Diabetes care and management Know what to do after you are diagnosed with diabetes By Dawn Sin Although the prevalence of diabetes among Singaporean adults fell from 9.0% in 1998 to 8.2% in 2004, according to the National Health Survey 2004, this figure is still alarming in comparison to the estimated global rate of 4% in 1995 and projected 5.4% by 2025. There is no cure for diabetes nor can diabetes disappear a few years down the road. The condition can only be kept under control with medication and lifestyle modifications, which are achievable through regular consultations with doctors and their allied health professionals.    Diabetes care Poorly managed diabetes can lead to a wide variety of complications over time. Says Dr Tey Beng Hea, senior consultant, Diabetes Centre, Alexandra Hospital (AH), “About half of all males with diabetes will experience impotence. Skin sores, poor oral health and swelling of the legs are also common diabetes complications.” Other more serious long-term complications include ischaemic heart disease, kidney and foot disease, impaired nerve functions, as well as eye problems like diabetic retinopathy and cataracts. Dr Tey estimates that complications can set in within five to 10 years’ time.   He adds that  aside from regular self-monitoring of blood glucose (SMBG), diabetic patients should undergo a yearly physical assessment to monitor their blood glucose levels, haemoglobin A1c (HbA1c – a measure of blood glucose control over the past three months), lipid profile (including triglycerides and cholesterol), urine albumin, cardiovascular function and eye-related complications, among others.   Generally, the goal of treatment is to get HbA1c down to less than 7% and fasting glucose levels to less than 7mmol/L (126mg/dL). For Type 1 diabetes patients, insulin injections are a must, together with lifestyle modifications, such as a healthy diet, frequent exercise and weight control. For Type 2 diabetes patients who present no complications as yet and are overweight, Dr Tey’s preferred treatment approach is to prescribe lifestyle modifications first, and if blood glucose levels are still not down to desirable levels, medications like oral anti-diabetic pills and insulin injections are then prescribed.   To achieve better patient compliance and understanding of their conditions, diabetes nurse educators are important. AH Diabetes Centre’s diabetes nurse educator Chua Chin Lian says, “Nurse educators like us are trained to counsel diabetes patients; we explain what diabetes is, the risk factors as well as the symptoms to look out for. We also highlight diabetes-related complications and the importance of screening and adhering to treatment plans. We also teach them proper SMBG and basic foot care.”   Nutrition To dispel common, well-meaning, but misguided advice for patients with diabetes to avoid foods high in sugar and carbohydrates, dietician Gladys Wong says, “People with diabetes are often told to avoid rice and bananas, and when they come to us, we have to change their mindset and teach them how to incorporate rice and bananas as part of their regular diet”. Wong is the chief dietician and manager of AH’s Nutrition & Dietetics Department. She adds, “The most important thing is really to follow a healthy diet, working within an optimum calorie and glucose count. The short-term goal is to maintain good blood glucose control, and the long-term goals are to control one’s fat, sodium and weight.”   There is no standard diabetic meal plan per se and the dieticians at AH usually provide patients with appropriate nutritional guidelines based on their individual lifestyles and conditions.   The American Diabetes Association advises the same healthy diet approach for diabetics. On its website (www.diabetes.org), it lists a Diabetic Food Pyramid with six main types of food groups and the recommended servings for each group.    Are food products specially developed for diabetics absolutely necessary then? Wong says, “Dieticians have never advocated that these food products are necessary for diabetes control.”   Exercise According to Dr Lee Chung Horn of Lee Chung Horn Diabetes and Endocrinology at Gleneagles Medical Centre, exercise is beneficial to diabetics because it uses up glucose, thus helping to lower blood glucose levels, and also helps prevent or delay cardiovascular diseases. These are in addition to the obvious benefit of weight management.   AH’s physiotherapist Lim Kian Chong recommends cardiovascular exercises like brisk walking, cycling and swimming, and muscle training exercises. “Start off by exercising for three days a week for at least 30 minutes each time, on non-consecutive days, then increase as your body gets more conditioned,” says Lim. He advises exercising within a heart rate bracket of 50% to 60% of the theoretical maximum heart rate – 200 minus age in years.   Muscle training involves using free weights, body weight or machines to increase muscle mass, increasing insulin sensitivity and strengthening the bones. He cautions against holding one’s breath when training muscles.   Lim warns, “It is important to monitor blood glucose before you exercise. Avoid exercising if your blood glucose exceeds 13.9mmol/L (255mg/dL) with ketones in urine, or exceeds 16.7mmol/L (306mg/dL).” Also, it is good to exercise with a companion, and if nausea, giddiness or weakness set in, stop exercising immediately.   Public awareness Nurse educator Chua and Dr Tey both observe that patients are more educated now and increasingly knowledgeable about diseases, especially the younger ones. This is in part due to more involved, multi-disciplinary care from the medical team. Says Dr Tey, “Diabetes management has seen some improvements over the years; one example is the fall in cases of diabetic comas due to excessively high or low blood glucose levels.” This observation is also reflected in the findings of the National Health Survey 2004, which found that among diabetics, the proportion of those who had previously gone undiagnosed fell to 49.4% in 2004 compared to 62.1% in 1998. The 2002 research paper titled “Public Awareness of Diabetes Mellitus in Singapore”, published in the Singapore Medical Journal, also found that the public was generally well-informed about diabetes, except in the areas of diabetes risk factors and, to some extent, complications and symptoms.   However, Singapore still has a long way to go before overcoming its diabetes scourge and patient education remains a very important element in the fight against diabetes. Dr Tey says, “Sometimes the elderly patients are resistant to advice and treatment, and they persist in taking their traditional concoctions, which may worsen their condition.” Hopefully, with more advanced and personalised medical care, many patients will be able to keep their condition under control and the prevalence of diabetes will decrease markedly.