According to the National Population Health 2020, there is an increase in the prevalence of Type 2 Diabetes from 8.8% in 2017 to 9.5% in 2020. 

Type 2 Diabetes is a growing epidemic worldwide with strong links to obesity, and tends to run in families. 

In most patients there are no symptoms for decades, but diabetes is the leading cause for kidney failure, foot amputations, blindness, and heart disease. 

It is often perceived as simply taking too much sugars, but this is only partly true. Obesity is a major risk factor for diabetes, along with having family members with diabetes, or if you had diabetes in pregnancy (also known as gestational diabetes). 

Taking too much carbohydrates (starchy food) like rice, noodles and bread as well as being inactive also contribute to this risk.

If you have questions or are unsure about anything related to preventing and managing diabetes, don't miss this opportunity to ask our Family Physician, Dr Sun Jingfeng.

Arming yourself with the right knowledge is the first step to beating diabetes!

About Dr Sun Jingfeng

Dr Sun graduated from Duke-NUS Medical School in 2016 with M.D. degree and obtained MRCP (UK) in 2019. She received her Master of Medicine in Family Medicine in 2022, and is currently practicing as a Family Physician at SingHealth Polyclinics.

Questions and answers on prevention and management of diabetes

1. Question by Rasid

Hi Dr,

I’m not sure if I have diabetes. How best to check?

Answer by Dr Sun Jingfeng

Dear Rasid,

The best way to check if you have diabetes is to do a blood test. The more accurate way is to do a fasting blood sugar test. If the result is 6.0 mmol/l or less, then you are considered normal. If it is more than 6.0 mmol/l, then you have pre-diabetes at the least called “impaired fating glucose”. 

Your doctor will then order an Oral Glucose Tolerance Test (OGTT). This consists of 2 tests: a fasting blood sugar test, and one done 2 hours after drinking a solution with 75 grams of sugar. If the 2-hour glucose test is more than 7.8 mmol/l, then you have “impaired glucose tolerance”, another type of “pre-diabetes”. If the result is 11.1 mmol/l or more, then you are in the diabetic zone.

It is best that you see your doctor to test for diabetes.

2. Question by Angie

Dear Dr Sun, this is a question related to my dad.

He got diabetes and been eating medicine and also cutting down all the sweets stuffs as well. I can say he is very disciplined. Especially on food.

Recently I noticed the polyclinic diabetic medicine like not effective on him anymore. He doesn’t take sweets stuffs and never white rice for a few years.

Been eating basmati rice for a few years. But somehow these few months his diabetes reading always at 10 or 11. It used to drop to 7.

Only these few months always this range.

Was it because the medicine not effective anymore or something else? Pls do advise.

Answer by Dr Sun Jingfeng

Dear Angie,

Unfortunately, diabetes can progress over the years as we age, even if one is careful with one’s diet and lifestyle. Most adults have type 2 diabetes, where there is resistance to the effect of a gut hormone called insulin. Insulin is produced in the pancreas and rises when we eat, to bring down the blood sugar. However, over the years the amount of insulin that the body can be produced decreases, especially if one is over-weight/obese.

Initially various oral diabetic medicine can help to bring down the blood sugar by different means. e.g., metformin makes the body more sensitive to insulin; other drugs may stimulate the body to produce more insulin, block the breakdown of insulin, cause more sugar to be passed in the urine, or delay the digestion of starchy foods.

As diabetes progresses (and the body produces less insulin) the doctor may start with 1, then 2, then 3 or more diabetic medicines. However, if by the time one is on 3 diabetic medications and the sugars are still high despite adhering to the right lifestyle, it probably means that one cannot produce much insulin, and this necessitates the initiation of insulin, which is given through a syringe and small needle over the abdomen. Once insulin is replaced, the blood glucose can go back to normal, albeit with some dose adjustments.

Do discuss with his doctor if it is time to initiate insulin for your father.

3. Question by Henry

Hi Dr,

I am a 75 year-old male Chinese.

All these years, I had annual fasting glucose test which were normal range.

Last year, a Polyclinic Dr included A1C test which was 6.3%. This suggest pre-diabetes. Repeat A1C 6 mths later was 5.7% with normal fasting glucose.

I am puzzled.  Do I hv pre-diabetes then?

I have hypertension, cholesterol and ckd 3a. Now all within normal range. Am overweight 70kg n 1.64m.

Does aging affect test results? I saw a guideline from Mayo clinic which provided A1C results by age. For my age, 7.0% is normal range.

Appreciate your opinion.

Answer by Dr Sun Jingfeng

Dear Henry,

Although HbA1c (glycated hemoglobin) can be used to screen for diabetes, there are several caveats that can sometimes make this test inaccurate.

Hemoglobin is the red pigment that makes our blood red. HbA1c (glycated hemoglobin) measures the amount of glucose (sugar) that sticks to hemoglobin over the last 90 to 120 days. The greater the average glucose in your blood over this period, the more the glucose sticks to hemoglobin, and the higher the HbA1c value.

However, conditions such as anemia and chronic kidney disease will affect the accuracy of HbA1C, as these conditions will affect the binding of glucose to hemoglobin. Thus, HbA1c is rarely used alone to diagnose diabetes. 

A HbA1c value of more than 6.0% is a signal to do a more detailed glucose test for diabetes. This is done either fasted, or after an oral glucose tolerance test (OGTT) whereby one drinks a 75g of glucose solution, and takes the blood glucose 2 hours later. If this is more than 7.8 mmol/l, then one has impaired glucose tolerance, and if one has a value more than 11.1 mmol/l, then one has diabetes.

Since your last fasting glucose is normal, then you don’t have diabetes or pre-diabetes. However, you are over-weight, and that puts you at risk for diabetes/ pre-diabetes. Do try to reduce your weight to about 61 kg (BMI 23), through a healthy diet and regular exercise.

4. Question by Henry

Dear Dr Sun,

Notably, there is an increase of Diabetes type II. What are the precautionary measures to adopt to minimise the chances of contracting the disease. Prevention is important to counter the problems. Kindly enlighten. Thank you.

Answer by Dr Sun Jingfeng

Dear Henry,

Preventing diabetes is more than just avoiding sweet food or drinks or avoiding rice. There are other forms of carbohydrates like noodles, pasta, prata, bread (especially white bread) that can be digested and broken down to become sugars in your blood. 

If you are obese, you should try to lose about 5% of your body weight. You should also try to be as physically active as possible.

Here are some ways to prevent:

• Lose about 5% of your body weight if you are over-weight or obese

• Not just reduce sugary food and drinks, but reduce the amount of carbohydrates (rice, noodles, bread, pasta, potatoes etc) you take to about ¼ of your plate, or a fist-sized portion

• Consider replacing carbohydrates with higher fibre like brown/basmati rice, whole meal bread or oats

• Take about a ¼ of your plate with lean / white meats like chicken and fish, and take about ½ a place of fruits and vegetables

• Stay physically active. Aim to brisk walk, cycle or swim at least 3-5 times a week, for 30 minutes each time

• Avoid or minimise alcohol consumption like beer

• If you are smoking, try to cut down or quit

5. Question by Daniel

Dear Dr,

My Hba1c is around 6.3-6.5% and the only medication that I take is a tablet of glucophage ER nightly.

In terms of diet and lifestyle, is there any difference between a diabetic and a pre-diabetic? Thank you.

Answer by Dr Sun Jingfeng

Dear Daniel,

It may be good to clarify with your doctor if you have diabetes or pre-diabetes. Glucophage (metformin) can be used to treat both.

There isn’t any difference in terms of diet and lifestyle between diabetic and pre-diabetic. They represent different degrees of the same spectrum.

6. Question by Hwee Yee

Dear Dr Sun,

I suspect my 21-yr-old son may have diabetes. But he has phobia for needles.

Is there any non-invasive ways to check his blood sugar level? He can't take finger prick test too. Thanks for your advice.

Answer by Dr Sun Jingfeng

Dear Hwee Yee,

The best way to check for diabetes is through a blood test. All other methods e.g. testing the urine for glucose, are not accurate. If he has enlisted to the army before, they usually will do a blood test also.

You may want to accompany him to see a doctor (with his permission) or discuss why you suspect that he has diabetes. Overt symptoms of diabetes are unexplained loss of weight, frequent thirst, and passing a lot of urine. He may also be obese.

Keeping a healthy weight, reducing the carbohydrate intake (e.g. rice, noodles, bread, cakes, cookies, pastries), and staying physically active are good ways to prevent diabetes even if he doesn’t have diabetes yet.

7. Question by Menon

Hello Dr Sun,

I have type 2 diabetes for about 20 years. I have managed to maintain a good level of control.

Last year I had an endoscopy done. That resulted in my new challenge as I am now having IBS-D.

Here lies my problem. How can I manage my type 2 diabetes and IBS at the same time, considering that the foods beneficial for diabetes management may worsen my IBS symptoms?

Thank you in anticipation.

Answer by Dr Sun Jingfeng

Dear Menon,

This isn’t a straightforward answer. Firstly, it is good to hear that you have maintained good glucose control for the last 20 years.

You may want to have a discussion with a dietitian, about the right diet for you. Generally, a healthy diet consists of about only 25% carbohydrates, 25% of lean meats and protein, and 50% of fruits and vegetables. But sometimes taking more fibre may not be suitable for some people with IBS. You have to find the right balance and monitor your blood sugars along the way.

Exercise is helpful for both diabetes and IBS. Do aim to be active on at least 3-5 days of the week (ideally 150 mins of exercise a week).

Management of stress, anxiety and sleep are also important aspects of managing both diabetes and IBS.

8. Question by Gerard

Dear Dr,

Can you explain the differences in length of needles (6mm vs 8 mm) and the capillary differences (say 30g vs 31g) and how they impact on delivery of insulin?

How do you find which would be the most comfortable to use for short-acting and long-acting insulin injections?

Also, why is there a price difference between the various combinations available on the market? Eg. between 6mm and 8mm etc. shouldn’t they all be at least based on a common price between brands? Thank you!

Answer by Dr Sun Jingfeng

Dear Gerard,

Insulin needles generally vary in terms of length (e.g. 4, 6 or 8mm), and bore size (e.g. 30, 31 or 32G).

The length of the needle often does not matter too much and most patients use the 4 or 6mm needle as this is long enough to penetrate the skin layer and reach the subcutaneous layer.

Some patients may want a longer needle if they feel that their skin is thicker, or if they tend to give their insulin over their clothes (e.g. in public places).

For the bore size, the bigger the number, the smaller the bore. Some patients feel less pain with smaller bores, but a bigger bore allows insulin to be injected with less resistance.

Ultimately, it’s not one-size-fits-all, and you may want to try out which is the most suited for you. As each needle is made by different companies, the prices may vary.

9. Question by Chin Song

Hi Dr Sun,

I am a 70-year-old man (I turn 71 next month) and received my HBA1c result recently. My reading is 6.0, the doctor who attended to me did not mention anything about my sugar level.

I checked the MOH webpage and realized I fell into the pre-diabetes category.

Do I need to be concerned about my reading? If yes what is your advice?

Answer by Dr Sun Jingfeng

Dear Chin Song,

According to the MOH guide, HbA1c is used to screen for diabetes without the need to fast. If the HbA1c is more than 6.0% (e.g. 6.1% or more) then the doctor will order an oral glucose tolerance test (OGTT). This involves doing both a fasting blood sugar test, and another done 2 hours after drinking a 75g solution of sugar. If the fasting glucose is more than 6.1 mmol/l or if the 2-hour sugar is more than 7.8 mmol/l, then you may have pre-diabetes or diabetes.

As your last HbA1c is 6.0%, it does not cross the threshold for doing the OGTT. However, it is at the high end, and you may still want to watch your intake of carbohydrates, such as rice, noodles, bread, cakes, cookies, pastries, sweetened drinks etc.

10. Question by Esther

Hi Dr Sun,

I have been taking fasting blood glucose tests yearly since 2015 and the readings have slowly crept up from 4.7 to 5.8. I'm now 56 years old.

In end 2021, I took the oral glucose tolerance test, the fasting blood glucose was 5.2 but the 2hr post OGTT glucose was 8.7. I repeated the OGTT this month and the results were the same.

My hba1c since 2022 varies between 5.4-5.7. I've been doing 16/8 intermittent fasting most days, occasionally doing 24-48 hr fast. My BMI is about 19. What else can I do to bring down my blood glucose? Appreciate your advice.

Answer by Dr Sun Jingfeng

Dear Esther,

It seems that you may have impaired glucose tolerance (a pre-diabetic state). This is when your fasting sugars are normal but tends to be high after a carbohydrate load. You are not diabetic yet.

Your BMI is on the low-normal side. There’s probably not a need to do intermittent fasting. What’s more important is what you eat when it is time to eat. If you tend to eat large meals with a lot of carbohydrates (e.g. rice, noodles, bread) to last your intermittent fasting period, you may cause your sugars to spike after those large meals.

Get a glucometer to check your blood sugars at home, before and 2 hours after a meal to see what that shows. If after 2 hours, your glucose reaches 10 mmol/l or more, than you probably need to cut back on the carbohydrates.

It may be easier to break up your meals to 2-3 portions a day, so that each is not large. This should consist of about 25% of carbohydrates, 25% of lean meats and protein, and 50% fruits and vegetables. For the carbohydrates, you may try brown or basmati rice, whole meal bread or oats.

Exercise is another aspect that can help control your blood sugars. Aim to stay active at least 3-5 times a week for about 30 minutes each.

11. Question by Michael

Dear Dr Sun,

My questions about diabetes are:

1. If someone who can improve the HbA1c by lowering down from 10 to 6.7 by taking medicine such as Galvusmet and Diamicron, can he/she reduce the medicine dosage gradually?

2. For someone with diabetes type 2, is there any way to improve the pancreas function by stem cell treatment so he/she is able to regenerate the good pancreas cell to minimise long-term medicine treatment?

Thank you for your advice.

Answer by Dr Sun Jingfeng

Dear Michael,

1.It is great that your HbA1C has been lowered significantly.

You are currently taking 3 types of diabetic medications, (Galvusmet consists of 2 diabetic medications: Metformin and Vildagliptin). Requiring 3 diabetic medications to control your diabetes means that you probably have increased resistance to the effect of a gut hormone called insulin, and need these medications to keep it at that level. In fact, if you’re no longer able to maintain your HbA1c below 7% despite taking 3 diabetic medication, you may need to consider starting insulin (a hormone given via a small injection over the abdomen).

If you reduce your medication dosage, it is possible that your blood sugar levels will start to rise again. You should regularly check your blood sugar levels with a glucometer, and keep your fasting sugar below 7.0 mmol/l, or below 10 mmol/l 2 hours after food.

Whilst a HbA1c of 6.7% is considered “good control” as it is below 7%, it is not normal. According to the American Diabetic Association, a patient without diabetes ought to have a HbA1c below 5.7%. Your control is probably just under control with the medication that you’re on, and reducing it is generally not advisable.

Do discuss with your doctor if you are keen to reduce the medication dosage. You should also continue a healthy lifestyle to keep your blood sugar levels under control.

2. Improving pancreas function via stem cell treatment is still being researched and not an established treatment option. Most adult patients with diabetes have Type 2, which is primarily due to insulin resistance rather than a lack of insulin. Thus, even if the insulin-making cells can be restored, some oral medication will likely still be needed.

The less common Type 1 diabetes have their insulin-making cells destroyed by their own immune system, but they don’t have insulin resistance. So at least in theory, they may benefit more if their insulin-making cells can be regenerated.

12. Question by Chan YL

Hi Doctor,

Can a diabetic patient go on intermittent fasting if on insulin jab and metformin? How can I do it safely?

Answer by Dr Sun Jingfeng

Dear YL,

You are not advised to go on intermittent fasting while on insulin jab and metformin. People on intermittent fasting tend to eat larger meals with a lot of carbohydrates (e.g. rice, noodles, bread) to last the fasting period, which may cause your blood sugar levels to spike after those large meals. There is also an increased risk of low blood sugars (hypoglycemia) if you fast for prolonged periods while on insulin jab, so it is generally not recommended. Rather, try to have regular meals, but avoid large meals each time.

You are advised to get a glucometer, and check your blood sugar levels at home, before and 2 hours after a meal. If your glucose reaches 10 mmol/l or more after 2 hours, you will probably need to cut back on carbohydrates.

It may be easier to break up your meals to 2-3 portions a day, so that each meal is not large. This should consist of about 25% of carbohydrates, 25% of lean meats and protein, and 50% fruits and vegetables. For the carbohydrates, you may try brown / basmati rice, whole meal bread or oats.

13. Question by Kim

Dear Dr Sun,

I have two questions:

I am obese and, did the glucose tolerance test in 2021 and informed by the doctor that my glucose level of 7 confirmed the diagnosis that I was diabetic.

I lost closed to 10kg in the three months following the diagnosis, and my glucose level returned to normal.

The past two years, the weight that I lost slowly crept back, and I noticed that my glucose is back to pre-diabetic level.

May I know if I am considered a diabetic? Thank you for your time.

Answer by Dr Sun Jingfeng

Dear Kim,

Diabetes is diagnosed either by doing a fasting glucose test, or after an oral glucose tolerance test (OGTT).

Normal fasting blood sugars should be no more than 6 mmol/l. When the fasting sugars are between 6.1 – 6.9 mmol/l, this is known as “Impaired Fasting Glucose (IFG)”, and when the fasting sugars are 7.0 mmol/l or more, this is in the diabetic range. When given a 75g glucose drink (the glucose tolerance test), and the blood sugars are in between 7.9 to 11.0 mmol/l, this is known as “Impaired Glucose Tolerance (IGT), and if it is 11.1 mmol/l or more, it is in the diabetic range.

If there are no overt symptoms of diabetes such as frequent thirst, passing a lot of urine, or unexplained loss of weight, Doctors would generally advise the patient to repeat any of the above glucose test on a separate day to see if any of them still falls in the diabetic range. If it falls in this range on at least two occasions, then the diagnosis of diabetes is established.

Diabetes is a chronic condition. Once diagnosed with diabetes, the label stays, even if the sugars come down. Diabetes and Pre-Diabetes are on the same spectrum at different degrees of severity. Both are due to insulin resistance from obesity.

However, diabetic patients can still achieve good control of blood sugar level via the following lifestyle modifications and diabetic medications if required:

• Lose about 5% of your body weight

• Not just reduce sugary food and drinks, but reduce the amount of carbohydrates (rice, noodles, bread, pasta, potatoes etc) you take to about ¼ of your plate, or a fist-sized portion

• Consider carbohydrates with higher fibre like brown/ basmati rice, whole meal bread or oats

• Take about a ¼ of your plate with lean / white meats like chicken and fish, and take about ½ a plate of fruits and vegetables

• Stay physically active. Aim to brisk walk, cycle or swim at least 3-5 times a week, for 30 minutes each time

• Avoid or minimise alcohol like beer

• If you are smoking, try to cut down or quit

You may want to discuss your weight management with your doctor.

14. Question by Fong HB

Dear Dr,

I am a male patient aged 82 years old.

I have been diagnosed with Type 2 Diabetes for several years.

As a result, I have significantly reduced my intake of Carbohydrates and Sugar and practice Intermittent Fasting 3 to 4 times a week. I exercise 3 to 4 times a week for an hour or more each time.

My weight has reduced from 78 Kg to 63 Kg

My HBA1c reading range between 4.9 and 5.2 for the past 2 years.

I am now on 2.5mg Glipizide and 2.5mgTrajentra once a day. (From 5gm each, twice a day)

I feel great!

My question is, when can I stop taking Medication? I understand that the side effects from continuous use of Glipizide is not desirable.

Appreciate your advice.

Answer by Dr Sun Jingfeng

Dear Mr Fong,

It is great that you are keeping a healthy lifestyle and having well-controlled diabetes. As you are 82-year-old (> 75 years old), an acceptable HbA1C is below 8%.

As your HbA1C is well controlled, you can choose to reduce or stop your medication gradually. If you stop your medication, you should regularly check your blood sugars with a glucometer. If you are not able to keep your fasting sugar below 7.0 mmol/l or below 10 mmol/l 2 hours after food, then you should resume back the old dose of your medicine.

Do discuss with your doctor first if you are keen to reduce/stop the medication dosage. You should also continue the healthy lifestyle to keep your sugar under control.

The main risk of taking glipizide is the risk of low blood sugar, especially given that your HbA1c is in the normal range, and that you are 82 years old.

15. Question by Doreen

Hi Dr,

Is sourdough bread better for diabetes?

If not the case, which type of bread is the best for diabetes? Thanks!

Answer by Dr Sun Jingfeng

Dear Doreen,

Bread made with 100% whole grains and no added sugar are suitable for diabetes. The high fibre content leads to a lower rise in blood sugar compared to other breads (especially white bread). 

Sourdough bread has a lower glycemic index than other types of bread and is a good choice for diabetic patients. Other types of bread that is recommended for diabetes is whole meal bread. Do remember to keep the sourdough bread portion and overall carbohydrate intake to ¼ plate or fist-size portion (1-2 slices)

Preventing diabetes is more than just avoiding white bread or sweet food or drinks. There are other forms of carbohydrates like noodles, pasta, and prata that can be digested and broken down to become sugars in your blood. If you are obese, you should try to lose about 5% of your body weight. You should also try to be as physically active as possible.

16. Question by Diana

Dear Dr,

I am a diabetic 2 patient.  I like to take rambutan and other seasonal fruits

Like Thailand long kong.

I ate a lot about 300g to 500g per day but I will check my blood sugar after one hour of consumed. Found that sugar level at 6.5.

So, I continue with this habit. Would like to find out is it very harmful?

Thank you for your advice.

Answer by Dr Sun Jingfeng

Dear Diana,

Both rambutan and long kong are fruits that are high in natural sugar and may increase blood sugar levels if taken in excess. The recommended daily intake for adults is around 2 servings of fruits a day. 1 serving of fruit is around 4-5 rambutans or 8 long kongs. 300g to 500g per day of rambutan and long kong is more than the recommended daily serving of fruits. It would be best to cut down your current servings of fruits to help control your blood sugar better.

Fruits that are recommended for diabetic patients are high fibre fruits like apples, and pears which does not produce high blood sugar spikes as the high fibre content slow down the rate at which sugar is being released into the blood stream.

It is recommended to check your blood sugar before and two hours after a meal to see what that shows. If your glucose reaches 10mmol/l or more two hours after consuming the fruits, you probably need to cut back on the fruits.

17. Question by Iris

Dear Dr Sun,

I am on follow-up appointment for my hypertension, high cholesterol and diabetes at a Polyclinic. At certain time, I tend to have high sugar level in my blood when tested. But doctor usually will tell me that it's not too alarming and no medication is required for my case. So, is mine considered as Type 2 diabetes and what kind of diet is good to control my blood sugar? Thank you.

Answer by Dr Sun Jingfeng

Dear Iris,

You most likely have type 2 diabetes which is the most common type of diabetes by far. Type 2 diabetes is often associated with high blood pressure (hypertension) and high cholesterol (dyslipidemia). All three “highs” (i.e. high-sugar, high blood pressure, and high cholesterol) needs to be controlled, most commonly with oral medicines.

Since you are not on medication for diabetes, you probably have well controlled diabetes, and will need to maintain a healthy lifestyle to keep your blood sugar levels under control. To be sure, I would advise that you get a glucometer, to check your own blood sugars. Ideally, your fasting sugar should be below 7.0 mmol/l, or below 10 mmol/l  two hours after food. Sometimes the decision whether to start treatment for diabetes or not also depends on your age, e.g. if you are already more than 75 years old, and your sugars are only slightly high.

Preventing diabetes is more than just avoiding sweet food or drinks or avoiding rice. There are other forms of carbohydrates like noodles, pasta, prata, bread (especially white bread) that can be digested and broken down to become sugars in your blood. If you are obese, you should try to lose about 5% of your body weight. You should also try to be as physically active as possible.

Here are some ways to control your diabetes:

• Lose about 5% of your body weight if you are over-weight or obese

• Not just reduce sugary food and drinks, but reduce the amount of carbohydrates (rice, noodles, bread, pasta, potatoes etc) you take to about ¼ of your plate, or a fist-sized portion

• Consider carbohydrates with higher fibre like brown/ basmati rice, whole meal bread or oats

• Take about a ¼ of your plate with lean / white meats like chicken and fish, and take about ½ a plate of fruits and vegetables

• Stay physically active. Aim to brisk walk, cycle or swim at least 3-5 times a week, for 30 minutes each time

• Avoid or minimise alcohol like beer

• If you are smoking, try to cut down or quit

18. Question by Wai LC

Dear Dr,

I have my type 2 diabetes for more than 20 years now and I am 57 years old.

I seldom eat sweet things and I eat brown rice but my hba1c is around 9 and my Dr always change medication for me, sometimes I have been changing medication every 3 months if my hba1c is high.

Can advise me what to eat and what should I do at the same time? Thanks.

Answer by Dr Sun Jingfeng

Dear Wai LC,

Unfortunately, diabetes can progress over the years as we age, even if one is careful with one’s diet and lifestyle. Most adults have type 2 diabetes, where there is resistance to the effect of a gut hormone called insulin. Insulin is produced in the pancreas and rises when we eat, to bring down the blood sugar. But over the years the amount of insulin that the body can be produced decreases, especially if one is over-weight/obese.

Initially various oral diabetic medicine can help to bring down the blood sugar by different means. For example, metformin makes the body more sensitive to insulin. Other drugs may stimulate the body to produce more insulin, block the breakdown of insulin, cause more sugar to be passed in the urine, or delay the digestion of starchy foods.

As diabetes progresses (and the body produces less insulin), your doctor may start with 1, then 2, then 3 or more diabetic medicine. If one is on 3 diabetic medications and the blood sugar levels are still high despite adhering to the right lifestyle, it probably means that you cannot produce enough insulin, and this necessitates the initiation of insulin, which is given through a syringe and small needle over the abdomen. Once insulin is replaced, the blood glucose can go back to normal, albeit with some dose adjustments.

Your target HbA1C is <7%, if your HbA1C is persistently 9% and you are already on 3 or more diabetic medications, so do discuss with your doctor if it is time to initiate insulin.

Preventing diabetes is more than just avoiding sweet food or drinks or avoiding rice. There are other forms of carbohydrates like noodles, pasta, prata, bread (especially white bread) that can be digested and broken down to become sugars in your blood. If you are obese, you should try to lose about 5% of your body weight. You should also try to be as physically active as possible.

Here are some lifestyle measures to control your blood glucose:

• Lose about 5% of your body weight if you are over-weight or obese

• Not just reduce sugary food and drinks, but reduce the amount of carbohydrates (rice, noodles, bread, pasta, potatoes etc) you take to about ¼ of your plate, or a fist-sized portion
  

• Consider carbohydrates with higher fibre like brown/ basmati rice, whole meal bread or oats

• Take about a ¼ of your plate with lean / white meats like chicken and fish, and take about ½ a plate of fruits and vegetables

• Stay physically active. Aim to brisk walk, cycle or swim at least 3-5 times a week, for 30 minutes each time

• Avoid or minimise alcohol like beer

• If you are smoking, try to cut down or quit

19. Question by Mdm Ong

Dear Dr Sun,

I have been a Type 2 Diabetic patient for the past 20 years. I am 75 years old this year. My last HbA1C in July 2023 was 6.9. I am currently taking 500mg of Metformin.

With the controlled diet and doing routine house chores with frequent walking exercise, I am able to keep my weight below 57kg at a height of about 130cm. My recent 2-3 weeks’ daily fasting blood glucose in the morning hovers around 6.0 to 7.5, mainly less than 7.0.

I was given to understand that once a diabetic patient, a person will be diabetic patient for life.

My question is: Is it true that diabetes cannot be cured based on medical research and large population surveys? If it is untrue, please advise how to induce pancreas to produce more insulin.

Looking forward to your reply, thank you.

Answer by Dr Sun Jingfeng

Dear Mdm Ong,

It is great that you have been keeping yourself active and keeping your glucose under control. The ideal fasting sugar should be below 7.0 mmol/l or below 10 mmol/l 2 hours after food.

It is true that diabetes once diagnosed is not curable, however, diabetic patients can still maintain optimal blood glucose level via a healthy lifestyle and medications.

In type 2 diabetes, there is resistance to the effect of a gut hormone called insulin. Insulin is produced in the pancreas and rises when we eat, to bring down the blood sugar levels. Over the years, the amount of insulin that the body can produce decreases, especially if one is overweight or obese.

As your BMI is 33.7 km/m2, you are considered obese, by losing 5% of your body weight, it can help to increase the amount of insulin your body produces.

Reducing the carbohydrate intake (e.g. rice, noodles, bread, cakes, cookies, pastries), and staying physically active are also good ways to control type 2 diabetes and help with insulin resistance.

Various oral diabetic medications can also help to control blood sugar in type 2 diabetes by different means. For example, metformin makes the body more sensitive to insulin. Other drugs may stimulate the body to produce more insulin, block the breakdown of insulin, cause more sugar to be passed in the urine, or delay the digestion of starchy foods.

20. Question by SC

Dear Dr,

Just to check with you - what is the accepted range of blood sugar reading for diabetics, 1 hour after food and 2 hrs after food?

Answer by Dr Sun Jingfeng

Dear SC,

For diabetic patients, the ideal fasting sugar should be below 7.0 mmol/l and below 10 mmol/l two hours after food. We do not typically advise to check blood sugar reading one hour after food, but this should also be kept below 10 mmol/l.

21. Question by Jason

Dear Dr Sun,

For people who are currently pre-diabetic, is it reversible?

Does it mean that a pre-diabetic person will certainly become diabetic in the future?

Answer by Dr Sun Jingfeng

Dear Jason,

Yes, pre-diabetes is reversible. Pre-diabetes patients can potentially revert to normal glucose levels by adopting the following lifestyle:

• Lose about 5% of your body weight if you are over-weight or obese.

• Not just reduce sugary food and drinks, but reduce the amount of carbohydrates (rice, noodles, bread, pasta, potatoes etc) you take to about ¼ of your plate, or a fist-sized portion

• Consider carbohydrates with higher fibre like brown/ basmati rice, whole meal bread or oats

• Take about a ¼ of your plate with lean / white meats like chicken and fish, and take about ½ a place of fruits and vegetables

• Stay physically active. Aim to brisk walk, cycle or swim at least 3-5 times a week, for 30 minutes each time
  

• Avoid or minimise alcohol like beer

• If you are smoking, try to cut down or quit
  

If you have pre-diabetes, you are at a greater risk of progression to frank diabetes, but it does not mean that you will certainly become diabetic in the future. You can adopt the above lifestyle modifications to reduce your risk of becoming diabetic.

22. Question by Clarence

Hi Dr,

I was recently diagnosed with Diabetes, and am currently on Metformin 500 which I usually take one after lunch and one in the evening.

I noticed that my blood sugar seems to spike to about 11mmol between 10 to 11 am despite not eating or having coffee. It would taper down within the hour. It would climb again after lunch, which I assume is normal. In your experience, is this indeed normal?

Answer by Dr Sun Jingfeng

Dear Clarence,

Blood sugar spike in the morning despite not eating breakfast can be the caused by several factors, such as if you ate a large meal with a lot of carbohydrates the night before, stress, or diurnal variation due to hormones that your body naturally makes in the morning.

It is however not normal to have a high fasting blood glucose of 11 mmol/L. Whenever possible, you should keep your fasting sugar below 7.0 mmol/l, or below 10 mmol/l 2 hours after food. You may want to speak to your doctor about being put on a continuous glucose monitor to understand your glucose pattern better. Regardless of the cause, you do have insulin resistance, and may need to increase your diabetic medication.

You can also try to reduce blood sugar spike in the morning by limiting your night-time intake of carbohydrates, and to exercise regularly.

23. Question by Karen

Dear Dr Sun,

I have the following questions related to diabetes.

a) What is the gold standard tools for measuring one’s blood sugar level? Is it the oral glucose test, the hba1c, the fasting blood sugar test or a continuous glucose monitor. I hear/read different opinions about each. And maybe this is not the right forum but if it’s the glucose monitor, why is it not a subsidised item if it can allow one to monitor one’s sugar level and make preventative decisions on the spot.

b) What is the healthy range of values for the above tests for the Asian population and age. My mum had a reading of 6.6 for her fasting glucose test and they said that was ok for her age (77 years). I thought that it was too high based on other range of values I’ve come across.

c) Is an insulin test equivalent to a glucose test? Are they measuring the same thing? Is one test a better/more accurate measure of diabetes?

d) Is time restriction fasting/intermittent fasting able to reverse type 2 diabetes and if yes, is it safe for someone who is post-menopausal.

I know it’s a lot of questions, hopefully they are appropriate for this forum, thank you for your time.

Answer by Dr Sun Jingfeng

Dear Karen,

a) The most accurate way to diagnose diabetes is to do a fasting blood sugar by drawing blood. If the measurement is 6.0 mmol/l or less, then it is considered normal. If it is more than 6.0 mmol/l, then you have pre-diabetes at the least (specifically this is called “impaired fating glucose”). Your doctor will then order an Oral Glucose Tolerance Test (OGTT). This consists of 2 tests - a fasting sugar, and one done 2 hours after drinking a solution with 75 grams of sugar. If the 2-hour glucose test is more than 7.8 mmol/l, then you have “impaired glucose tolerance”, another type of “pre-diabetes”. If the measurement is 11.1 mmol/l or more, then you are in the diabetic zone.

Although HbA1c (glycated haemoglobin) can be used to screen for diabetes, there are several caveats that can sometimes make this test inaccurate, such as if you have anaemia (low haemoglobin) or chronic kidney disease. Thus, HbA1c is rarely used alone to diagnose diabetes. A HbA1c value of more than 6.0% is a signal to do a more detailed glucose test for diabetes. This is done via either fasting blood sugar, or an oral glucose tolerance test (OGTT).

Continuous glucose monitor measures the glucose in the fluid surrounding your cells (interstitial fluid) instead of measuring the glucose level in your blood and may not be as accurate as fasting blood sugar. It is not used to diagnose diabetes, but is a useful tool to monitor one’s blood sugars over time once the diagnosis of diabetes or pre-diabetes has been made. Similarly, you may also monitor your blood sugar using a glucometer, but this only gives you a value at the point that you check it. Continuous glucose monitor can give you a 24-hour profile.

Unfortunately, I am unable to address why tests are not subsidised.

b) The normal fasting blood glucose should be 6.0 mmol/l or less in someone who does not have pre-diabetes or diabetes. Likewise, HbA1c value should be less than 6%, a HbA1C reading of more than 6.0% is abnormal and is a signal to do a more detailed glucose test for diabetes.

Your mother has a fasting glucose of 6.6 mmol/l, which puts her in the “Impaired Fasting Glucose” category, which is a pre-diabetic condition. Her doctor was probably not too concern, as it may take several years for her to develop diabetes, and then perhaps another 10-15 years to develop any complications from diabetes. By which, she will likely be in her 90s. Nevertheless, since she does have pre-diabetes, she should reduce the amount of carbohydrates she takes.

c) A glucose test measure the blood sugar, while an insulin test measures the C-peptide, a marker of how much insulin the body has. An insulin test is used to test for type 1 diabetes, which usually happens in teens or adolescents, due to the body’s immune system destroying the insulin-producing cells. A very low level indicates that the patient has type 1 diabetes. Most adults who have type 2 diabetes, are usually due to insulin resistance rather than a lack of insulin. Hence, to diagnose diabetes, the more accurate way is to do a fasting blood glucose as mentioned above.

d) Unfortunately, Type 2 diabetes once diagnosed is not curable. However, diabetic patients can still maintain optimal or near normal blood glucose level via a healthy lifestyle and medications.

We do not generally advise to go on time-restricted fasting or intermittent fasting, as intermittent fasting tends to cause you to eat large meals with a lot of carbohydrates (e.g. rice, noodles, bread) to last the fasting period. This may cause your sugars to spike after those large meals. There is also a risk of low blood sugars (hypoglycemia) if you fast for prolonged periods, and is generally not recommended. Rather, try to have regular meals, but avoid large meals each time.

You may break up your meals to 2-3 portions a day, that consists of about 25% of carbohydrates, 25% of lean meats and protein, and 50% fruits and vegetables. For the carbohydrates, you may try brown or basmati rice, whole meal bread or oats.

Here are some ways to control your diabetes:

• Lose about 5% of your body weight if you are over-weight or obese

• Not just reduce sugary food and drinks, but reduce the amount of carbohydrates (rice, noodles, bread, pasta, potatoes etc) you take to about ¼ of your plate, or a fist-sized portion
  

• Consider carbohydrates with higher fibre like brown/ basmati rice, whole meal bread or oats

• Take about a ¼ of your plate with lean / white meats like chicken and fish, and take about ½ a place of fruits and vegetables

• Stay physically active. Aim to brisk walk, cycle or swim at least 3-5 times a week, for 30 minutes each time

• Avoid or minimise alcohol like beer

• If you are smoking, try to cut down or quit

24. Question by Kulvinder

Hi Doctor,

I started intermittent fasting 16:8 to manage my weight and food intake.  However, I have not seen significant improvement on my HBA1c. I took part in a study conducted by SGH.

What should I be doing differently? How should I monitor my blood sugar on a daily basis?

Answer by Dr Sun Jingfeng

Dear Kulvinder,

Your fasting glucose is high (about 8 mmol/L) and spikes during the 6 hour window when you eat. Intermittent fasting does not seem to be bringing down your blood glucose. If you are not on diabetes medications yet, you will need to start diabetes medications to aim fasting glucose of <7.0 mmol/L. If you are already on diabetes medications, the dose will need to be increased.

It is probably better not to do intermittent fasting, but rather break up your meals to 2-3 portions, so that each meal is not large. Each meal should consist of about 25% of carbohydrates, 25% of lean meats and protein, and 50% fruits and vegetables. For the carbohydrates, you may try brown or basmati rice, whole meal bread or oats.

You should also aim for about 150 min of moderate intensity exercise a week, such as brisk walking, cycling or swimming. If you are sedentary, you can start light, and gradually increase the duration and intensity of exercise.

You should speak to your doctor about the Libre report, and also consult a dietitian on how to optimise your glucose profile. Your doctor will advise you on what diabetes medication you should be taking.

25. Question by Philip

Dear Doctor,

I am a type 2 diabetic for more than 20 years now. Here are my questions:

a) I am on insulin - Nova Rapid for 3 times depending on my meals ranging from 10 - 14 and Lantus Solostar - 20 morning and 5 dinner. I notice that if I take a drink like milo or a pack of biscuit (3 pieces), I get up less for the toilet, like 2 to 3 hours interval. But if I do not take anything before bed, I tend to go to the toilet hourly. I am just puzzled. Is there any reason for this?

b) I am also on metformin (850) for the 3 meals, I just want to know what are the effects of having metformin.

Why I ask is because I have many incidents of low blood sugar count in the middle of the night. My doctor allows me to split the solostar as I have found that it has a better control on my fasting blood sugar. I prompted whether is it because of the metformin which I usually take it before sleep as well with my other heart medication. Her reply that it should not be and suggested that I reduce the dinner dose of sololstar from 8 to 5, which it helps with very rare low blood sugar count. I reduced to 4 for the dinner dose which does not help with the fasting blood count.

So I just want to know how the metformin acts after dinner and should it be taken immediately after meal?

The reason is because I am doubting the effectiveness of metformin.

Thank you for your advice.

Answer by Dr Sun Jingfeng

Dear Philip,

a) Your increased urinary frequency may not be related to your blood glucose level or the food you eat.

In poorly controlled diabetes, especially if your blood glucose is persistently very high, there will be symptoms of frequent thirst and passing of a lot of urine. However, if you do not consume anything before bed, it should not cause high glucose level, or explain why you have increased urinary frequency. However, hypoglycaemia (low blood sugar) may also happen when you do not eat anything before sleeping.

This may be the cause of what is waking you up, and you may perhaps want to pass urine at the same time.

If your blood glucose is well controlled but experiencing persistent urinary frequency, you should consult your doctor to see if there are other possible causes, such as urinary tract infection or side effects of other medications that you may be taking, causing your frequent urination.

b) Metformin decreases the amount of glucose produced by the liver and makes the body more sensitive to insulin, thereby reducing the sugar level in the blood. Metformin is less likely to cause low blood sugar compared with insulin and should be taken together with or after your meals.

If you experience repeated incidence of low blood sugar count in the middle of the night, it is likely due to your night dose of insulin. You should discuss with your doctor to see if your medication needs to be adjusted further to reduce your incidence of low blood sugar in the middle of the night. This may include lowering your Novorapid dose before dinner, as it may contribute to hypoglycaemia during the night.

26. Question by Marco

Dear Dr Sun Jingfeng,

I have the following questions:

a) Can diabetes be reversed?

b) Can TCM help?

c) Can the medication to be stopped? How?

d) Monk Fruit - is it helpful for Diabetics? Can take it daily to replace sugar or sweet drink?Da

e) Dandelion Root & Dandelion Lead - Drink. Does it help to reduce/ lower blood sugar levels? How much and how often to drink it to be safe?

f) Diabetic dermopathy. This condition is also known as shin spots, and it’s harmless. The spots look like red or brown round patches or lines in the skin and are common in people with diabetes. They appear on the front of your legs (your shins) and are often confused with age spots. The spots don’t hurt, itch, or open up.

Can it be treated? Will the spot be reduce if diabetes is well control?

Thank you in advance.

Answer by Dr Sun Jingfeng

Dear Marco,

a) Unfortunately, Type 2 diabetes once diagnosed is not curable. However, diabetic patients can still maintain optimal or near normal blood glucose level via a healthy lifestyle and medications.

b) Conventional ways to control diabetes is via healthy lifestyle and diabetes medications. Traditional Chinese Medicine (TCM) should not replace conventional medical treatments for diabetes. If you want to use TCM in conjunction with your diabetes medications, it should always be done with the knowledge and advice of a qualified TCM practitioner. Do discuss with your western medical doctor first if you are planning to use TCM. More importantly you should monitor your own glucose levels with a glucometer, to see there are effects on the treatment.

c) Diabetes medicines work with a healthy lifestyle to keep your sugar in the normal range. For most patients, diabetes medication will need to be taken for life to control diabetes.

If you choose to stop your medication it is likely that your sugars will start to rise again. You should check your blood sugars with a glucometer regularly. If you are not able to keep your fasting sugar below 7.0 mmol/l or below 10 mmol/l 2 hours after food, then you should not stop your medication. Please consult your doctor before stopping any diabetes medication.

d) Monk fruit is naturally very sweet, it does not seem to contain much carbohydrates and is used as an artificial sweetener. However, there is no established data to prove that it is effective for diabetes. As with all food, you should take it in moderation. Do consult your dietitian and doctor first before using it daily to replace sugar or sweet drinks.

e) Dandelion root and dandelion leaf may contain chemicals that lower blood glucose. However, it is not a conventional treatment for diabetes and there is no established data to prove that it is safe or effective for diabetes. The chemicals may also interact with other medications and have other side effects. Hence, do consult your doctor first prior to taking dandelion root or dandelion leaf drink.

f) There is currently no treatment for diabetic dermopathy or shin spots. This skin condition may resolve spontaneously over time or persist indefinitely even if diabetes is well controlled.

27. Question by William

Dear Dr Sun,

Is it possible to reverse type 2 diabetes naturally without medication?

Does intermittent fasting help reverse type two diabetes? Thank you.

Answer by Dr Sun Jingfeng

Dear William,

Unfortunately, Type 2 diabetes once diagnosed is not curable. However, diabetic patients can still maintain optimal or near normal blood glucose level via a healthy lifestyle. Most type 2 diabetes patients will also require medications to control their glucose level.

While intermittent fasting can lead to drop in blood glucose level, it does not cure or reverse type 2 diabetes. We do not generally advise to go on time-restricted fasting or intermittent fasting, as intermittent fasting tends to cause you to eat large meals with a lot of carbohydrates (e.g. rice, noodles, bread) to last the fasting period. This may cause your sugars to spike after those large meals. There is also a risk of low blood sugars (hypoglycemia) if you fast for prolonged periods and is generally not recommended. Rather, try to have regular meals, but avoid large meals each time.

You may break up your meals to 2-3 portions a day, that consists of about 25% of carbohydrates, 25% of lean meats and protein, and 50% fruits and vegetables. For the carbohydrates, you may try brown or basmati rice, whole meal bread or oats.

Here are some lifestyle modifications you can adopt to control your glucose:

• Lose about 5% of your body weight if you are over-weight or obese

• Not just reduce sugary food and drinks, but reduce the amount of carbohydrates (rice, noodles, bread, pasta, potatoes etc) you take to about ¼ of your plate, or a fist-sized portion

• Consider carbohydrates with higher fibre like brown/ basmati rice, whole meal bread or oats
  

• Take about a ¼ of your plate with lean / white meats like chicken and fish, and take about ½ a place of fruits and vegetables

• Stay physically active. Aim to brisk walk, cycle or swim at least 3-5 times a week, for 30 minutes each time

• Avoid or minimise alcohol like beer

• If you are smoking, try to cut down or quit

28. Question by Jenny

Dear Dr Sun Jingfeng,

As a Diabetes patient, can I take bee pollen granules or bee pollen tablets as a supplement? Thank you.

Answer by Dr Sun Jingfeng

Dear Jenny,

Bee pollen granules and tablets comes from the pollen that collects on the bodies of bees as they fly from one flower to another. There is no proven health benefits based on literature data, and if you have pollen allergy or are allergic to bees, there is also a chance of developing allergic reaction if you take bee pollen granules or tablets. Some bee pollen granules or tablets may also contain carbohydrates content, which may increase blood glucose level.

You should check with your doctor prior to consuming bee pollen granule or tablets as a supplement. More importantly, you should monitor your blood sugar regularly, regardless of whether you choose to take the bee pollen or not. This will help you see if your blood sugars are under control.

Ref: I23