DIABETES I am not a doctor and therefore whatever provided in this web page is for information and for those interested to use as a starting point to explore further. I have provided links for further exploration. What is diabetes mellitus? It is a condition where the sugar in the blood is abnormally high. Sugar comes from the food we eat. We need not eat raw sugar for the sugar level in the blood to become abnormally high. In fact, just by eating a lot of the usual food we take, the sugar level in the blood will rise. Sugar can come from any food with carbohydrates, even from plain rice or bread. This is normal for everyone. The difference is that the sugar level in the blood of a diabetic person rise much higher than normal as a diabetic lacks the control a normal person has. This is a condition not a disease. The amount of sugar in the blood of a normal person is closely controlled by a substance called insulin. Insulin is made by the pancreas, a gland found below the stomach. Diabetes either do ot produce enough insulin or the insulin produced does not work well. As a result, sugar builds up in the blood. If the level of sugar in the blood remains high consistently, problems like infections, blindness, kidney disorders, heart diseases and foot and leg disorders will arise. About 8.6% of the adults in Singapore have diabetes and over 90% of the diabetics are over 40 years old. Risk factors include: *Family History *Overweight *Over 40 years old *Pregnancy (Gestational Diabetes) *Viral Infection which may damage the insulin-making cells There are two main types of diabetes: *Type 1: Insulin-Dependent Diabetes (IDD) The pancreas here produces little or no insulin. Type 1 diabetes usually occur in young people and would need insulin injection. *Type 2: Non-Insulin dependent Diabetes (NIDD) The pancreas produces insulin normally but the body does not use it effectively. 80% of all diabetic belonged to this group. Type 2 diabetic can be controlled by diet, exercise and medicine. If these fail, then insulin injection would be required. Symptoms of Diabetes *frequent passing of urine *increased hunger *weight loss, even when eating well *excessive thirst *tired and weak *slow healing of cuts and scratches *reduced feeling in the hands or feet *blurred vision MANAGING YOUR DIABETES The goal of a diabetic is to control the sugar level in the blood within the target range specified by the doctor. Diabetics who do home blood glucose monitoring maintain better diabetic control and the risk of developing complications is hence much lower. HbA1c (Glycated Haemoglobin) is a blood test which gives a weighted average of your blood glucose level over the last two or three months. Note that the level of sugar level varies throughout the day depending on what you eat, how much you eat and how much energy you use, hence the average gives a better picture. People with diabetes often have high blood cholesterol and triglycerides (lipids). These are fats that float around in your blood. they can block your blood vessels (arteriosclerosis) resulting in heart attacks, strokes and foot gangrene. 1) Monitoring Blood Glucose Level Currently there are two standards for meters which you can buy to monitor your own blood glucose level. These are mmol/l and mg/dl. You can convert the values from mg/dl to mmol/l by dividing by 18. Targets for before meals and after meals should be: for mmol/l Before After Excellent 4-6 6-8 Good <8 <10 Acceptable <10 <13 Poor >10 >13 OR for mg/dl for before and after meals Before After 60-100 100-150 2) HbA1c LEVEL Range Control < 6% Excellent 6 - 8% Good 8 - 9% Acceptable > 9% Poor 3) Lipid targets should be as follows LDL - Low Density Lipoprotein HDL - High Density Lipoprotein Total Cholesterol (TC) < 5.2 mmol/l LDL Cholesterol < 3.2 mmol/l HDL Cholesterol > 1.0 mmol/l Triglycerides < 2.0 mmol/l Ratio of TC/HDL < 4.5 mmol/l For more information on LDL and HDL, please refer below. Apparently for diabetics, it is good to have a high HDL level as this will help to keep the level of LDL low. High HDL cannot be raised by eating food with high HDL. You need to exercise. 4) Proper Diet *to keep blood sugar (glucose) and fat (lipids) at a desirable level *to achieve and maintain desirable body weight (your BMI - Body Mass Index) Weight (kg) BMI = ---------------------------- Height (m) X Height (m) BMI Status >30 Very Overweight 25 - 30 Overweight 20 - 25 Ideal <20 Underweight OVERALL DIETARY RECOMMENDATIONS FOR DISEASE RISK REDUCTION AND GENERAL WELL-BEING (From recommendations of the National Advisory Committee on Food and Nutrition) 1) Eat a variety of foods. - eat a balance of food from the three basic food groups: rice & alternatives, meat & alternatives and fruits & vegetables. 2) Maintain desirable body weight. Lose weight if obesity is a problem. - follow a long term plan involving sensible eating habits and a programme of physical activity. 3) Restrict total fat intake to 20-30% of total energy intake. - choose lean meat and trim any visible fat from it, eat more white meat (fish and chicken) in place of read meat (pork, beef, mutton, duck), eat fewer rich desserts and snacks like chocolates, cookies, ice-creams, restrict deep-fried food to not more than twice a week, etc. 4) Modify the composition of fat in the diet to consist of: --a) 1/3 polysaturated fat --b) 1/3 monunsaturated fat --c) 1/3 saturated fat - use corn or soya oil instead of animal fat like lard, try more vegetable-based dishes, use less coconut cream, moderate intake of dairy products like milk, butter, cheese 5) Reduce cholesterol intake to less than 300 mg a day. - replace meat dishes with beancurds, nuts, peas and beans on some days, when eating organ meats (liver, kidney, brain) and shellfish, have smaller portions and eat no more than twice a week, normal adults to adolescents should limit to 3-5 eggs a week, young children can have 5-6 eggs a week and for those with high cholesterol level, limit to 2-3 eggs a week. 6) Maintain intake of complex carbohydrates at about 50% of total energy intake. - make daily selections of fresh fruit with skin or peel, vegetables, legumes (peas and beans) and whole grains (brown rice, oatmeal, wholemeal bread). 7) Reduce salt intake to less than 5g a day (2000 mg sodium). - cut down on salt in cooking, cut down on MSG (MonoSodium Glutamate) in cooking, choose fresh food in preference to processed food, reduce intake of salted food like salted nugs and crisps, salted vegetables and eggs. 8) Reduce intake of salt cured, preserved and smoked foods. - eat more fresh food in preference to preserved food. Limit intake of smoked fish and fish roe, salted dry fish, ham, bacon, luncheon meat, corned beef and other cured meat, barbecued meat, salted vegetables, salted eggs and picked food. 9) Reduce intake of refined and processed sugar to less than 10% of total energy intake. - gradually reduce the amount of sugar in drinks and desserts, try to develop a liking of these with a little sugar or no sugar, avoid sweetened drinks, limit use of sweet jams. 10) Increase intake of fruit, vegetable and whole grain cereal products, thereby increasing vitamin A, vitamin C and fibre intakes. - include green leafy and yellow/orange vegetables such as spinach and carrots, eat more local fruits particularly the yellow/orange ones like guava, papaya, yellow-core bananas, eat fruit and vegetables fresh where possible. 11) For those who drink, limit alcohol intake to not more than 2 standard drinks a day (about 30g alcohol). - wines (not more than 2 wine glasses), beers (not more than 660 ml), spirits (not more than 90 ml). Cut alcohol altogether during pregnancy and breastfeeding. 12) Encourage breastfeeding in infants till at least 6 months of age. - start breastfeeding soon after birth, eat well when breastfeeding, have enough fluid. 5) Treatment **Sulphonylureas - Help the pancreas to release more insulin and the body to use glucose more effectively *Gilbenclamide (Daonil) *Gliclazide (Diamicron) *Chlorpropamide (Diabinese) *Glipizide (Minidiab) *Tolbutamide (Rastinon) **Biguanides *Metformin (Glucophage) - Help the body use glucose more effectively **Alpha-glucosidase Inhibitors - Help stop the quick rise of blood glucose after a meal *Acarbose (Glucobay) COMPLICATIONS OF DIABETES 1. Diabetic Ketoacidosis - very high sugar level (20-40 mmol/l) causes the diabetic to become thristy and may become drowsy or unconscious. A large amount of acid is produced in the bloodstream. 2. Hyperosmolar Nonketotic Diabetic Coma - very high sugar level (20-50 mmol/l) causes severe dehydration and patient often goes into a coma. 3. Severe Hypoglycaemia - sugar level becomes do low (<3.0 mmol/l) that the patient loses consciousness. This is usually due to use of insulin or sulphonylureas when no food is taken. Long term poor sugar control leads to: 1. Retinopathy - long term poor sugar control will cause bleeding and leaky blood vessels and this will lead to blindness 2. Nephropathy - kidney damage 3. Neuropathy - nerve damage 4. Heart Attack - diabetics have a higher risk 5. Strokes 6. Foot Gangrene - long term poor sugar control can damage blood vessels, cutting off blood supply to foot or toes. Poor blood supply could lead to other compilcations. Long term poor sugar control leads to damage to the finer and more delicate blood vessels. Such vessels are found at extremities of the body (like toes) and the more delicate areas in our body (eyes). Damage will lead to poor oxygen supply and this will cause such areas to be damaged. ================================ Updated on 21st November 1998 HS Lim