Diabetes Treatment and Prevention in Singapore
by: Dr. Paul Chang, General Practitioner, Regis Medical
Diabetes is a major health concern within Singapore, with statistics suggesting that 1 in 3 Singaporeans will develop diabetes within their lifetime.
Diabetes in Singapore
More than 400,000 Singaporeans live with the disease, and it is projected that the number will rise to more than a million by 2050 if nothing is done. Based on the 2019 Global Burden of Disease Report for Singapore, being overweight and dietary risks are the main contributing factors to diabetes in Singapore.
The majority of Singaporeans spend a large amount of time sitting down, both during work and at home. This sedentary lifestyle together with a lack of exercise can lead to obesity, which brings about many health risks and possible complications. Studies have also found that Asians are at a higher risk of developing diabetes due to a tendency to have less muscle and more abdominal fat in comparison to other ethnic groups.
In recent years, trends in food have led to Singaporeans’ diets being increasingly high in sugar content. Singaporeans also consume a large amount of rice as it is their staple food. Certain types of rice such as the short-grain white rice have a high glycaemic index (GI) score, meaning that its consumption can increase blood sugar levels significantly at a rapid pace.
What is Diabetes?
Diabetes is a chronic health condition where the body is unable to produce sufficient insulin or is ineffective in using the insulin produced. Insulin is a hormone created by your pancreas that controls the amount of glucose in your bloodstream. The main function of insulin is to regulate the sugar in our bloodstream. High blood sugar levels, if left untreated, can lead to many serious health complications such as nerve damage, heart disease, loss of vision, and kidney disease.
Types of Diabetes
There are typically 2 types of diabetes: type 1 and type 2.
Type 1 Diabetes
Type 1 diabetes is when your body’s immune system destroys your cells that produce insulin, resulting in a lack of insulin in your body.
Type 1 diabetes typically develops in the early stages of life but can happen at any age. In type 1 diabetes, autoimmune reactions occur, where the immune system attacks the body by mistake. The cells in the pancreas that create insulin are destroyed by these reactions over a period of time. This results in the pancreas making very little or no insulin, which the body requires for sugar in the bloodstream to enter the body’s cells. When sugar is stuck in the bloodstream, blood sugar levels remain high which can lead to many complications. Type 1 diabetes is chronic and requires lifelong management in the form of exogenous insulin.
Type 2 Diabetes
Type 2 diabetes is when your body does not produce enough insulin, or your cells are not reacting with insulin.
Type 2 diabetes is mainly developed as a result of one’s lifestyle habits and is most common in adults aged above 45. An unhealthy diet and lack of exercise can cause blood sugar levels to remain high over long periods of time. The pancreas must overcompensate in order to create more insulin to regulate blood sugar levels. This eventually damages the cells within the pancreas, affecting its ability to create insulin. Patients with type 2 diabetes may also develop a resistance to insulin, where the body’s cells do not respond to insulin. Type 2 diabetes is chronic and requires lifelong monitoring and follow-up.
Prediabetes
Prediabetes refers to the stage before type 2 diabetes has fully developed in a patient. During this stage, blood sugar levels are high but not high enough to diagnose the patient as diabetic. In 2017, the Ministry of Health (MOH) reported that 14% of Singaporeans, between the age of 18 to 69, had been diagnosed with prediabetes. Prediabetes in general will lead to the development of type 2 diabetes if left unmanaged. Fortunately, prediabetes is reversible if managed properly alongside lifestyle changes.
Gestational Diabetes
Gestational diabetes refers to a type of diabetes that develops specifically during pregnancy for women who do not already have diabetes. In Singapore, it is estimated that around 15 – 20% of pregnant women develop gestational diabetes. Hormones produced by the placenta during pregnancy have a blocking effect on insulin, resulting in abnormally high blood sugar levels. While gestational diabetes generally disappears after pregnancy, if left uncontrolled during pregnancy, it can lead to complications for both the mother and child.
These include:
- Increased risks of miscarriage
- Increased risks of premature birth
- Low blood sugar for the baby
- Breathing difficulties
- Stillbirth
- Increased risk of obesity and diabetes in the child
Early Symptoms of Diabetes
It is important to spot early signs and symptoms of diabetes. These include:
- Feeling exhausted all the time
- Increased levels of thirst
- Feeling hungry all the time
- Blurred vision
- Numbness or tingling in the limbs
- Frequent urination
- Loss of weight without trying
- Frequent infections
Early treatment of diabetes can help to prevent diabetes complications. In the case of prediabetes, early discovery can even help to reverse the condition.
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Stages of Diabetes
In 2018, the American Association of Clinical Endocrinologists created the dysglycaemia-based chronic disease (DBCD) multimorbidity care model, to reduce type 2 diabetes complications through early preventive measures. Diabetes is a progressive disease and typically worsens over time, with serious life-long complications such as permanent vision loss, amputation of limbs and cardiovascular diseases.
Stage 1
In this stage, the body starts to develop insulin resistance, making it progressively harder for glucose to be brought from the bloodstream into the cells. This forces the pancreas to overcompensate and produce more insulin in order to keep blood sugar levels at a normal range.
Stage 2
This stage is better known as prediabetes. In this stage, the insulin resistance of the body has gotten severe enough to the point where the additional insulin produced by the pancreas is insufficient to control blood sugar levels in the patient. While the blood sugar level of the patient in the stage is typically not high enough to be considered diabetes, it remains higher than normal.
Stage 3
In this stage, blood sugar levels have reached the point where the patient will be diagnosed as diabetic. Type 2 diabetes has fully developed, with abnormally high blood sugar levels posing a risk of damaging other parts of the body such as the nerves and organs, leading to serious health complications.
Stage 4
Sometimes referred to as end-stage diabetes, patients in this stage of the development of diabetes often experience damage to their vascular systems as a result of their high blood sugar levels. Various complications such as chronic kidney disease, heart failure, peripheral neuropathy and stroke are common in diabetic patients in this stage of the disease.
Diabetes Risk Factors
Type 1 Diabetes risk factors
For type 1 diabetes, risk factors include:
- Family history. If your parents had type 1 diabetes, you will be at a higher risk of developing type 1 diabetes.
- Age. While type 1 diabetes can develop at any age, it typically develops in children, teens or young adults.
Type 2 Diabetes Risk factors
- Have Prediabetes. Prediabetes leads to the development of type 2 diabetes if left untreated.
- Overweight or obese. The risk of developing type 2 diabetes increases linearly with an increase in body mass index.
- Aged 45 and above. The risk of developing type 2 diabetes increases with age, with people aged 45 and above being most at risk.
- Physically inactive. A lack of physical activity can lead to irregular blood sugar levels as well as insulin resistance.
- Have a family history of type 2 diabetes. Having a family member who has had type 2 diabetes puts you at a higher risk of developing type 2 diabetes.
- Smoking. Smokers are 30%-40% more likely to develop type 2 diabetes in comparison to non-smokers.
- Excess alcohol consumption. Excessive consumption of alcohol has been associated with increased risks of developing type 2 diabetes.
Complications of Diabetes
Diabetes can lead to many serious health complications if left untreated. These include:
- Heart diseases. Diabetes can damage your blood vessels causing them to be blocked, potentially causing heart attacks and strokes.
- Kidney disease. Diabetes can damage the kidneys resulting in kidney failure or diseases, which will require dialysis or kidney transplant.
- Nerve damage. Diabetes can damage the nerves, causing tingling, numbness or pain in the limbs.
- Loss of vision. Blood vessels of the retina can be damaged, potentially causing blindness or other serious vision problems.
- Foot damage. Damage to nerves in the feet can result in untreated wounds becoming serious infections, possibly requiring amputation.
- Skin conditions. Diabetic patients are at a higher risk of developing skin problems, such as fungal and bacterial infections.
Diagnosing Diabetes
If you experience any symptoms or early signs of diabetes or prediabetes and suspect that you may have diabetes or prediabetes, do visit a doctor to get your condition diagnosed. Early diagnosis of diabetes is crucial in preventing permanent damage to your organs and avoiding any complications that may come along with the disease. In the case of prediabetes, early diagnosis and treatment can prevent or slow down the development of diabetes and even aid you in reversing your condition. Our general practitioners can provide you with the following diagnostic tests:
Screening methods for Type 1 and Type 2 Diabetes/Prediabetes
- Non-fasting Blood Test (HbA1c). Indicates your average blood sugar levels over the past 3 months. Results below 5.7% are considered normal, while results between 5.7 to 6.4% indicate prediabetes and results above 6.5% indicate diabetes.
- Fasting Blood Glucose (FBG) Test. This blood test is done after an 8-hour fast.
- Oral Glucose Tolerance Test (OGTT). This tests your body’s glucose tolerance, with two blood tests. The first is done after an 8-hour fast, and the second is done 2 hours after the consumption of a sugary drink.
Preventing Diabetes
Diabetes is a chronic condition that cannot be cured. Managing diabetes can be very difficult and stressful. Type 2 diabetes is generally a result of an unhealthy lifestyle, and steps can be taken to reduce your risk of developing diabetes. This is especially important if you have been diagnosed with prediabetes.
The Singapore Health Promotion Board (HPB) conducted a study where a 6-week long program was designed for patients diagnosed with prediabetes. Participants attended classes that taught them how to change their lifestyles for the better, with access to dietary coaches as well as group exercise sessions. Cash incentives were also offered if participants managed to lose more than five per cent of their original weight. The program benefited about 150 Singaporeans, with more than half seeing a return to normal blood sugar levels one-year after the program. The success of this program highlights the importance of lifestyle changes in preventing diabetes.
Regulating your weight
Being overweight or obese puts you at a higher risk of developing type 2 diabetes. People with excessive amounts of fat near their abdominal area are at an increased risk of developing diabetes. Putting yourself in a healthy weight range can reduce your risk of developing diabetes by a significant amount. A healthy body mass index (BMI) is between 18.5 and 24.9. While those within a healthy BMI range can still develop diabetes, studies have proven an association between a high BMI and increased risks of developing type 2 diabetes.
Drink water instead of sugary drinks
Replacing your consumption of sugary drinks with water intake can effectively improve your blood sugar management and insulin response, which reduces your risk of developing type 2 diabetes. The recommended daily intake of sugar for the average male is about 36 grams of sugar and 24 grams of sugar for females. Sugary drinks contain a large amount of sugar, often exceeding the recommended daily intake. For example, a can of coke, a common drink in Singapore, contains 39 grams of sugar.
Physical activity or exercise
Regular physical activity or exercise can be effective in reducing your risk of developing type 2 diabetes. Regular physical activity has been proven to:
- Reduce insulin resistance
- Lose weight
- Lower blood sugar levels
Incorporating exercises as simple as brisk walking into your regular schedule can be a big step on your road to preventing diabetes. An ideal amount of physical exercise would be around 30 minutes or more of moderate to vigorous exercise a day, totalling up to a minimum of 150 minutes a week.
Reducing the amount of inactivity is also helpful in controlling blood sugar levels. Take the time to stand up and stretch your body or walk around every 30 minutes spent sitting down.
Diet to prevent diabetes
Diets high in sugar or refined carbohydrate intake contribute to an increased risk of developing type 2 diabetes. Sugar and refined carbohydrates increase your blood sugar levels, stimulating the body to produce more insulin. Fibre is effective in regulating blood sugar levels and lowering insulin levels. To prevent diabetes, you may want to consider increasing your consumption of high-fibre foods.
Fibre-rich foods include:
- Sweet potatoes
- Whole grains
- Lentils
- Vegetables
- Kidney beans
- Berries
By changing your diet to consume less sugar and replacing refined carbohydrate intake with carbohydrates high in fibre such as wholegrain bread and pasta, you can better regulate your overall blood sugar levels, lowering the risk of developing type 2 diabetes. Lowering the sizes of your meal portions can also reduce spikes in your blood sugar level, which helps lower your risk of developing type 2 diabetes.
Having a high amount of visceral fat is also a risk factor for diabetes, so foods high in fat should be avoided or consumed in moderation. Western dietitians and food writers have suggested the effectiveness of a Mediterranean diet in combating and preventing diabetes. The Mediterranean diet focuses heavily on:
- Fresh fruits and vegetables
- Legumes
- Whole grains
- Olive oil
- Fish
This particular diet includes fibre-rich foods mentioned in our list above, only consuming sweets and meat sparingly, and avoiding junk food and packaged food. The diet is simple to follow and at the same time, is capable of providing you with the nutritional value you require for your daily routines while staying healthy.
Dietary patterns should also be taken into consideration when designing your diet. Binge-eating has been heavily linked to obesity, a risk factor for developing diabetes. Instead of consuming large portions of food at one go, you can split them into multiple smaller portions which will be helpful for managing blood sugar levels.
Quit smoking
Smoking has been associated with a higher risk of developing type 2 diabetes. By quitting smoking, you can lower your risk of diabetes by a significant amount. Studies have shown that smokers are 30% - 40% more likely to develop type 2 diabetes in comparison to a non-smoker. They are also more prone to developing problems with insulin dosing and have difficulties managing diabetes.
Avoid excessive drinking
Excessive consumption of alcohol has been associated with a higher risk of developing type 2 diabetes. You can lower your risk of diabetes by a significant amount by reducing your consumption of alcohol. Studies have shown an increase in the risk of developing type 2 diabetes for people who consume more than 21 drinks or 14 drinks of spirits a week, while those who consume less than this amount of alcohol did not see an increase in the risk of developing type 2 diabetes.
The financial aspects of treating diabetes in Singapore
Diabetes is a costly disease since it cannot be cured, requiring long-term management and regular medication. Type 2 diabetes alone has cost Singapore more than S$1 billion in 2010 and is estimated to soar beyond S$2.5 billion if trends do not change.
Studies have suggested that the annual direct medical costs of diabetes add up to about S$2,034. However, this alone does not account for other costs, such as hospitalisation fees or having to hire a caregiver. Further health complications could also increase the financial burden of diabetes. For example, amputation of the limbs as a result of diabetes can lead to patients being unable to continue their previous line of work. Cardiovascular diseases could lead to the patient having to undergo costly surgeries and treatment.
Diabetes Treatment
Treatment for diabetes, for type1, generally requires the use of insulin injections and regular blood sugar checks. However, for type 2, there is a gradation of treatment, from conservative (diet and exercise) approaches to oral medications, and finally also involving insulin. In both type 1 and type 2, we advocate regular blood sugar checks and for patients to own a blood glucose meter at home.
Monitoring blood sugar levels
Monitoring your blood sugar levels is important when it comes to managing diabetes. Your blood sugar level helps you to make informed choices when it comes to your diet, physical activity and medication. Understanding how your body reacts to factors such as diet, physical activity, medication, alcohol and stress can help you avoid sudden spikes in sugar levels and related health complications. Devices such as a glucometer or a continuous glucose monitor will be required.
Insulin
Patients with diabetes often require insulin treatment due to their body’s inability to produce sufficient amounts of insulin. Insulin therapy can come in the form of injections or through the use of an insulin pump.
Diabetes Medication
Medication for your diabetes can be prescribed by a doctor depending on your condition. This medication can come in the form of oral medicine or injections. In general, diabetes medication aims to:
- Improve insulin production levels
- Improve insulin sensitivity
- Prevent glucose from being reabsorbed into the kidneys
- Slow down gastric emptying
Commonly used diabetes medication includes:
Medication that improves insulin production:
- Sulfonylureas
- Meglitinides
- Dipeptidyl-peptidase 4 inhibitors
Medication that improves insulin sensitivity:
- Biguanides
- Thiazolidinediones
Medication that prevents glucose from being reabsorbed into the kidneys:
- Sodium-glucose transporter 2 inhibitors
Medication that slows down gastric emptying
- Glucagon-like Peptide-1 Agonists
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