Why is Stroke so common in Sri Lanka?

By Dr Harold Gunatillake - Health Writer

According to the Consultant Neurologist in Sri Lanka 1 in 100 people in Colombo has had a stroke. Prevalence of such a ratio is unbelievable and people, young and old should take notice of its seriousness.
Stroke in young adults is more common in India and Sri Lanka and the reasons for this are not well understood, according to a paper presented by Ranil De Silva, MBBS, MPhil,* Ranjani Gamage, MBBS, MD, MRCP,† Chandika Wewelwala, MBBS,* Dinusha Gunarathna, MBBS,* Steven Kittner, MD, MPH,‡ Dharshan Sirisena, MBBS, MD,† Anura Weerasinghe, MBBS, MD, PhD,§ and Pryani Amarasinghe, PhD//
It is considered a preventable disease, and why so many are affected is difficult to understand. Let’s discuss some risk factors.

Stress factors
In Sri Lanka, people of the low socio-economic group lead an over-stressed life with acceptance in accordance with the “karmic” theory.

When you are on the road going to work each day, you wouldn’t know whether you’ll come home safely. Driving a car on the roads is most stressful and annoying. Road rules are created by the road-users to their benefit, without caring for the fellow users. Most working class people travel by bus or train to work. Travelling by these means such by bus or train is more stressful and tiring. You are not sure whether you could catch the next bus to go home and the wait is quite anxious and frustrating. Buses are overloaded like sardines without much breathing space. On trains people hang-on even outside the train just to reach home with all its dangers involved. The carriages are jam-packed.

These stress factors, though not brought to light, known to the people, are the causes that lead to many chronic diseases, including stroke.

The wages of average workers are insufficient even to have a square meal with the family. Most people are ill and mal-nourished. This is part of stressful life living in a developing country. Humidity and the daily heat of an average 40Deg C. makes you feel tired and there is no inclination of even doing an evening walk as a form of exercise in places like Colombo.

This may be one of the reasons why stroke is common to all ages and not restricted to the over 60’s as before. The affluent class of people having a good life style also are open to chronic diseases including stroke, but the factors are different to those of the lower socio-economic groups.

Food-factors
People now have no time to cook in their respective homes. Both husband and wife need to work and meet at home quite late, unlike the old days when the wife anxiously waits till the husband comes home, to have a home-cooked meal in relaxed mood.

Whichever way you turn there are food outlets at every corner, a most flourishing business in Sri Lanka. This is the picture in the villages, too. What food do you find in these outlets- foods cooked with processed rice flour or wheat flour? Such foods are hoppers, indiappans, pittus, and rotties among others.

Food parcels cooked with white polished rice with meagre curries are sold on the pavements, quite cheap and very popular among the lower middle class city workers. These packets provide sufficient energy in calories, but nutritionally they are inadequate.

Fruits are generally expensive and most people do not eat even one serving per day. Smoking is less of a problem today among the people because spending money to buy a rice packet is more essential with the limited earnings. Walking as an exercise is seen in parks and walking paths especially by the rich folk and those who have had cardio-vascular disease including heart attacks. These are people who had no time to walk before such episodes and find the time after.

Road pollution, however much is being controlled, is a silent killing factor for cardiovascular and lung disease among the city dwellers. In the cities and outskirts people live by the main road-sides and railway lines, and they are exposed to pollutant contaminations.

Diabetes
Uncontrolled diabetes is the gateway to cardio-vascular and kidney disease. People do not take diabetes as a serious disease until complications such as kidney disease, peripheral vascular, and vision problem such as retinopathies occur, when the doctors find it difficult to reverse the situation.

Another problem most people have is there earnings are insufficient to maintain proper control to monitor their blood sugar levels with a glucometer and insulin seems to be out of reach of most average earners. So, the tendency is to take it easy until complications arise.

In most developed countries the diabetic associations subsidise the cost of diabetic strips and insulin injections and the needles. In Australia the needles are given free of charge. People in Sri Lanka do not read much about health issues in magazines and newsletters as prevalent in most developed countries. Even, at a railway station in most countries you could buy a health magazine to read whilst travelling. There is not much information given on mass media like the television channels, either.

Even, when doctors come on TV channels and give talks on health issues the language they use, especially in the Sinhala media, most average people cannot understand the high flown Sinhala words they use. There should be a health channel to provide alerts on health issues and the presentations should be more basic.

The common causes of risk factors for stroke are hypertension (high blood pressure), uncontrolled diabetes, transient ischaemic attacks (TIA) where the blood clots and segments of plaques travel from the heart and neck arteries to the brain, heart valve defects and irregular heart rates, obesity,  birth control pills and hormone replacement therapy. With education and change of lifestyles these factors that cause stroke can be prevented.

 The commonest cause being, not knowing the importance of checking your blood pressure regularly as one gets older. One fine day when the pressure is critically high a blood vessel in the brain bursts, and the regional brain cells are deprived of blood carrying oxygen molecules. This type of stroke is referred to as a ‘Haemorrhagic stroke’. How easy to prevent such episodes, if one is aware and checks their blood pressures by their local GPs’ regularly., or purchase a BP apparatus and check regularly in the home environment.

What is a stroke?
In Sri Lanka, it is not the common thought to take measures to prevent diseases by visiting the doctor on a yearly basis for a general check-up, except in the private sector where the companies subsidise the health bills. They wait for an episode and then visit the doctors, specialists and are subjected to paying big bills to the private hospitals. Even the lower socio-economic groups too prefer going to private hospital for specialised care by the government specialists after hours.

The other way one could get a stroke is due to a blockage of a brain vessel due to a travelling blood clot. These are also called ‘ischaemic strokes’ because the blood supply to the regional brain cells are deprived or reduced

The common types are thrombotic ischaemic strokes and embolic ischaemic strokes. In the thrombotic variety a blood clot forms in a brain artery due to a build-up of plaques, and in the embolic variety the clot travels to the brain from the heart or from a plaque in the carotid arteries. In younger people the embolic clot may be an early warning of a more serious episode. It is referred to as a ‘Transient Ischemic attack and is curable if taken to the hospital immediately.

Stroke symptoms
People must be educated to early detect the signs of a stroke.

Sudden numbness or weakness on one side of the body is an early sign of a stroke. Sometimes the victim can have sudden vision changes in one or both eyes or difficulty in swallowing. Some may start with a severe splitting headache, or feel dizzy and inability walk steadily. Difficulty to talk and confusion are other signs. You must call for the ambulance immediately because within 4 hours the doctors could reverse the process with little residual disability.

Whilst the ambulance is on its way, you should carry out some tests to verify. Ask the patient to smile: there will be a droop of the mouth on one side. Get the patient to raise the arms, and one side may side drift down.

When the patient is sent to Emergency Department in the hospital, the doctors need to differentiate between a haemorrhage and a clot. A CT scan will help to differentiate. Additional tests may also be used to find the location of a blood clot or bleeding within the brain. After the acute stage is over rehabilitation will be required for months to regain the ability to take care of them.

Prevention of strokes
Prevent stroke and disability is possible with a healthy lifestyle. Women seem to be higher at risk compared to men, and also more women die from stroke than men. “Women have more risk factors than men,” said European Society of Cardiology spokesperson Professor A John Camm, professor of clinical cardiology in the Cardiovascular and Cell Science Research Institute at St George’s University of London, UK.
Exercise daily and more physically active and maintain a healthy weight

Limit alcohol and salt intake. Eat a healthy diet with less saturated fats and sugar. Eat unprocessed whole grain foods. Plenty of vegetables and fish are recommended.

Antiplatelet drugs are recommended to keep the blood thin. High blood pressure seems to be the commonest cause of stroke. Keep your BP checked up regularly and medication taken, if required.

Remember, strokes are avoidable and 50% could be prevented. Start on a healthier lifestyle and visiting your GP to find out risk factors you have that need attention. Take action from today.

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