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Understanding diabetes in Singapore

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With the introduction of CHAS Green, all Singaporeans – regardless of income bracket – are eligible for subsidies for chronic conditions such as diabetes at GP clinics.

Public and private healthcare providers continue to partner to tackle this national health issue. The long-term management of diabetes is indeed costly and inconvenient, resulting in poor management of the disease. The expansion of CHAS is timely, inclusive and helps to flag that inadequate management and poor education will impact many individuals. Individuals with borderline diabetes must take active steps to reduce their risk of progressing to the next stage of the disease in the coming years.

The Active Age spoke with Dr Chua Chong Bing, a Family Physician from Healthway Medical (Lengkong Tiga) about diabetes. This is part one of the Q&A.

The Active Age (AA): What does it mean to be prediabetic?

Dr. Chua: Prediabetes is a precursor to diabetes, and it should be considered as a warning sign. An individual is considered pre-diabetic if his/her blood glucose level (blood sugar level) is higher than normal but it is not high enough to be considered diabetes.

A fasting blood sugar test is one of the common ways to test for diabetes. To ensure an accurate reading at the blood test, a blood sample is taken after you fast for at least eight hours overnight. A fasted sugar level between 6.1 – 6.9 mmol/l1 is considered prediabetes, and anything above 7.0 mmol/l indicates type 2 diabetes.

Additional tests such as an oral glucose tolerance test can also be done to measure the blood sugar level 2 hours after 75g of glucose have been consumed. A level of 7.8 – 11.0 mmol/L is considered prediabetes as well. Anything more than 11.1 mmol/L is considered to be diabetic.

Prediabetes is an indication that you could develop full-blown Type 2 diabetes if you do not make immediate and lasting lifestyle changes. Some ways to prevent prediabetes from developing into Type 2 diabetes include making healthy decisions for your diet, maintaining a healthy weight, and by incorporating exercise in your daily lives. It is always recommended to consult your family physician regularly to track your progress and take appropriate action where necessary.

AA: What is the definition of Type 1 and Type 2 diabetes?

Dr. Chua: There are three main types of diabetes. Type 1 diabetes occurs when the body does not produce enough of the hormone insulin, the hormone that tells cells in the body to receive sugar from the blood. Without enough insulin, glucose cannot enter the cells and thus, remain
in the bloodstream. Type 1 diabetes can occur at any age but it is more common in children and young adults. Its exact cause is still unclear, but it is likely to be due to both genetic and environmental factors, which leads to the destruction of the cells that are in charge of manufacturing the hormone insulin.

A person with Type 1 diabetes will need to take insulin for the rest of their life as they have no natural ability to produce insulin. Not doing so can result in ever-increasing blood sugar levels and dangerous complications.
There are more children with Type 1 Diabetes than Type 2 Diabetes in Singapore. However, the prevalence of Type 2 diabetes in children is increasing due to a widespread increase in childhood obesity.

The most common form of diabetes is Type 2 diabetes. In Singapore, Over 90% of diabetics suffer from Type 2 diabetes. With Type 2 diabetes, the pancreas usually produces some insulin. However, the amount produced is either not enough for the body’s needs, or the body’s cells are resistant to it.

People who are obese are at particularly high risk of developing a number of chronic diseases, including Type 2 diabetes and its related medical problems.

According to the World Health Organization (WHO), the body mass index (BMI) is a tool measuring overweight and obesity. Taking weight and height into account, the BMI represents different levels of health risks. An individual is considered obese if his/her BMI is more than 28.

The third type of diabetes is the Gestational Diabetes Mellitus (GDM). GDM is a form of diabetes that develops during pregnancy. It occurs either when a mother is unable to produce enough insulin, or the insulin is not working well enough to cause glucose to enter cells. This leads to excess glucose in the bloodstream, which can be passed on to the baby.

According to a study done by the Agency for Care Effectiveness at the Ministry of Health in Singapore, up to one in five women are at risk of GDM, which puts them at an increased risk of certain conditions during pregnancy. This health risks include higher birth weight of the baby, premature birth, low blood sugar levels in the baby during birth and the development of high blood pressure.

Gestational diabetes typically goes away following pregnancy. A doctor will check the woman’s blood sugar levels shortly after delivery and then again within 6 weeks. For mothers who have had gestational diabetes, they are at risk of developing Type 2 diabetes later in life.

AA: How do you track and interpret your blood glucose levels, even for those without diabetes?

Dr. Chua: If you do not have diabetes, then tracking your blood glucose levels daily will not be necessary. Screening for diabetes is recommended for adults who have an increased risk of having diabetes, or at age 40 for those without any risk factors. A fasting blood glucose level drawn at the doctor’s office can determine if one has diabetes or not.

If you do have diabetes, tracking will help you understand your condition and how different foods, medications, and activities affect your condition. If you take insulin to manage your diabetes, your doctor may recommend blood sugar testing a few times a day, depending on the type and amount of insulin you use.

Testing is usually recommended before meals and at bedtime if you’re taking multiple daily injections. If you manage Type 2 diabetes with oral medications or with diet and exercise alone, you may not need to test your blood sugar daily.

Testing for your blood glucose levels can be done with a monitor called a glucometer. These work by analysing a small amount of blood, usually from your fingertip. To begin, you must first prepare the glucometer. Every box of test strips for the glucometer will come with a code key. The glucometer needs to be coded with a new code key each time a new box of test strips is opened. Once this is done, wash and dry your hands thoroughly, or disinfect your finger with an alcohol swab. Obtain blood sample from the disinfected finger by using the lancet to prick the tip of the finger and hold a drop of blood to the edge of the strip. Depending on the type of glucometer used, place the test strip with the blood sample into the meter. Your blood glucose result will be displayed on the screen usually within a minute.

All diabetics should ideally track their fasting blood glucose levels and their HbA1c2 levels to track how well their sugar is maintained over a period of time at the doctor’s office twice a year. More frequent blood tests to track progress is necessary if there have been recent therapy changes or worsening of diabetes. This will ensure optimum levels of treatment is given and to perform necessary tweaks to their treatment programme to achieve target levels.

AA: What are some unexpected risk factors or warning signs for diabetes?

Dr. Chua: Type 1 diabetes is classified as an autoimmune disease. An autoimmune disease means that your immune system sees your body’s own tissue as foreign invaders and attacks itself. In the case of Type 1 diabetes, the pancreas is unable to make insulin because the immune system is attacking it and destroys the cells that produce insulin.

Researchers are still working to fully understand what causes or triggers Type 1 diabetes, and without any conclusive findings, it is currently difficult to prevent the disease. However, patients who have family history of Type 1 diabetes are at risk of getting the disease.

The onset of Type 2 diabetes can be gradual, and symptoms can be mild during the early stages. As a result, many people may not realise that they have the condition. Anyone can develop Type 2 diabetes, but certain factors can increase a person’s risk. These risk factors include:

  1. Being 45 years of age or older
  2. Living a sedentary lifestyle
  3. Being overweight or obese
  4. Eating an unhealthy diet
  5. Having a family history of diabetes
  6. Gestational diabetes
  7. Polycystic ovary syndrome

The risk factors for developing Gestational Diabetes Mellitus is similar to developing Type 2, but also includes:

  1. Being pregnant at 35 years of age or older
  2. A past history of diabetes in pregnancy
  3. A past history of delivering big babies that are heavier than 4kg
  4. Suspected macrosomia, a term to describe when a baby larger than average at a particular gestational age
  5. History of unexplained stillbirth: Most patients do not present with symptoms when they first have diabetes.

This makes it difficult to detect. However, some symptoms can manifest, and they include:

  1. Frequent urination: When blood sugar levels are high, the kidneys try to remove the excess sugar by filtering it out of the blood. This can lead to a person needing to urinate more frequently, particularly at night.
  2. Increased thirst: The frequent urination that is necessary to remove excess sugar from the blood can result in the body to lose water. Over time, this can cause dehydration and lead to a person feeling more thirsty than usual.
  3. Always feeling hungry: People with diabetes often do not get enough energy from the food they eat. The digestive system breaks food down into a simple sugar called glucose, which the body uses as fuel. In people with diabetes, not enough of this glucose moves from the bloodstream into the body’s cells as the body is not responsive to insulin. As a result, people with Type 2 diabetes often feel constantly hungry, regardless of how recently they have eaten.
  4. Feeling very tired: Type 2 diabetes can impact a person’s energy levels and cause them to feel very tired or fatigued. This tiredness occurs because of insufficient sugar moving from the bloodstream into the body’s cells and dehydration from the increased urination.
  5. Blurry vision: An excess of sugar in the blood can damage the tiny blood vessels in the eyes, which can cause blurry vision. This blurry vision can occur in one or both eyes and may come and go. High levels of glucose in the blood can also cause glucose to accumulate in the lenses of the eyes which can affect one’s ability to focus on an object.If a person with diabetes goes without treatment, the damage to these blood vessels can become more severe, and permanent vision loss may eventually occur.
  6. Slow healing of cuts and wounds: High levels of sugar in the blood can damage the body’s nerves and blood vessels, which can impair blood circulation and the body’s ability to deliver protective mechanisms and nutrients to an affected area. As a result, even small cuts and wounds may take weeks or months to heal. Slow wound healing also increases the risk of infection.
  7. Tingling, numbness, or pain in the hands or feet: High blood sugar levels can affect blood circulation and damage the body’s nerves. In
    people with Type 2 diabetes, this can lead to pain or a sensation of tingling or numbness in the hands and feet. This condition is known as neuropathy, and it can worsen over time and lead to more serious complications if a person does not get treatment for their diabetes.
  8. Bad breath, also known as halitosis: Having diabetes could increase your chances of developing bad breath. This is because the body burns fat instead of glucose when there’s not enough insulin in the body. The reaction produces ketones as a side-product – a chemical that can cause bad breath in the mouth



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