Managing your diabetes and making the necessary changes to your lifestyle can be challenging at times. While effective diabetes self-care starts with you, there just seems to be so many things to take into account - from nutrition and exercise to foot care and medication:

Diabetes management starts with awareness.

Dr Ian Phoon Kwong Yun, Family Physician at SingHealth Polyclinics, gives detailed answers to your questions.

Question by ​dave

My dad has diabetes and now he is scared to eat any kind of fruits. But I thought fruits were part of a healthy diet, and has good fibre, vitamins and minerals?

Q: What fruits can he eat or not? How many and how often should he eat them? If he can't eat fruit, then what he should eat instead to compensate for the fibre and vitamins? Hopefully not with supplements because he hates eating tablets!

Thanks in advance.

Answered by Dr Ian Phoon Kwong Yun, Family Physician, Associate Consultant, SingHealth Polyclinics - Pasir Ris

Hi Dave,

There is nothing wrong with eating fruits every day, even if you have diabetes. As you have pointed out, fruits are part of a healthy diet for everyone, as it has dietary fibre, vitamins and minerals. The key here is the portions.

One can have 2 servings of fruits a day, 1 serving at a time, e.g. with breakfast, lunch or dinner. An example of 1 serving of fruits include:

• 1 small apple, orange, or pear
• ½ a medium-sized banana
• ¾ to 1 cup (250 ml) of berries, grapes, chopped melon or mango.

Choose to eat fresh or whole fruits rather than canned ones (which tends to be sweetened) or fruit juices (which tend to filter out most of the fibre).

In addition, the above should be accompanied by a healthy balanced diet, and regular physical activities.

You may take a look at Health Promotion Board's “My Healthy Plate”.

Best regards
Dr Ian Phoon

Reposted by Administrator

Dear doctor

We are trying to make our father understand that part of managing his diabetes is to take his medicines as directed. Could you please tell us (so we can tell him again):

1. Why it is important to take his medicine regularly – he thinks that if he follows a strict diet he doesn’t have to take his medicine every day.
2. What can he do if he misses a day or two of meds – this has not happened yet but his current caregiver will be leaving in 2 months – as he is getting more forgetful.
3. And in general, what can we/he do if he forgets to bring his medicine while he’s travelling? Aside from checking that he brings his meds we worry that he might misplace them along the way.

Thanks! Pacman78

Answered by Dr Ian Phoon Kwong Yun, Family Physician, Associate Consultant, SingHealth Polyclinics - Pasir Ris

Hi Pacman78,

It’s really good that you’re taking an interest in the health of your father, and trying to help him live more healthily.

1. Generally, there are 3 areas that we need to work on to keep diabetes under control.
• ​​Eat a healthy, balanced diet (e.g. limiting the amount of carbohydrates to about ¼ of the plate per meal, choosing wholemeal bread or brown rice or noodles, eating more fruits and vegetables, avoiding sweetened drinks, or use a little artificial sweetener, if needed).
• Stay physically active (e.g. brisk walking, swimming, cycling, or dancing about 5 times a week for about 30 mins each time).
• Take the right medication to help his body cope with the blood sugar levels.

So while a) is important, that’s only 1/3 of the equation. For most diabetics, it’s difficult to control one’s blood sugar levels with just diet alone. The reason for this is that once one is diagnosed with diabetes, it means that:

• there is insulin resistance, meaning that the body organs (e.g. muscle, liverbrain) is not able to respond to a hormone (insulin) that allows it to draw sugar from the blood into the organs. Thus the sugar stays in the blood, rather than being used by the organs, and;
• the body isn’t able to produce enough insulin (from the pancreas) to overcome this resistance.

So even if the person with diabetes does a fast (i.e. do not eat), the blood glucose is often still high. This can be seen in your father’s fasting glucose. Normal fasting glucose is 6 mmol/l or less, but this is very difficult to achieve for a diabetic without medication.

Diabetic medication helps the body in various ways, depending on the type of medication taken:

• Metformin helps to reduce the body’s resistance to insulin, and reduce the production of sugars by the liver.
• Sulphonylureas e.g. glipizide, glicazide, or tolbutamide, helps to stimulate the body (pancreas) to produce more insulin.
• Acarbose blocks the digestion of some of the carbohydrates eaten, so that it takes a longer time to be absorbed.
• DPP4 inhibitors such as sitagliptin blocks a hormone that leads to more insulin being produced by the body.

This list is not exhaustive. But the point is that the medication helps a person with diabetes cope better with the high blood sugars and is complementary (not mutually exclusive) to a healthy diet and exercise.

2. As mentioned above, the medication helps his body cope with the high blood sugar levels. If he misses his medication, it would likely mean that his blood sugars will be higher on those days. One way to check is to get a glucometer, a small device that can be used to check your father’s blood sugar levels. A reading of more than 10 mmol/l about 2 hours after a meal is high. Thus it is important for your father not to miss his medication as far as possible.

It is also important for your father to take his medication when he has his meals. If taken apart from a meal (e.g. if fasting, or 1-2 hours after a meal) there is the risk that the blood sugar level can fall too low (a condition called “hypoglycaemia”). Symptoms include confusion, cold sweats, tremors, dizziness and general weakness. If this happens, check his blood glucose (with the glucometer if you have one). If it’s less than 4 mmol/l this confirms the low blood sugar. Have him drink ½ a cup of fruit juice or soft drink immediately suck on 3 sweets, or 1 teaspoon of sugar. Wait for 15 mins, recheck his blood sugar and see if his symptoms are resolved. If they are not, call the ambulance.

Keep the medication in a pill box may help some older patients remember to take their medication. Otherwise, you should train the person who is preparing your father’s meal to check that he has his medication with him during meal times.

3. Prevention is better than cure. You’re right to say that you should check that he has his medication ready and packed when he travels. One way to remember this is to ensure that this is part of his / your packing list. It is as important as bringing his passport or bringing enough cash.

If he needs a reminder, ask for his passport and clip a note in front of it to remind him to pack enough medication for the trip. If he really forgets his medication, then there’s little he can do. Even if he goes to a doctor overseas, he must be able to tell them what medication he is taking, the dosage and frequency.

On another note, do monitor your father’s behaviour to see if he is getting more and more disorganised or forgetful (aside from forgetting his medication) over time. One thing to consider is if he is developing early dementia.

Best regards
Dr Ian Phoon

Reposted by administrator

Hi doctor,

My 68-year-old grandma has diabetes – over 40 years now. I notice her appetite during regular meals seem to have gone down and I suspect she has been bingeing on “forbidden foods” like cakes and other sweet stuff. Old folks have smaller appetites but is this normal to see a sudden drop in appetite? Should portion sizes and even types of foods/fruits for old folks with diabetes be even stricter controlled? Do you have a meals guideline to share please?

Thank you! TrishNot

Answered by Dr Ian Phoon Kwong Yun, Family Physician, Associate Consultant, SingHealth Polyclinics - Pasir Ris

Hi TrishNot,

It is true to say that older people tends to have smaller appetites. There may be a few reasons for this, such as reduced smell and taste as we age, and sometimes it’s because their teeth aren’t healthy enough to chew all the food. She may need to have her food cut up if this is a problem.

But one thing to note is whether she’s depressed or not. How is her mood generally? Can she smile or joke? Depression is another reason for loss of appetite.

Is there any change in her weight? If she is losing some weight, then it is unlikely that she is getting her calories from other sources. Sometimes the best way to find out why her appetite is poor is to ask her directly. You can also ask her or those taking care of her (and staying with her) if she has been snacking between meals. Check the items that she keeps in her fridge.

How is her diabetic control overall? Is it getting worse over time, or stable? If stable, she probably isn’t bingeing much.

The diet for a diabetic is no different from a healthy diet that all of us should be having, even if we do not have diabetes. Below is a link to the Heath Promotion Board’s “My Healthy Plate”. Roughly half of our foods should come from fruits and vegetables while ¼ is from carbohydrates (e.g. brown rice, noodles, wholemeal bread), and another ¼ from (lean) meats and proteins (preferably white meats like chicken and fish, tofu, beans, legumes or nuts).

www.hpb.gov.sg/HOPPortal/health-article/HPB064355#fill_half_plate_veggie_subheader

There’s no need to be too strict in controling your grandmother’s diet, as long as she follows this guide on most days. An occasional indulgence e.g. a small piece of cake or small bowls of sweet dessert 1-2 times a week should be ok, but she may need to cut her other carbohydrates for that day.

Reposted by administrator

Dear doctor

What is late or adult-onset diabetes and can anyone get it? Why does it happens and what are the signs that I should look out for, doctor? Is anyone particularly predisposed to late onset diabetes e.g. above age 45? Thank you for your time. DDayishere

Answered by Dr Ian Phoon Kwong Yun, Family Physician, Associate Consultant, SingHealth Polyclinics - Pasir Ris

Hi Ddayishere,

Type 2 Diabetes Mellitus is the most common type of diabetes that usually occurs in adults. It sometimes occurs (though it’s not common) in teenagers who are very obese.

Anybody can get type 2 diabetes, but there are certain risk factors that increases one’s chances significantly, such as

• Obesity (e.g. body mass index = {height in meters/(weight in kg)2 } greater than 23 in Asians)
• 1st degree relatives with diabetes (parents or siblings)
• Above 40 years old
• Gestational diabetes (or diabetes in pregnancy)
• Pre-diabetes (blood sugar levels just below that seen in a diabetic)

The more risk factors you have, the higher the risk.

Type 2 diabetes happens because the body becomes resistant to the effects of a hormone called insulin. Insulin is secreted into the blood stream all the time by an organ called the pancreas, and during meals, its level increases. Its function is to bind to cells in your body to open up channels to bring in sugars from the blood into the cells, where the sugars are used as fuel for energy, so that the cells can function normally.

If the cells are resistant to insulin, then they don’t open the channels so much to bring in the blood sugars, thus causing the blood sugars to rise. Fat, especially internal ones (visceral fat) are less responsive to insulin, thus those that are obese tend to develop type 2 diabetes. Genes may also play a part. So if your close relatives have diabetes, you’re more likely to carry the same genes as them.

In the early stages, there are no symptoms at all. This represents the vast majority of patients. Thus, if you have any one of the above risk factors, and/or are above 40 years old, you should go for a fasting screening blood test with your doctor, even if you feel well. Early detection and treatment of type 2 diabetes can prevent the many complications (e.g. kidney disease, bleeds in the eye, heart attacks or strokes) later on.

Overt symptoms of diabetes include frequent thirst, frequent passing of urine, feeling hungry all the time, and an unintended loss of weight. These are late signs of diabetes, and by the time this occurs, the sugar levels are often very high, and most patients at this stage will require insulin injections to control their diabetes.

If you have any risk factors for diabetes, including having a parent with diabetes, it’s never too early to start living healthily, because you may develop diabetes one day too. This includes having a balance diet (see link below, from Health Promotion Board), and regular exercise.

www.hpb.gov.sg/HOPPortal/health-article/HPB064355#fill_half_plate_veggie_subheader

Best regards,
Dr Ian Phoon

Reposted by administrator

Dear doc,

Are there exercises that are really good for older people with diabetes? Thanks!

SoupKitchen58

Answered by Dr Ian Phoon Kwong Yun, Family Physician, Associate Consultant, SingHealth Polyclinics - Pasir Ris

Hi SoupKitchen58,

The best exercise is one that can exercise the heart. Aerobic type exercise helps to improve one’s stamina, strength, and metabolism.

As many older people have arthritis, it is better to choose exercises that are low impact (i.e. no running or jumping). Brisk walking, cycling (including stationary bicycle), swimming, and even dancing are good exercises. Tai Chi or Qi Gong are also good for strength and balance, although it may work the heart a little less.

Start exercising slowly and gradually increase the frequency, duration, and intensity – in that order. Ideally, one should aim to exercise at moderate intensity for 30 mins for at least 5 days in a week. As a rule of thumb, light exercise is when one can still sing a tune when exercising. Moderate exercise is one where you can only talk in short sentences but not sing.

If any diabetic wishes to engage in any exercise more intense than a brisk walk, they should check with their doctor first.

During the exercise, one needs to know when to stop. For e.g. if one develops breathlessness or chest pain, one should stop immediately, and rest for 5 mins. If the symptoms persist, he should call 995 for an ambulance, as it could be due to a heart attack. If he develops cold sweats or dizziness, it could be due to low blood sugar level. He should carry at least 3 sweets (not sugar-free ones), and quickly suck on them. If he does not feel better after 15 minutes, he should call 995 for the ambulance. So before one starts to exercise, he needs to ensure that he hydrate himself first, have a phone and some sweets on hand.

Footwear is important for diabetics who want to exercise. The shoe should be padded and covers the whole foot. The person should wear socks to prevent callous or ulcers in the feet. Track shoes are ideal for this purpose. The person should check the condition of their feet before and after the exercise.

As each older person may have various functional disabilities, the best exercise may need to be discussed with the person’s doctor first to help individualise the exercise.

Best regards,
Dr Ian Phoon.

Reposted by administrator

Dear doctor,

I have low blood sugar but I don’t think I have diabetes. What can cause this to happen? And what’s the best food or snack to carry around – in case of an emergency like I suddenly get hit by low sugar levels – aside from drinking packet Milo!

Thank you for your reply.

Shayshona_June

Answered by Dr Ian Phoon Kwong Yun, Family Physician, Associate Consultant, SingHealth Polyclinics - Pasir Ris

Hi Shayshona_June,

The symptoms of low blood sugar (hypoglycaemia) are

• Dizziness
• Confusion
• Cold sweats
• Tremors
• Weakness
• Extreme hunger
• Blur vision

It usually happens if you skip a meal or eat it later than usual. It can sometimes happen during an exercise session.

The surest way to confirm that the symptoms are due to a low blood sugar level is to use a glucometer (a hand-held device that can check your blood sugar with a finger prick) to check your blood sugars. A level below 4 mmol/l is low.

For diabetics, the most common cause of low blood sugar is due to their medication. This could be because the patient took their medication without eating, or the dose is too high. Also, they can get a low sugar reading if they delay or skip their meals or during exercise as well.

Milo isn’t the best thing to take for hypoglycaemia, as it contains milk (fats), which delays the absorption of the sugars. The best thing to carry around is 2-3 sweets (not the sugar-free ones), and pop all of them into the mouth at 1 time. Chewing will make them dissolve faster.

Alternatives are ½ a glass of sweetened soft drinks or fruit juice, or a teaspoon of sugar or honey. Wait for 15 mins to see if your symptoms recover. If not, please see your doctor or call 995 for an ambulance. If you do recover, eat a proper meal, with carbohydrates like bread, rice or noodles.

Do consider why the low blood sugar event occurred. As prevention is better than cure, knowing why it happened can help you avoid another similar episode.

Best regards,
Dr Ian Phoon.

Reposted by administrator

Hi doctor,

I am quite sporty and love to eat meat. Recently I was told that I am pre-diabetic and I am now on the Paleo diet. Is a high protein diet better for me? Can this diet help me reverse the condition? How much protein is too much if I have diabetes?

Thank you.

Xtremetrails

Answered by Dr Ian Phoon Kwong Yun, Family Physician, Associate Consultant, SingHealth Polyclinics - Pasir Ris

Hi Xtremetrails,

The diet for a diabetic or pre-diabetic is no different from a healthy diet that all of us should be having, even if we do not have diabetes. Below is a link to the Heath Promotion Board’s “My Healthy Plate”. Roughly half of our foods should come from fruits and vegetables while ¼ is from carbohydrates (e.g. brown rice, noodles, wholemeal bread), and another ¼ from meats and proteins (preferably white meats like chicken and fish, tofu, beans, legumes or nuts).

www.hpb.gov.sg/HOPPortal/health-article/HPB064355#fill_half_plate_veggie_subheader

There is no strong reason to say that a high-protein diet is better for you. Certainly a little more protein may be needed if you’re trying to build muscle bulk. But it’s not recommended for most people. One meat portion serving should be about a palm-sized piece of meat (i.e. your hand minus the fingers). Stop eating if you feel full. We often eat a little beyond our fullness because it’s our “favourite” food, or just want to avoid wasting food.

I’m not an expert in the Paleo diet, but I did try to find out a little more about this. There are good points about this diet, in that it encourages fruits, vegetables, lean meats, fish, nuts and seeds, and healthy fats, while discouraging processed foods and sugars. But it also discourages dairy products, grains, legumes, and starchy foods (e.g. rice, noodles and bread), which may be unnecessary. It’s ok to take some low fat dairy products as they’re a good source of calcium. Brown rice and noodles, and wholemeal bread are preferred over the white versions, as they contain more dietary fibre.

It’s difficult to say whether the diet will reverse your condition, but if you stick to the diet as described above, and stay physically active, you can at least delay the onset of diabetes by a few years or even decades. Nevertheless, you are still at risk of progressing to diabetes sometime in the future, and should still go back to your doctor, at least yearly, to have your blood sugar level checked.

Best regards,
Dr Ian Phoon.

Question by lowhl@ymail.com

Does consumption of Metformin over a long period caused dry mouth and bitter taste?

Thank you.

Lyon

Answered by Dr Ian Phoon Kwong Yun, Family Physician, Associate Consultant, SingHealth Polyclinics - Pasir Ris

Hi Lyon,

The more common side effects of metformin are: nausea, bloating, reduced appetite, and sometimes diarrhoea. Less commonly, it may cause altered taste or a metallic taste. Some have also reported dry mouth, although it is uncommon.

There are many drugs that can also cause dry mouth, like certain flu medication (e.g. antihistamines such as chlorpheneramine, loratadine, cetirizine, or decongestants like pseudoephedrine), anti-depressants, and muscle relaxants. So if you’re taking other medications as well, you may want to check with your pharmacist if these too can cause your symptoms. Sometimes if you tend to breathe through your mouth (e.g. if your nose is often blocked), or if you’re in an air conditioned environment most of the time, this can also cause your mouth to become dry. Rarely, very high blood sugar levels can cause extreme thirst, but this is usually associated with passing a lot of urine and loss of weight.

Taking sips of water or sucking on a sugar-free sweet may help with the dry throat.

Best regards,
Dr Phoon.

Question by rachel

Hi doctor,

My mum has diabetes. When she feels jittery, she sometimes rushes to eat a packet of sugar from any coffee house. Is this okay for the long term ? Any side effects? Or should she take something like glucose tablets. What's the difference ? Look forward to your help please.

Answered by Dr Ian Phoon Kwong Yun, Family Physician, Associate Consultant, SingHealth Polyclinics - Pasir Ris

Hi Rachel,

It sounds like your mother has recurrent episodes of hypoglycaemia. Other symptoms of hypoglycaemia are: dizziness, tremors, cold sweats, weakness, and extreme hunger. Management of hypoglycaemia includes taking 2-3 sugar-sweets, glucose tablets (chew these as it will cause the sugar to dissolve faster), a sachet of sugar, ½ a cup of sweetened drink, or fruit juice. Each of these represents about 15g of simple sugars that will quickly raise her blood sugar.

She should then wait 15mins, and if she’s not better, repeat the above and call for the ambulance (995).

Ideally, she should have a glucometer, a hand-held device that can check the blood glucose level with a drop of blood from the finger. A reading of less than 4 mmol/l (or 72 mg/dL) with the above symptoms confirms hypoglycaemia (low blood sugar). After taking the sweets/ glucose tabs, she should have the blood rechecked to ensure that it is more than 4 mmol/l.

The more important question is why she’s getting these episodes of hypoglycaemia. Some common reasons are:

1. She skipped or delayed her meal (breakfast/ lunch/ dinner), or ate much less than her usual quantity.
2. She took her diabetic medication too early before a meal, or not with a meal. For e.g. she may be fasting for a blood test, but took her diabetic tablets anyway.
3. The dose of the medication is too strong for her (you’ll need to check with her doctor how her overall diabetic control is). Please ensure that she’s taking the right dose at the right time (please check with her doctor).
4. She went exercising without eating something before she started.

Patients with poor kidney function or high doses of insulin (from injections) are more prone to hypoglycaemia, as are patients who are older (e.g. more than 75 years old).

The few ways to prevent hypoglycaemia include having meals at regular times, preferably 3 main meals a day, and taking the diabetic medication in close timing with these meals (they’re usually taken just before or just after the meal). As mentioned, get a glucometer for her and periodically check her blood sugars, some before meals, and some 2 hours after, and record this in a diary. This will tell you and her doctor how her blood sugar level varies throughout the day, and whether there’s any pattern to her low blood sugarlevels. If all the readings are normal to low, then her doctor may consider lowering the dosage of her medication.

Hope this helps.

Best regards,
Dr Phoon.

Question by lovebellsg

Dear doc,

My mother has been experiencing hypoglycaemia quite frequently even though her mixtard dosage has been reduced. She was hospitalised for fever and thereafter she has hypo quite often and mixtard reduced from 44u in the morning and 36u at night to 36u in the morning and 26u at night. Her latest HbA1c reading is at 7.4 and so the polyclinic doc reduced dosage to 34u in the morning and 24u at night. I am worried her HbA1c reading would not be at its optimal the next round. How could we better manage this. Also, do diabetes patients have to avoid alcohol totally? Are red wines harmful to them or they just need to watch the amount they drink?

Thank you doc!

Answered by Dr Ian Phoon Kwong Yun, Family Physician, Associate Consultant, SingHealth Polyclinics - Pasir Ris

Hi Lovebellsg,

This is indeed a challenge: Trying to control the blood sugar overall, while avoiding hypoglycaemia.

Some common reasons for hypoglycemic episodes are:

1. She skipped or delayed her meal (breakfast/ lunch/ dinner), or ate much less than her usual quantity.
2. She took her diabetic medication too early before a meal, or not with a meal. For e.g. she may be fasting for a blood test, but took her diabetic tablets anyway.
3. The dose of the medication is too strong for her.
4. She went exercising without eating something before she started.

Patients with poor kidney function or high doses of insulin (from injections) are more prone to hypoglycaemia, as are patients who are older (e.g. more than 75 years old).

Ways to prevent hypoglycaemia include having regular meal times, preferably 3 main meals a day, and taking the diabetic medication in close timing with these meals (they’re usually taken just before or just after the meal). As mentioned, get a glucometer for her and periodically check her blood sugars, some before meals, and some 2 hours after, and record this in a diary. This will tell you and her doctor how her blood sugar level varies throughout the day, and whether there’s any pattern to her low blood sugar levels. If all the readings are normal to low, then her doctor may consider lowering the dosage of her medication.

Mixtard (30/70) insulin acts slower, and needs to be given about 30 mins before the meal. If given just before the meal, it may “peak” later, and cause the glucose to drop too low. Novomix (30/70) will act within about 10-20 mins, and can be given a short time before meals. Using the latter insulin tends to cause less hypoglycaemia than mixtard. But it is more expensive than Mixtard (Novomix cost about $15 for 300 units of insulin at the polyclinic).

Discuss with your doctor if she should switch to the latter insulin. Also, if she her glucose is very labile (shows very high and very low readings), it may be better to accept a slightly higher HbA1c (e.g. < 8%) so as to avoid the hypoglycaemic events. You can consider aiming for her pre-meal glucose to be about 5-8 mmol/l, and post-meal glucose to be below 13 mmol/l, but this should be discussed with her doctor.

Regarding metformin and alcohol: When there’s a moderate to large amount of alcohol taken with metformin, the interaction may cause a condition called lactic acidosis, whereby there is excessive acidity in the blood. This is made worse if the patient also has liver or kidney disease, or is dehydrated (not enough water). Symptoms include muscle cramps, breathlessness, weakness, and nausea. Overall, this potentially life-threatening side effect is very rare. If your mother’s kidneys and liver function is normal, she can take a small glass of wine with her meals if she chooses to. Anything more is not advisable.

Best regards,
Dr Phoon.

Question by healthblur

I have heard that the main people at risk of getting diabetes are those who are overweight. Yet, I have two friends who are skinny and they told me they have diabetes type 2. They don't even eat a lot of sweet stuff. This is freaking me out !! What do I need to do to ensure I never get diabetes in my life ? I don't want to be another statistic in the wrong category... Help !!! Your advise please.

Answered by Dr Ian Phoon Kwong Yun, Family Physician, Associate Consultant, SingHealth Polyclinics - Pasir Ris

Hi heathblur,

The risk factors for diabetes are:

• Obesity (e.g. body mass index = {height in meters/(weight in kg)2 } greater than 23 in Asians)
• 1st degree relatives with diabetes (parents or siblings)
• Above 40 years old
• Gestational diabetes (or diabetes in pregnancy)
• Pre-diabetes (blood sugar levels just below that seen in a diabetic)

So while we do not need to be obese to have diabetes, being overweight increases the risk. Thus it is important to control your weight with a balanced diet and regular exercise.

Diabetes is more than just “eating a lot of sweet stuff”. Carbohydrates, like rice, noodles, bread, pasta, and potatos will also be broken down to sugars in our body. They don’t taste sweet when we eat them. But that does not mean we should avoid carbohydrates either. The key is the amount, type and proportion of carbohydrates consumed.

The diet for a diabetic is no different from a healthy diet that all of us should be having, even if we do not have diabetes. Below is a link to the Heath Promotion Board’s “My Healthy Plate”.

www.hpb.gov.sg/HOPPortal/health-article/HPB064355#fill_half_plate_veggie_subheader

Roughly half of our foods should come from fruits and vegetables while ¼ is from carbohydrates (e.g. brown rice, noodles, wholemeal bread), and another ¼ from (lean) meats and proteins (preferably white meats like chicken and fish, tofu, beans, legumes or nuts).

Remember to stop eating if you feel full already. We often eat a little beyond our fullness because it’s our “favourite” food, or just want to avoid wasting food. This adds to our calorie intake. Likewise, we should watch what we snack on in between meals (e.g. cakes, pastries, desserts, chips, crackers). This can add to our calories. Healthier snacks include nuts, fruits, granola bars and the like. Avoid soft drinks, which contain a lot of sugar. If you must have a soda, go for the “zero” ones. Or just drink water, coffee or tea (with low-fat milk), and with or without artificial sweeteners.

Exercise e.g. brisk walking, swimming, cycling, or dancing, helps to raise your metabolism, and burn calories. If you want to start exercising, you should start slowly and gradually increase the frequency, durationand intensity, in that order. Ideally, you should aim to exercise at moderate intensity for 30 mins for at least 5 days in a week. As a rule of thumb, light exercise is when one can still sing a tune when exercising. Moderate exercise is one where you can only talk in short sentences but not sing.

All these can reduce your risk of developing diabetes. But it is still good to see your doctor at least annually, to check your fasting blood sugars, cholesterol and blood pressure.

Best regards,
Dr Phoon.

Question by janey

If I can't help myself and just HAVE to eat my favorite cake, can I just balance it out by eating some vegetables for fibre just before or after? Does that work ? So it's all balanced out within the stomach at digestion ? Yes? No?

Answered by Dr Ian Phoon Kwong Yun, Family Physician, Associate Consultant, SingHealth Polyclinics - Pasir Ris

Hi Janey,

No, it doesn’t quite work that way. It’s more about having a balanced meal throughout the day. Firstly, you don’t have to feel too guilty about an occasional indulgence (about 1-2 times a week), as long as you’re eating a balanced meal on most days, while avoiding eating beyond fullness.

As cake is largely carbohydrate, with some fat (e.g. the cream), so limit your intake to a small slice if possible. Drink water after that rather than any sweetened drinks. For your next meal, reduce your carbohydrate (rice/noodle/pasta/bread) intake.

With regards to a balanced meal, below is a link to the Heath Promotion Board’s “My Healthy Plate”.

www.hpb.gov.sg/HOPPortal/health-article/HPB064355#fill_half_plate_veggie_subheader

Roughly half of our foods should come from fruits and vegetables while ¼ is from carbohydrates (e.g. brown rice, noodles, wholemeal bread), and another ¼ from (lean) meats and proteins (preferably white meats like chicken and fish, tofu, beans, legumes or nuts).

Don’t forget to exercise regularly too, which can help you burn calories.

Best regards,
Dr Phoon.

Question by tsendjaja

I have been consuming diabetic medicines for nearly 10 years with no changes. Now my hba1c is 6.5 and 137 before eating. My question is : should I change the medicine's dose? Forr your info of medicine: Amaryl 3 - 1x1 tab; Galvusmet 850 - 2x1 tab. Thank you doctor

Answered by Dr Ian Phoon Kwong Yun, Family Physician, Associate Consultant, SingHealth Polyclinics - Pasir Ris

Dear tsendjaja,

Your diabetic control seems good while on this drug. If you had not had frequent low sugar level events (hypoglycaemia), and you feel fine with these medications, then you should continue, with no changes, since it’s working for you.

Best regards,
Dr Phoon.

Question by vls0

I have reversed my diabetes by adopting a ketogenic style diet. My glucose levels have dropped and chlosterol levels are improved. Why does my GP say this is not healthy?

Answered by Dr Ian Phoon Kwong Yun, Family Physician, Associate Consultant, SingHealth Polyclinics - Pasir Ris

Dear vls0,

There is some debate about the usefulness of this diet in the longer term. The ketogenic diet is generally a low carbohydrate, high fat diet. Some studies show that it does help in weight loss, and improvement in the overall glucose levels in the short term (less than 1 year). But the benefits are less clear in the longer term.

I’ve attached an article here from Diabetes UK

www.diabetes.org.uk/About_us/What-we-say/Food-nutrition-lifestyle/Low-carbohydrate-diets-for-people-with-Type-2-diabetes/

These are some of the excerpts:

“When considering a low-carbohydrate diet as an option for weight loss, people with diabetes should be made aware of possible side effects such as the risk of hypoglycaemia, head-aches, lack of concentration and constipation.”

“In conclusion, low-carbohydrate diets may be effective in facilitating weight loss in people with Type 2 diabetes in the short term, but there is no evidence that this approach is more successful in the long term than any other approach”

Below is an article from the Dietitian Association of Australia about this diet.

daa.asn.au/for-the-media/hot-topics-in-nutrition/low-carbohydrate-high-fat-diets-for-diabetes/

Excerpts:

“Both your brain and red blood cells require glucose and while some can be supplied by breaking down proteins in your body, there are a number of reasons why this is not beneficial and is specifically not recommended – for example, during childhood (due to growth requirements) and during pregnancy. The long-term effect of placing this demand on the body has also not been tested and there is evidence to suggest that performance in mental and physical tasks could be affected. Therefore, a diet that is very low in carbohydrate may not be physically or mentally sustainable as a diet pattern.”

“All fats are rich in energy (kilojoules) – containing twice the amount of kilojoules as either protein or carbohydrate – so if eaten in large amounts, can make weight control more difficult.”

Below is the “My Healthy Plate” recommendation by the Health Promotion Board. While it doesn’t avoid carbohydrates (rice/noodles/ bread etc), it limits this to only ¼ of your meal portion, which is a lot less than what most of us usually eat. It promotes more dietary fibre in fruits and vegetables (half the meal), and limits proteins like lean meats, tofu, and legumes to another ¼ of the plate. It does not promote foods rich in animal fats.

www.hpb.gov.sg/HOPPortal/health-article/HPB064355#fill_half_plate_veggie_subheader

You may want to discuss this with a certified dietitian.

Best regards,
Dr Ian Phoon.

Question by ribena

The husband's family history has diabetes. At the age 30, the husband does not have diabetes. Will the 1st child has a reduced chance of having diabetes in his later life. At the age 35, the husband has diabetes. Will the 2nd child has much higher chance of having diabetes in his later life. What are the chances respectively? What is the pregnancy complication? Should the family stop at 1 child?

Answered by Dr Ian Phoon Kwong Yun, Family Physician, Associate Consultant, SingHealth Polyclinics - Pasir Ris

Dear Ribena,

The risk factors for diabetes are:

• Obesity (e.g. body mass index = {height in meters/(weight in kg)2 } greater than 23 in Asians)
• 1st degree relatives with diabetes (parents or siblings)
• Above 40 years old
• Gestational diabetes (or diabetes in pregnancy)
• Pre-diabetes (blood sugar levels just below that seen in a diabetic)

While having 1or 2 parent(s) with diabetes (versus someone else who doesn’t) raises the risk of diabetes later on in life, there are factors other than genes (e.g. weight, diet, exercise, lifestyle) that’ll determine whether the child will eventually get diabetes or not.

Both the 1st and 2nd (or even 3rd or 4th) child carries the same risk of developing diabetes as they all share the same parents (and thus the gene pool), regardless of when the father develops diabetes (whether before or after they’re born).

You mentioned pregnancy complication. I presume you mean that of gestational diabetes (or diabetes in pregnancy). This is completely independent of whether your husband has a strong family history of diabetes or not. It has more to do with whether the wife is prone to getting diabetes or not, e.g. if she is overweight, was told she had high blood sugar levels before, has a parent or sibling with diabetes, or if she had a previous pregnancy with gestational diabetes.

Note that in gestational diabetes, it is the mother who has the diabetes, not the foetus. Complications of gestational diabetes include having a large baby, which can make delivery difficult, baby being born a little premature, baby may have breathing problems at delivery (respiratory distress), and ironically, baby has low blood sugar level after delivery (because the mother’s own high glucose over-stimulates the baby to produce insulin, a hormone that lowers blood sugar levels).

There’s no need to limit the number of children that this couple wants to have. As mentioned, the children may or may not develop diabetes in adulthood, and this risk can be reduced with a healthy lifestyle, and avoid becoming overweight. But even if they do eventually develop diabetes, they can still live a full and productive life while taking medications to control their blood sugar levels.

I hope I’ve answered your question.

Best regards,
Dr Phoon.

Question by mixpasta

I have pain (deep in the muscle) of both legs. Is this condition "pheripheral neuropathy"? Is there a need to see a neuro specialist or seek some physio treatment?

Answered by Dr Ian Phoon Kwong Yun, Family Physician, Associate Consultant, SingHealth Polyclinics - Pasir Ris

Dear mixpasta,

Peripheral neuropathy in diabetics usually presents with numbness or pins-and-needles from the toes, and extending upwards to the ankles and lower legs. It does not sound like what you have. Deep pain in the muscles of the legs may be due to other reasons, e.g. after walking or standing for a long time, or occasionally as a side effect of statins (a cholesterol-lowering drug). Aches from statins are usually mild, and will improve with some stretching and simple pain killers, and rarely need to be stopped.

Sometimes with a degenerative spine, the pain from the back can “spread” to the thighs (called “referred” pain), or it can pinch on one of the nerves coming out of your spinal cord, causing an “electric current” to run down your leg.

You may want to see your doctor to see exactly which muscle in your legs is having the pain (e.g. thighs or calves). Stretching, physiotherapy, and some oral pain killers may help to relief the pain.

Best regards,
Dr Phoon.

Question by leng leng

Dr Phoon,

I have my type II Diabetes for more than 10 years now I am 49 years old and I have been taken DIALOSA 3MG for more than 7 to 8 year and my diabetes is will control my sugar hypcount is from range 4 to 6 mmo/l recently the Dr told me that there is no stock for DIALOSA 3MG and he change me to DIAMICRON MR 60MG Just started for a month and I realize that my sugar hypcount range from 9 to 12 mmo/l. Beside is medication i also taking metformin 500mg 2 tablets 2 times per day. I really wonder is the medication not suitable for me can please help because of this I got no mood in my jobs.Thank.

Regard,
Linda Chong

Answered by Dr Ian Phoon Kwong Yun, Family Physician, Associate Consultant, SingHealth Polyclinics - Pasir Ris

Hi Linda,

Dialosa (Glimiperide), and Diamicron MR (Glicazide) are both of the same class of anti-diabetic medication called “sulphonylureas”. They act by stimulating your pancreas to produce more insulin, which in turn helps to lower the blood glucose level. Both drugs are taken once in the morning before breakfast.

The maximum dose for Dialosa is 8mg, and for Diamicron, it’s 120mg. So it seems that both the drugs you’ve been taking were at mid-dose. The effectiveness of both drugs is generally similar. It’s difficult to say if the higher blood glucose you’re seeing now with Diamicron MR is solely due to the change in drug, as there may be other factors, e.g. if you were less disciplined with your diet and exercise lately, or that your diabetes has actually progressed with time. If your lifestyle has not changed, then the last mentioned is the most likely explanation.

Your doctor may want to consider a few options (I’m assuming that your diet is controlled, and you’re trying to stay active already). One is to increase the metformin. The maximum dose of metformin is 1g, 3 times a day –higher doses may cause bloating, nausea, or flatulence. You’re already on 1g, twice a day, so this would just mean adding 1 more dose of metformin with lunch. Alternatively, he can increase the Diamicron MR to 120mg OM, but you’ll need to be careful about low blood sugar levels (hypoglycaemia). To avoid this, your meals should be regular.

Other options could include adding a 3rd anti-diabetic drug. But ultimately, if diet, exercise, and adding more drugs don’t control the blood sugar levels, then it may be a signal that your body isn’t able to produce enough insulin (the hormone that allows the blood sugar to be pulled into your cells in your organs for energy). Starting insulin injections once a night is a good way to overcome this problem. Modern insulin comes in pre-filled pens, and modern needles are very fine (like a strand of thick hair) and short (5-8 mm long). They can be injected into the tummy area easily with minimal discomfort. As it is given only once a night (at least initially), there is no need to take this insulin with you to work.

I know you must be frustrated. But if you have done your best to eat a balanced diet, stay active and taken your medication as prescribed, then it really isn’t your fault. Diabetes unfortunately is progressive, and your body will produce less insulin as you age. So even if you need to increase your diabetic medication, or even start insulin, please do not blame yourself. The important thing is that your blood sugar is controlled; to minimise the damage it can otherwise do to your organs. If you’re feeling depressed, talk to your doctor about this as well, as he may be able to help you cope with your feelings.

For easy reference, I’ve provided a link to the Health Promotion Board’s “Healthy Plate” webpage. This will serve as a guide to planning your meals.

www.hpb.gov.sg/HOPPortal/health-article/HPB064355#fill_half_plate_veggie_subheader

Take care.
Dr Phoon.

Question by austin3

I've recently been told I am pre-diabetic. And advised to cut down my drinking drastically. I love my wine and beer! But of course I love my life more... Can u give me advice on what is the reasonable maximum limit I can drink each day or week, without increasing my risk of getting diabetes ? Anything I can do like eat before / during and/or after I drink each time to balance out the sugar from the drinking ? Is that do able? Please advise.

Answered by Dr Ian Phoon Kwong Yun, Family Physician, Associate Consultant, SingHealth Polyclinics - Pasir Ris

Dear Austin3,

For any patient, including non-diabetics, and diabetics, the recommendation is to drink in moderation. That means not more than 2 standard drinks a day for a man, and 1 standard drink for a woman. Examples of 1 standard drink: 1 can (330 ml) of beer, or ½ a glass (175 ml) of wine.

Drinking with food slows down the absorption of alcohol, especially if the meal has more fats and oils. Sipping the alcohol beverage rather than gulping it down will also allow for a slower absorption of the alcohol. But nevertheless the calories in the alcohol will still be absorbed eventually, so it needs to be taken into account, and you may want to cut back on your carbohydrate portions (e.g. rice, noodles, bread, pasta etc).

So it’s ok to enjoy a little alcohol, if you know your limits. Staying physically active and eating a balanced meal (more fruits and vegetables, lean meats, limited carbohydrates) regularly will also help to prevent or delay the onset of diabetes.

For easy reference, I’ve provided a link to the Health Promotion Board’s “Healthy Plate” webpage. This will serve as a guide to planning your meals.

www.hpb.gov.sg/HOPPortal/health-article/HPB064355#fill_half_plate_veggie_subheader

Best regards,
Dr Phoon.

Question by patseet

I had several GTTS done over the past few years and most results have shown "borderline" diabetic condition. Most recent test also showed borderline condition and the doctor had prescribed "METFORMIN 250 mg tablet to be taken one every morning. Can you please advise whether such medication had to be taken for "life"? I am 68 years old and currently taking tablets every day for HBP & HCL.

Answered by Dr Ian Phoon Kwong Yun, Family Physician, Associate Consultant, SingHealth Polyclinics - Pasir Ris

Dear patseet,

I presume you’re already a diabetic, based on the last oral glucose tolerance test (OGTT). That means that either you have 2 fasting glucose at or above 7.0 mmol/l, or your 2-hour post-glucose drink is 11.1 mmol/l or more.

In this case then, what is your HbA1c reading? Ideally this should be less than 6.5%, but if it’s less than 7% it is acceptable. If less than 6.5% then you may not need to take the diabetic medication, but rather control your food intake, especially the carbohydrates, and exercise regularly. If it’s just below 7%, then it’s probably better to keep on the medicine, as your diabetes may worsen if you stop it.

The dose of metformin you’re taking now is not high. So it is also not wrong to take the medication even if your HbA1c is less than 6.5% as it may help to prevent the blood sugar levels from creeping up over time. The maximum daily dose of metformin is 1000mg, 3 times a day.

Find out your latest HbA1c level. You can discussit with your Dr if you can stop the medication and monitor your condition with just lifestyle control.

But do remember that diabetes can progress as we age, even if we do control our diet and try to exercise. So if you’re not able to control your HbA1c to below 7%, then you’ll need to be on the medication, or even add other diabetic medications – depending on the level of control you’re at.

Best regards,
Dr Phoon.

Question by rains_sg

Dear Doc,

If I had not eat anything for whole day due to work, shall I take something sweet or still avoid sugar. If I have 5 small meals instead of 3 normal meals, should I still take my medicine after breakfast, lunch and dinner?

Thanks,
May

Answered by Dr Ian Phoon Kwong Yun, Family Physician, Associate Consultant, SingHealth Polyclinics - Pasir Ris

Dear May,

Regarding what to eat if you haven’t eaten the whole day: If you have symptoms of hypoglycemia (e.g. dizziness, tremors, cold sweats, weakness ), then you should take half a glass of fruit juice or soda, or 3 sweets to quickly bring up your blood sugars. If you have a glucometer, you can check your blood sugar levels when you have these symptoms. A reading of less than 4 mmol/l would suggest that you have hypoglycemia.

But if you do not have these symptoms, you should eat a normal meal. This should include about 25 % carbohydrates (e.g. brown rice or noodles, whole meal bread), 25% proteins (lean meats, preferably white meats like chicken or fish, tofu, eggs), and 50% fruits and vegetables. You can take your diabetic medication with this meal.

If you decide to have 5 meals a day (e.g. breakfast, branch, lunch, dinner, supper), it’s still reasonable to take your medication with breakfast, lunch and dinner. This allows the medication to be spaced out throughout the day. Presumably your branch and supper should be lighter meals vs your breakfast/lunch and dinner.

Best regards,
Dr Phoon.

Question by colin.tingfm

Hi there,

My father suffered a stroke in November 2013 and was diagnosed with stroke with reduced blood flow affecting his left leg, and affected his frontal lobe. At that time, there was also conditions with high cholesterol and blood sugar (diabetes). Since then, he has been nursing and now he has been discharged by the stroke doctor. His other doctor assigned mainly monitors his blood sugar and cholesterol. I noticed that the blood sugar seems difficult for him to control, mainly between 10mmol and 13mmol. Sometimes there were days when it dropped to below 10 (about 9+) and sometimes it rose up to 11mmol the next day. I also noticed that he sweats easily and gets hungry easily. As a caregiver (together with my mother), what can we do to help him control his blood sugar without "provoking" him (noticed his change in behaviour), as I read from books and was advised from friends in the medical professionals, that stroke at frontal lobe does affect one's personality. His daily routines are having breakfast and lunch at hawker centre, and dinner at home. His medication are taken twice a day with Metformin, Aspirin, high blood medication in the morning and Sivasatin and Metformin after dinner.

Answered by Dr Ian Phoon Kwong Yun, Family Physician, Associate Consultant, SingHealth Polyclinics - Pasir Ris

Dear Colin,

So your father has a stroke (of the frontal lobe), diabetes, peripheral vascular disease (poor blood flow to the left leg), hypertension, and high cholesterol.

From his blood sugar readings, it does seem rather high. However his episodes of sweating and hunger are also a concern, as this may be due to low blood sugar readings. The best way to know if it is low, is to check his blood sugars when he has his sweating or hunger episodes. If the readings are less than 4 mmol/l, then he definitely has hypoglycaemia (low blood sugar), which means that his blood sugar is really labile. This can be due to irregular meals – both in timing and portions, as well as irregularities with his medication. Having kidney failure (if he does have this) would also make him more prone to labile sugars. Avoiding hypoglycaemia would mean trying to eat at regular times, and have similar portions each time.

But if during the above episodes, the blood sugars are as you’ve mentioned – from 9+ to 13 mmol/l, then these episodes aren’t due to hypoglycaemia. In which case, the metformin dose may need to be increased (e.g. taken 3 times a day), or a second oral diabetic medication can be added (if he is already on a high dose of metformin). As to what second oral diabetic medication is needed, you may need to discuss with his doctor, as there’re several classes of diabetic medication, which varies in their action, cost, and side effect profile.

It seems like he eats out for 2 meals of the day (breakfast, and lunch). So despite his stroke, he still seems quite independent, which is good. But it’ll be of interest to find out what he eats and drinks at the hawker centre. You or your mother may suggest going with him to the hawker centre to see what there is, or what he would recommend. Hopefully he’ll see this more as you or your mother wanting to keep him company, or showing interest in what he does, rather than trying to spy on him. Things that would push up his blood sugars would include pancakes with syrup, kaya bread, rice or noodle portions bigger than a fist size, big bowl of porridge, fried rice or noodles, sauces, sweetened beverages, condensed milk. Perhaps some healthier choices include popiah, sliced fish bee hoon, wonton mee (without the ketchup), yong tau fu (without the ketchup, chilli sauce), coffee/tea without sugar or condensed milk.

People with stroke do sometimes go into depression, so it’s good to also look to see if he has become more withdrawn. But the fact that he still goes to the hawker centre regularly, may suggest that he’s not currently depressed. Be supportive always, and show that you care for his well being.

Best regards,
Dr Phoon.

Question by ben_cheungs

Hi Doctor,

I've been into weight training for 15 years. That said, I've been taking sports supplements for the same period of time. 2 years ago, I'm diagnosed with diabetes type 2. I have mild diabetic condition and is taking 500mg of metformin twice a day. My condition is stable. GPs have been shunning my questions of taking sports supplements in particular to creatine monohydrate and I'm unable to get correct advice. My questions below: 1) Can a diabetic take creatine monohydrate? 2) will the consumption of creatine increases the level of creatinine in the kidney? 3) If creatine is safe for diabetic, what could possibly be the right doses that a diabetic should watch out. I'm taking 5g a day for a period of 3 mths and cycle off to rest for 3 mths before taking it again. Hopefully you can advise on the taking of creatine monohydrate for a diabetic patient.

Answered by Dr Ian Phoon Kwong Yun, Family Physician, Associate Consultant, SingHealth Polyclinics - Pasir Ris

Hi,

Unfortunately, there aren’t many studies done to be able to answer your questions definitively. Creatine is naturally found in meats. There are some studies that suggest that creatinine supplementation would improve short burst of energy such as the number of repetitions in your weight lifting or short sprints. However, it seems to have no effect on endurance sports. Also there’re uncertainties of the effects of creatine when taken long term (many years)

1. It isn’t known to worsen (nor improve) diabetes, and is probably safe, as long as your kidney and liver function is normal. But you’ll need to ensure that you hydrate yourself adequately.
2. Taking a high dose of creatine (e.g. > 5g a day) for prolonged periods, may cause the creatinine in your blood to rise as some of the creatine will be converted to creatinine. Stop creatine if your blood creatinine levels begin to rise. Again, you should ensure adequate hydration, but be cautions of “energy drinks”, which tends to have more glucose (sugars)
3. The optimal dose of creatine is unknown, especially in the long term. But it’s probably safer to avoid the high doses (> 5g a day).

You may want to explore why you need to take creatine supplements. Are you still able to exercise without it, especially if the goal is to keep fit, rather than for competition?

You may also want to include some aerobic exercises (e.g. jogging, cycling, or swimming) into your exercise regime, not just focus on weights, as the former will also exercise your heart, improve your stamina, and help to keep your blood sugars under control. This will give you a more balanced fitness. Creatine supplements do not seem to affect this type of exercises.

Best regards,
Dr Phoon.

Ref: Q15