Background There is limited data on the prevalence and outcome of prediabetes (PDM) and the incidence of type 2 diabetes mellitus (T2DM) in South Asia. We investigated these in a prospective, community-based study involving a cohort of urban adults in Sri Lanka, with a seven-year follow-up. Methods Participants were selected by age-stratified random sampling, and were initially screened in 2007 and reevaluated in 2014. To assess the participants, structured interviews, anthropometric measurements, liver ultrasound, biochemical, and serological tests were performed on both occasions. Results 2985 individuals were recruited in 2007 [54.8% women, median age (IQR) 53 (47-59)]; 737 had T2DM [baseline prevalence 24.7% (95% CI: 23.1–26.2)] and 525 had PDM [baseline prevalence 17.9% (95% CI: 16.2-19.6)]. 2148 (71.6%) attended follow-up in 2014 [57.5% women; median (IQR) 60 (54–66) years], which included 1650 who did not have T2DM in 2007. By 2014, 436/1650 (27.6%) had developed new T2DM [annual incidence 3.9% (95% CI:3.0-4.9)]. On logistic regression, PDM, central obesity, dyslipidemia, and nonalcoholic fatty liver disease (NAFLD) at baseline showed significant association with new-onset T2DM. Of 525 with PDM in 2007, 365 (69.5%) presented for follow-up in 2014; 147/365 (40.3%) remained in PDM, 201/365 (55.1%) had progressed to T2DM and 17/365 (4.6%) had reverted to normoglycemia. Annual conversion rate of PDM to T2DM was 7.9%. Increase in waist circumference and low HDL from baseline predicted progression to T2DM. Conclusions Presence of features of the metabolic syndrome at baseline predicted new-onset T2DM and conversion of PDM to T2DM. Targeted lifestyle interventions are essential for individuals with metabolic risk to prevent future T2DM.

Background:Data on the alcoholic fatty liver (AFL) is limited. Therefore, we investigated alcohol use and AFL patterns among urban, adult Sri Lankans. Methods:The study population (selected by age-stratified random sampling) was screened in 2007 (35-64 years) and re-evaluated in 2014. They were assessed by structured interviews, anthropometric measurements, liver-ultrasound, and biochemical and serological tests. AFL was diagnosed on ultrasound criteria, 'unsafe' alcohol consumption (Asian standards: males>14units, females>7units per week) and absence of hepatitis B/C markers. Controls were unsafe alcohol consumers who had no fatty liver on ultrasound. Results:2985/3012 (99%) had complete data for analysis. 272/2985 (9.1%) were unsafe-drinkers in 2007 [males-270; mean-age-51.9, SD-8.0 years]. 86/272 (31.6%) had AFL [males-85; mean-age-50.2, SD-8.6 years]. Males [p<0.001], increased waist circumference (WC) [OR 4.9, p<0.01] and BMI>23kg/m2 [OR 3.5, p<0.01] and raised alanine aminotransferase (ALT) [OR 2.8, p<0.01] were independently associated with AFL. 173/272 (63.6%) unsafe alcohol consumers from 2007 were re-evaluated in 2014. 134/173 had either had AFL or had changed to 'safe' or no alcohol consumption. 21/39 (53.8%) [males-21 (100%), mean-age-57.9, SD-7.9 years] who remained 'unsafe' alcohol users who had no fatty liver in 2007 developed AFL after 7-years (annual incidence 7.7%). On bivariate analysis, only males were associated with new-onset AFL. Of the 42 who had AFL at baseline but changed their drinking status from unsafe to safe or no alcohol, 6 had resolution of fatty liver in 2014. Conclusion:In conclusion, in this community-based study among urban Sri Lankan adults, the annual incidence of AFL among unsafe alcohol users was 7.7%. Furthermore, new-onset AFL was associated with males.

Background There is limited data on prevalence and outcome of prediabetes (PDM) and incidence of type 2 diabetes mellitus (T2DM) from South Asia. We investigated this in an urban, adult population in Sri Lanka that was followed-up for seven years. Methods The study population (selected by age-stratified random sampling from the community) was initially screened in 2007 and re-evaluated in 2014. On both occasions they were assessed by structured interview, anthropometric measurements, liver ultrasound, biochemical and serological tests. Results In the original cohort of 2985 recruited in 2007 [54.8% women, median age (IQR) 53 (47-59)], 737 had T2DM [baseline prevalence 24.7% (95% CI: 23.1–26.2)] and 525 (17.7%) had PDM [54.1% women, median age (IQR) 56 (50-60)]. 2148/2985 (71.6%) attended follow-up in 2014 [57.5% women; median (IQR) 60 (54–66) years], which included 1650 who did not have T2DM in 2007. By 2014, 436/1650 (27.6%) had developed new T2DM [annual incidence 3.9% (95% CI:3.0-4.9). On logistic regression, PDM, central obesity, dyslipidemia and non-alcoholic fatty liver disease (NAFLD) showed significant association with incident T2DM. Of 525 with PDM in 2007, 365 (69.5%) presented for follow up in 2014; 147 (40.3%) remained in PDM, 201 (55.1%) had progressed to T2DM and 17 (4.6%) had reverted to normal. Annual conversion rate of PDM to T2DM was 7.9%. Increase in waist circumference and decrease in HDL predicted progression to T2DM. Conclusions Presence of components of the metabolic syndrome at baseline predicted new-onset T2DM and conversion of PDM to T2DM. Targeted lifestyle interventions are essential for individuals with metabolic risk to prevent incident T2DM.

Objective To describe patterns and predictors of mortality in a semi-urban population in Sri Lanka. Design A prospective population-based cohort study. Setting Ragama Medical Officer of Health area in the Gampaha district, Sri Lanka. Participants Adults between 35 and 64 years of age were recruited using an age stratified random sampling technique in 2007. Measures At baseline, we recorded socio-demographic, lifestyle, anthropometric, biochemical and clinical data of the participants. Over 10 years, we obtained the cause and date of death from the death registration documents of deceased participants. We determined the survival probability of the cohort over 10 years and estimated Hazard ratios (HRs) for all-cause mortality (ACM), cardiovascular mortality (CVM) and cancer-related mortality (CRM) using Cox's proportional hazards model. We also estimated the survival probabilities for men and women in each 10-year age group and standardised mortality ratio relative to the source population. Results There were 169 deaths over 10 years with standardised mortality rates of 5.3 and 2.4 per 1000 years of follow-up for men and women, respectively. Independent predictors of: ACM were older age, lower income, smoking and diabetes mellitus while gender, education, occupation, harmful alcohol use, waist circumference and hypertension were not; CVM were older age, lower income, smoking, diabetes and hypertension while gender and harmful alcohol use were not; CRM was older age while gender, smoking and diabetes were not. Those engaged in clerical and technical occupations or unemployed had a lower risk of CRM as compared with those engaged in elementary occupations. Conclusions Older age, lower income, smoking, diabetes and hypertension strongly predict mortality in this cohort. Addressing the identified modifiable predictors through behavioural modification will improve longevity in similar populations.

Background Data on outcomes of non-alcoholic fatty liver disease (NAFLD) from South Asia are lacking. We compared mortality, among those with- and without-NAFLD, after 10-years follow-up among urban, adult Sri Lankans. Method Participants (aged 35-64 years), selected by age-stratified random sampling, were screened by structured-interview in 2007. Anthropometric measurements, liver ultrasonography and biochemical/serological tests were done. NAFLD was diagnosed on ultrasound criteria, safe-alcohol consumption (Asian-standards) and absence of hepatitis B/C. Subjects without NAFLD were those without any ultrasound criteria of fatty liver, safe-alcohol consumption and absence of hepatitis B/C. The cohort was re-evaluated to assess mortality in 2017. Participants or their households were contacted by telephone/post, and deaths confirmed by home-visits and death certificate review. Cox-regression was used to determine predictors of all-cause mortality (ACM) and cardiovascular mortality (CVM) in those with- and without-NAFLD. Results 2724 (91.2%) of 2985 original participants were contacted (851-with NAFLD and 1072-without NAFLD). Overall there were 169 (6.2%) deaths [41-deaths among NAFLD (17-cardiovascular; 9-cancer-related; 4-liver-specific; 11-other) and 79-deaths among no-NAFLD (28-cardiovascular; 17-cancer-related; 1-liver-specific; 33-other)]. Metabolic syndrome (MetS), low-education level, higher age and male-gender independently predicted ACM. MetS, increasing age and male-gender independently predicted CVM. NAFLD did not predict either ACM or CVM. In those with NAFLD, MetS and age >55-years were independently associated with ACM, while MetS and male-gender were associated with CVM. Conclusion In this community-based study, increasing age, male-gender and MetS, but not NAFLD, predicted 10-year ACM and CVM. Among those with NAFLD, only those metabolically abnormal were at a higher risk for mortality.

Background There are few studies investigating the natural course of non-alcoholic fatty liver disease (NAFLD) in the community. We assessed resolution of NAFLD in a general population cohort of urban Sri Lankans adults. Methods Participants were selected by age-stratified random sampling from electoral lists. They were initially screened in 2007 and re-evaluated in 2014. On both occasions structured interview, anthropometric-measurements, liver ultrasonography, and biochemical/serological tests were performed. NAFLD was diagnosed on ultrasound criteria for fatty liver, safe-alcohol consumption (<14-units/week for men, <7-units/week for women) and absence of hepatitis B/C markers. Non-NAFLD was diagnosed on absence of any ultrasound criteria for fatty liver and safe-alcohol consumption. Resolution of NAFLD was defined as absence of ultrasound criteria for fatty liver. Changes in anthropometric indices [Weight, Body-Mass-Index (BMI), waist-circumference (WC), waist-hip ratio (WHR)], clinical [systolic blood pressure (SBP), diastolic blood pressure (DBP)] and biochemical measurements [Triglycerides (TG), High Density Lipoprotein (HDL), Total Cholesterol (TC), HbA1c%] at baseline and follow-up were compared. Results Of the 2985 original study participants, 2148 (71.9%) attended follow-up after 7 years. This included 705 who had NAFLD in 2007 and 834 who did not have NAFLD in 2007. Out of 705 who had NAFLD in 2007, 11(1.6%) changed their NAFLD status due to excess alcohol consumption. After controlling for baseline values, NAFLD patients showed significant reduction in BMI, weight, WHR, HDL and TC levels and increase in HbA1c levels compared to non-NAFLD people. Despite this, none of them had complete resolution of NAFLD. Conclusion We did not find resolution of NAFLD in this general population cohort. The observed improvements in anthropometric, clinical and biochemical measurements were inadequate for resolution of NAFLD.

Background and aims: The Neonatal Behavior Assessment Scale (NBAS) was introduced by Brazelton is a useful tool to assess neurodevelopment in newborn in research setting. However, it is complex, time-consuming and requires specialized training for administration and is therefore difficult tool to use in routine clinical settings. The Alberta Infant Motor Scale (AIMS) is a simple tool to assess of motor maturation of a child up to 18 months and can be administered with minimal training for the health care professionals. The study goal of this study was to evaluate the reliability and validity of the AIMS in comparison with the NBAS in assessing motor maturity at birth. Methods: We administered the AIMS and NBAS to a total of 66 newborn babies delivered in three obstetric units at the Colombo North Teaching Hospital in Ragama, Sri Lanka. The subjects were selected from a sample of 545 newborn babies in an ongoing birth-cohort study evaluating effects of prenatal exposure to biomass smoke and infant neurodevelopment. Trained research assistants administered first the NBAS, followed by the AIMS one-hour later. Univariate and bivariate statistics were used to compare the two scales.Results: Irrespective of maturity, sex, birth weight or socio-demographic characteristics, all babies had scored on the 75th percentile in the AIMS. In the NBAS, there was a significant variation in the Brazelton motor score scaled to 100. Low birth weight babies showed a narrower variation in the NABS score. None of the scales indicated a motor deficit in any of the children.Conclusion: NBAS identifies subtle differences in motor maturity of full term babies that the AIMS fails to detect.