

A: Type 1, Type 2 and Gestational diabetes are the common types. In Type 1, the body does not produce any insulin and there is life-long insulin dependency. Very often children under 10 years develop this type although symptoms could occur in adolescence as well.

Type 2 is the most common, where the body does not use insulin which is produced by the pancreas effectively. This insulin resistance is also attributed to obesity where insulin is prevented from working well at tissue-level. Although Type 2 is called ‘adult-onset diabetes,’ today we see many young people developing it giving enough time to develop other complications. After about 10-15 years of having Type 2 Diabetes, the pancreas can get exhausted and it could stop producing insulin. Therefore initially although a person can manage Type 2 with drugs, later he/she may need insulin as well.

Diabetes during pregnancy is what is known as gestational diabetes. The long term consequences of this type could be serious. If a pregnant woman has gestational diabetes, there is a 50% chance of her children getting it. There is also the risk of children being obese. This is why we say that when we manage diabetes of an expectant mother, we also manage the condition in the next generation.

Q: Who are at high risk of developing diabetes?

A: Being a South Asian per se is a risk factor. Besides that, being overweight or obese, appearance of blackish velvety skin behind the neck, having a family history of diabetes (children whose both of whose parents have diabetes have more than 75% chances of developing the disease) and children of mothers with gestational diabetes and people who are on certain drugs such as steroids are at high risk.

Q: Can you throw light on the new interventions in managing diabetes?

A: Today the global trend is to look at the condition from a positive perspective. The traditional understanding was that the moment a person is diagnosed with diabetes, he/she becomes a ‘diabetic’ or a ‘diabetic patient’. Imagine a person being diagnosed at 15 or 20 with diabetes; are we going to call that person a ‘diabetic’ for the rest of his/her life? What will be his/her social and psychological well being in that case? Today diabetes is considered as a condition which you need to manage. Instead of calling ‘diabetics’ or a ‘diabetes patients’ we call them ‘individuals with diabetes’.

A few decades ago the most feared thought was going on a ‘diabetic diet’. Today we are talking of a healthy diet for everyone in the family; we are talking about giving advice to the whole family because it has to be essentially a family affair. For instance, you are going to cook a healthy meal for the entire family and not only for the member with diabetes.

The pharmacological management landscape of diabetes has also changed. Instead of the gluco centric approach which looked only at glycemic or sugar control, today a holistic approach is in place which is known as ‘cardio-renal’ approach. This looks at reducing cardio-renal complications (kidney and heart related complications). Although morbidity and mortality due to diabetes is largely heart attacks, the root cause is underestimated because the cause of death goes as ‘heart attack’ and most of these heart attacks can be prevented. To strengthen the cardio-renal management of people with diabetes, our health sector is trying its best to make the latest cardio-protective drugs available in government hospitals.

In diabetes management, we not only address sugar levels but the entire spectrum of micro vascular and macro vascular complications. When diabetes is mismanaged both small (micro) and big (macro) vessels can be damaged. While micro vascular damage will involve the retina of the eye, kidneys and nerves, macro vascular damage will lead to stroke, heart attack and peripheral vascular disease. As Endocrinologists, our ultimate goal is to prevent people from getting micro and macro vascular diseases. To realize this, we encourage people with diabetes to monitor their blood glucose levels at home using glucometers. It is imperative that they have good metabolic control and healthy cholesterol levels. Diseases such as ischemic heart disease and non-alcoholic fatty liver should also be kept at bay. Then only can we prevent amputations and even death. Today we look at the bigger picture.

Another new trend is what we call ‘diabetes remission’. New clinical trials have shown that in case of recent onset of diabetes, if a person is able to lose weight coupled with a healthy diet and exercise and also with the use of drugs such as Metformin, a person can go into a remission for a long period of time with a fully normalized blood sugar levels.

Q: What measures are in place to empower people with diabetes, so that they become independent and can improve their quality of life?

A: Sri Lanka College of Endocrinologists (SLCE) carries out many educational programmes including training of trainers and health care personnel. Guidelines are also developed by the SLCE.

Education and awareness is very much a part of Endocrinology Units of state hospitals today. We look at the entire metabolic picture and deliver a comprehensive diabetic care delivery through our clinics.

Q: What is the role of diet and exercise in preventing and managing diabetes?

A: Eating in moderation is the key and rather than what you eat, you need to be mindful of how you eat. Managing portions is crucial here. Our plate should ideally have 1/4th of rice and the rest should be green leaves, fish, etc. People should also be more creative and intelligent in their food choices. Mixing food which contains more sugar with fibre-rich food for example, can be a smart way of eating. It is not realistic to stay away from delicacies during festive seasons, nor depriving a child of sweets; the key is enjoying what you like in moderation. Eating fruits in between meals is encouraged so that they serve the dual purpose of having a snack as well as fulfilling the daily fruit requirement. Processed food and fast food should be minimal.

In terms of exercise, we encourage at least half an hour of physical activity such as brisk walking, cycling, swimming or aerobics, at least five days a week. Exercising itself can help minimize insulin resistance.

Even people with disabilities are encouraged to exercise their muscles while being seated or lying down.

Q: What challenges do you see for people with diabetes during the pandemic and how can they be mitigated?

A: When a person has poorly controlled diabetes, his/her immunity is compromised and chances of catching infections are very high. So it is essential that people manage their diabetes and take their drugs diligently. Mismanaged diabetes can result in COVID pneumonia. Even during the lockdowns, we ensured that drugs reached people and most clinics operated uninterrupted in the best interest of the public.

We see more people becoming sedentary during the pandemic. Both children and adults are spending a considerable time before computer screens with little or no exercise. This could make them susceptible to obesity which is a precursor to diabetes. Hence, children should be encouraged to indulge in some kind of physical activity and even adults should regularly take breaks from their desks and take a short walk around.

Q: Finally, how important do you think it is to adopt a multidisciplinary approach to combat diabetes instead of making it the sole responsibility of the health sector?

A: Although management of diabetes has to be customized, it is very crucial that we have a multi modal approach with the participation of schools, policy makers, employers and media to prevent the numbers from escalating. Today we have the traffic light system for certain foods, however there is still a question of consumer literacy. We also see children being the target of advertisers and there is a need for regulation here. Hence it is imperative that all stakeholders get together in preventing diabetes which could take a toll both on individual productivity as well as the health sector.



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It all began in the late 19th Century…

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During the time of British Imperialism when the Sinhalese were on the verge of losing their innate Sinhala Buddhist identity, and with the growth and expansion of the Christian missionary education in Ceylon, the need arose to educate them by combining the English language as a medium of education.

Amid religious restlessness, Sinhala Buddhist elites, some of who were heavily influenced by the Theosophical Society, stepped forward and became the life-blood of the Sinhala -Buddhist revival movement. Realizing the need and the necessity to empower young Buddhist girls on par with the missionary education, Mr. William de Abrew, a philanthropist and an affluent member of the Theosophical Society, followed by his son Mr. Peter de Abrew took the initiative to form a new structured educational institute in Cinnamon Gardens. They recognized the talents and administrative skills of the German born Educationalist, Mrs. Marie Musaeus Higgins who was also a part of the Theosophical society to commission the school, which they named, Musaeus Buddhist Girls’ School.

In 1891, Musaeus College was born in a simple mud hut with a thatched roof, with 12 girls. With time, it evolved into a grand edifice formed on a firm foundation laid by our Founders, Mrs. Marie Musaeus Higgins, Mr. Peter de Abrew, Col. Henry Steel Olcott and Ms. Annie Besant. At present, Musaeus College houses over 6,500 students and an academic faculty of 362. Both the National and British Curricula are followed by giving our students an opportunity to expand their horizons in this fast-paced competitive world.

Musaeus College amidst challenges and obstacles

The Easter Sunday attacks in April 2019, followed by the pandemic situation soon after, disrupted the smooth functioning of schools and created a standstill in all aspects of our lives. Being visionaries, the management of Musaeus College, had already implemented digitalization of teaching and learning of the school, by purchasing Smart Boards and offering teacher-training, unaware that this will be a blessing in disguise during this unforeseen time. Thirty Master- Teachers had already been given training in this field and were well- geared to this challenge of using online platforms for teaching, learning and testing, by the time Covid 19 afflicted our island. Since the teachers were well equipped with the tech- knowledge, within a short span of time Muasaus College launched Microsoft Teams as their digital platform as soon as lockdowns were imposed. With this, Musaeus College became a pioneer and a model school where a virtual, structured, and formal teaching plan was implemented from the Lower Nursery classes to the Advanced Level classes.

By this time the College was in the forefront in completing the academic curriculum and received much praise from the school community and the general public.

We went a step ahead by introducing an evaluation system for all grades, paying special attention to students who were preparing for National and International academic examinations such as GCE O/L, GCE A/L, Cambridge, and Pearson Edexcel examinations.

The constant lockdowns at different time periods restricted our functioning and this had a huge negative impact on our students whose carefree school life had come to an abrupt halt. The teachers, understanding their students’ plight, took the initiative to continue with the extra-curricular activities and sports training through virtual platforms. Presently the school has more than 25 clubs and societies and many of these organized virtual Intra-school and Inter-school events. The students participated in International Competitions and won World Prizes.

A virtual Vesak festival, Debating Competitions, most Inter-House Competitions, Young Inventors, Wild Life Conservation seminars, five-day virtual Guide Camp, motivational sessions, and student Power Hours etc. were continued uninterrupted. Further, many other activities such as text book distribution, admission interviews, plant distribution for the newly admitted Grade 1 students and even an all-night Pirith Ceremony in memory of our Founders were conducted virtually and Drive Thru modes. The highlight of this was the ‘Drive Thru Prize Giving’ where 742 students received their prizes.

As Musaeus College reaches another milestone in her long epic journey of 130 years, we pledge to continue to carry forward the vision and legacy of our Founders into the future.

Long live Musaeus College.

Musaeus College celebrates

130 years of excellence

By Principal, Mrs. Nelum Senadira

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The Garden School

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Musaeus College in the 1970s shrouded and static in time, when my mind voyages among the gossamer memories of girlhood, to scale those high and hefty walls of that stronghold of discipline – that kept the girls locked in, (and perhaps, any romantic notions locked out?)

Beyond the ice dome of the Shrine Room with its single Wathusuddha plant, through the emerald green Tunnel alongside the Courtyard of exotic orchids the Reception Counter with its black dial-up telephone to the right; always alert – to the Parlor and Principal’s Office beyond opposite the cream-tiled Dining Hall; now regaled by the cords of a piano from the Western Music Room

(with its elaborate white metalwork cage); fronting the five-storied new building – its top floor inviting surreptitious morning siestas with an eye open for raids by prefects and teachers.

Thereafter, arrested,

by the aroma of deep-frying Chinese Rolls; to taste that distinctive Onion and Green Chili Fish Paste of the Tuck Shop Sandwich…

Then, in the distance, lecture theatres

and science laboratories outfitted with Bunsen Burners and a myriad of glass: beakers, droppers, test tubes, cylinders and syringes; overlooking the washing of white and navy blue cotton hung to dry.

Following the fawn grounds of the Tennis Courts to the left, across the walkway of a charming mosaic design to the Quadrangle of grass (lush at the beginning of term but somewhat threadbare towards the end – with the toll of dreaded PT, athletics, netball, and hockey); bordered by a pastel rainbow of classrooms, to halt – by that perimeter of flora and foliage

(a no-go, no-girls’ land for us).

Between the ornate wrought-iron palisade

(visited by a black Koha with a steadfast scarlet eye) and the simple white paling – a kaleidoscope of tropical tones and tinctures: riotous Bougainvillea and Hibiscus of every hue, the golden cascades of Ahala, swatches and strips of Barbertons, Ixora, Das Pethiya; faces and tongues of candy-red Anthuriums; fiery Heliconia hanging down; where once a Peacock was perched on the Takarang roof.

The spectacle too lurid to my liking at the time, but now recalled with the attachment of loss.

Passing by old Parakumba (or was it some unknown mysterious sage?) holding a sheaf of Ola leaves (which the girls chose to see as a slice of Papaya), shaped out of the gloomy-grey, phony-rock beside the pink lotus pond – was it to epitomize the education of men?

Even then, it occurred to me where were the role models of erudite women?

Then, the solid wooden doors of the Art Room en route to the lime-green radiance of the two-storied Library Chamber lined with books upon books upon books, with the central spiral staircase leading to more worlds of words, long before the universe of the world wide web and internet.

Turning left to the Nursery adorned with characters of rhymes across from the shrubberies and greenery surrounding the half-circle of the white lotus pond, to the line of classrooms in the Western Boundary and sometime later, to the abundant vegetable beds of tender Ladies’ Fingers, deep-coloured Egg Plants, red Chilis as well as Plantain Trees laden with ripening Bananas.

Turning right to the Main Hall, the wooden stage which had seen the performances of many fledgling singers, orators, actors, dramatists, debaters and dancers; flanked by the pure white marble busts of Marie Musaeus Higgins and Colonel Henry Steele Olcott (enclosed in glass cabinets); and a sepia photograph of Peter de Abrew, but not of Annie Beasant – surprisingly missing…

The Theosophists whose philosophical vision led to the realization of a school for girls in the year 1891 – an autonomous citadel with its own hostel, kitchens, laundry, sickroom, sewingroom, potteryroom, boutique and bakery.

With that – I leave you with a topography of Musaeus, that garden school – now effaced and even replaced …. but perennial – in my mind.

Maithree Wickramasinghe

Past Pupil

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Lihini Fernando – being the change she wants to see

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by Zanita Careem

Lihini Fernando does not come from a political family, neither does she have political wealth to sustain her. However, it did not deter her from pursuing her passion to be the change she yearned to see in Sri Lanka.

An attorney-at-law, Lihini believes in empowering women as an empowered woman is living statement. Meeting her offers an opportunity to be amazed at a person who has enormous energy and infectious enthusiasm.

She traces her interest in politics from her school days. “I have always been vocal about discrimination in society and the injustice caused to women and children. Heading her own legal firm- Velox Partners, with a few other lawyers, as well as being an achiever at the 2021 Women in Management Awards in which she was awarded the ‘Inspirational Woman of the Year’ award for the category; Emerging Woman Politician, she also works in the family business of advertising and furniture.

What is remarkable about her is her belief that women have the capability to ‘stretch themselves’ above and beyond the status quo.

Passion for politics

Lihini also spoke on what inspired her to become a politician. Today she is a Municipal Councilor from Moratuwa. “I took up politics because of my passion for it and the passion for change,” said Lihini, emphatically quoting Mahatma Gandhi’s words- ‘be the change you wish to see in this world.’

Working with people at the grass root level and advocating social causes is indeed rewarding says Lihini. “Only honest, committed educated and capable people can change the political landscape of women in politics,” says Lihini calling for more women to take the centre stage in politics.

Specifically in Sri Lanka’s 2019 post-COVID context, the brunt of the ethnic war is borne by women who lost their loved ones across the ethnic divide, suffering debilitating loss whether psychological or economic. The real challenge for Lihini is the need to build up women for political leadership in order to foster and inculcate a capable and emphatic government. She strongly believes that women are the live wire, the decision maker, the strength of every family and hence they have the potential to be a decisive factor in decision making be in politics or the corporate sector.

Lihini is confident that Sri Lanka can address gender related issues. Women make up more than half of the population and in terms of eligible voters they lead men at 56% and outnumber males at Universities at 54%. Despite these impressive statistics, the representation of women in the active labour force is just 35%, reflecting the disappointing scale of gender inequality and discrimination against women, laments the young social and political advocate.

“There is very little done to address the wide discrimination against women or to provide them protection and empower them to be equal partners in the country’s growth and progress,” reflected Lihini emphasizing that women can support any decision-making role in the country and can even change dynamics of politics as well if given a chance.

As to why female representation in the economy and even politics is low, she responded: “the main reasons for that is the conventional stereo typical roles assigned and imposed on women as wives and mothers. We take pride in having the first woman Prime Minister in the world but our society still assigns separate roles for women and men and hence place severe constraints. We need to be encouraging and supporting, so women do not feel intimidated by politics perpetuated by the ruling class. There is nothing better than to see more women representation in Parliament. Sri Lanka still has hope. People can and must eradicate corrupt officials and hold leaders to account. Your right is not limited to a vote,” remarked Lihini in conclusion.

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