After 51 years of relative peace, Singapore is at war. This time it's with diabetes .
A taskforce has been unleashing a salvo of initiatives since 2016 . Fellow citizens young and old have convened and plotted ways to fight this abomination . A Guardian of Health, adroit as she is in Chinese martial arts, has sliced thousands of bak kwa from greedy hands with sugar defeating darts.
Enter you. You’re indifferent to this strife, idly munching on the figurative and/or literal popcorn as you watch the drama unfold.
Chances are, you belong to one of two categories:
Category 1: The Courageous Prediabetic
Your doctor has diagnosed you with prediabetes:
Prediabetes: a condition where your blood glucose levels are higher than normal, but lower than diabetes thresholds .
You might have been scared into abstaining from your daily cup of teh c for two weeks, but your worry has evaporated. Your resolve has solidified. You’re officially back to your old ways, washing away any fear of type 2 diabetes mellitus (T2DM) with that sweet, sweet tea.
Category 2: The Confident Non-prediabetic
You’re not prediabetic, so you’re pretty sure that you’re far from the clutches of T2DM. Or, at least, your doctor didn’t say anything about T2DM and was more concerned about the flu you were having. You don’t remember the last time you went for a health screening precisely because you never thought you needed one.
In either case, your body doesn’t feel bad, which makes you think you’ve got the time and the means to continue your lifestyle.
But how much time do you have until that pesky T2DM sneaks in?
It's probably wiser to learn more about your risks first. That way, you can keep an eye on T2DM and make sure it doesn’t come smack you in the face while you’re busy gorging on roti prata.
T2DM Risks for Category 1: The Courageous Prediabetic
If you’re prediabetic, you could probably relate to my mum attempting to defy all odds of T2DM. This might include stirring sugar into your tea vehemently with rationalisations such as:
“Prediabetes is not diabetes. “Pre”, what. Means ‘not yet’.”
“The doctor never give me medicine or injections, so it’s not that bad.”
This is exactly why some doctors and researchers have frowned upon using the term ‘prediabetes’. It downplays the severity of having higher-than-normal blood glucose levels, considering how many people with prediabetes do eventually get T2DM .
In Singapore, about 1 in 3 prediabetics will progress to T2DM within 8 years .
But wait, you say. Don’t try to cheat me.
You’ve dutifully done your research and found articles stating that, according to a team of British and American researchers, many people with prediabetes won’t develop T2DM , . It’s simply a case of doctors being too eager to diagnose.
Well, not quite.
What these articles don’t mention is the context of the research. In 2003, the American Diabetes Association (ADA) relaxed one of the diagnostic criteria for prediabetes, thus implicating throngs of people that may not all have the same, significant risk for T2DM , .
One of ADA's diagnostic criteria for prediabetes has a lower threshold than that of WHO.
That’s what the researchers are referring to when they say that the diagnosis of prediabetes isn’t helpful: using ADA’s criteria would unnecessarily increase the prevalence of prediabetes and cause an epidemic.
(Un)fortunately for us, Singapore adopts WHO’s more stringent diagnostic criteria for prediabetes, which are more accurate predictors of those at a higher risk of developing T2DM .
Meaning if your doctor tells you that you have prediabetes, it is a cause for concern!
In fact, if you share other risk factors as the people in Category 2 as outlined below, your risks for T2DM are further amplified.
T2DM Risks for Category 2: The Confident Non-prediabetic
Since there’s a category of people with prediabetes, surely you, free from such a diagnosis, are at least one degree further away from getting T2DM.
For the love of ice kachang, I really wish I could say that’s the case. But alas, having prediabetes is just one of the risk factors. Other factors may put you at equal risk of developing T2DM, including :
Researchers have already identified at least four genes which allow T2DM to be passed down from one generation to the next . So if you have a parent or sibling with T2DM, you’re at higher risk of developing it yourself.
Body Mass Index (BMI)
Having a BMI of 23 and above puts you at moderate risk of getting T2DM, while anything above a BMI of 27.5 constitutes high risk .
Singapore's BMI classifications .
But wait, you say. Don’t try to cheat me again.
You’re 1.65m tall and weigh 62.6 kg. Sure, that’s not exactly stick thin, but your BMI of 23 places you within the normal weight range. Aren’t overweight and obese people the ones who should be worried about T2DM ?
WHO's BMI classifications .
Turns out, us Asians have different associations between BMI, body fat percentage and T2DM risks than the ones gleaned from WHO’s BMI classifications. WHO itself has agreed that there’s been high prevalence of T2DM in Asia where the average BMI falls below the cut-off point of 25 kg/m^2 for its overweight category . This could be because we tend to store 3 to 4% more body fat than Caucasians for the same BMI , making us comparatively more susceptible to T2DM.
That sucks, huh? Lemme add one final sprinkle of salt to your wounds.
You’ve heard that the older you get, the higher your chances of developing T2DM. Again, this trend mostly applies to those of European lineage .
Over here, about 1 in 3 people with T2DM develop the condition before hitting 40 years old ! According to Dr Goh Su-Yen, the Senior Consultant and Head of Department of Endocrinology at Singapore General Hospital:
The average age that diabetes was diagnosed in this group was 30. That’s quite young. … When diabetes is diagnosed at a younger age, it means the patient would be living longer with diabetes.
Which only means that you’ve gotta be mindful of T2DM - the sooner, the better.
T2DM, So What?
Statistics are worrying. The outlook is bleak. Snack aisles lie abandoned, save for one lone wolf hoarding chips.
Maybe, you venture. Just maybe, it doesn’t matter if I get T2DM so long as I can live with it. What’s the worst that can happen, right?
Alright, you asked for it. Let’s find out.
Signs and Symptoms of T2DM
These include :
I mean, I guess you could avoid driving. Don’t bump into chairs or cut yourself. Shift your bedroom into your bathroom. What else is there to fret about, right?
Complications of T2DM
These include :
Yikes! This is serious. Granted, not all T2DM patients will develop these complications, but I sincerely hope you’re not gonna take your chances. Might as well play it safe, eh.
Ugh, But How?
I know how horribly low motivation can be, so I’m only gonna talk about the simplest ways to start managing your risks of developing T2DM.
Old (Dietary) Habits Die Hard
Let’s face it. Completely staving off desserts is impossible if you’ve got a sweet tooth, or if you’re just too used to having a soft drink with your meal.
What you can do is reduce the amount and the frequency at which you consume your vice. If your habit has been to have two scoops of ice cream every week, try cutting it down to one scoop a week (and maybe share the sugar - er, I mean, love - with your friends and family). Then when you’re ready, drop it to once a fortnight. Once in three weeks. Once a month, and so forth. It’s better than nothing.
Same thing for your starchy staples. If you’re used to eating white rice, which has a sky-high glycemic index (GI) of at least 70, why not try mixing it with lower GI alternatives like brown rice or basmati rice if you can’t make a thorough switch? The lower the GI of the food, the less your blood glucose level spikes after consumption .
Personally, I haven’t had a food coma since switching to brown rice, so the 20-30 minutes I used to spend napping post-meal can now be devoted to other things. Yay!
I've also been able to eat smaller portions and stay full longer.
An example of my meal portion. Bye bye, sky-high GI!
Doing 100 reps of push-ups and sit-ups alone at home is … well, repetitive, and boring. Entice your friends and family with a weekly game of badminton or jogging session; take it as an covert apology for stuffing them with your ice cream earlier. Agreeing to exercise together holds you both accountable for each other, so you’re way more likely to sustain your schedule.
Or if you’ve just missed your bus, why not walk? This suggestion is especially relevant if you live one kilometre away from the MRT and the frequency of the only bus in your area is fifteen freaking minutes --
But I digress.
Yes. In the sweltering heat of Singapore, arm yourself with an umbrella and hit the road.
And if you’re worried about people mocking you for resembling an auntie, simply look them dead in the eye, declare your status as a diabetes infantry trooper, and carry on.
A little goes a long way in using up that blood glucose.
$5 Health Screening!
For the price of one plate of rojak, you’ll be offered a health screening by the Health Promotion Board if you’re found to be at risk of diabetes through their diabetes risk assessment tool, which you can take here.
The assessment tool is totally free, only seven questions long, and takes two minutes to answer!
To Fight, or Not to Fight
Congratulations! You’re now more aware of your risks of developing T2DM, regardless of whether you were a courageous prediabetic or confident non-prediabetic.
If you choose to continue in your ways, then please stay alert. Keep monitoring for signs of T2DM’s presence.
But if you decide to take up arms against our national enemy, then I wish you the best of luck.
Spring forth, soldier. The time to fight is now.
Ministry of Health, "Speech by Mr Gan Kim Yong, Minister for Health, at the Opening Ceremony of World Diabetes Day Singapore 2016, 13 November 2016 | Ministry of Health", 13 November 2016. [Online]. Available: https://www.moh.gov.sg/content/moh_web/home/pressRoom/speeches_d/2016/speech-by-mr-gan-kim-yong--minister-for-health--at-the-opening-c0.html. [Accessed: 1 Jun 2018].
Ministry of Health, "ANNEX B DIABETES PREVENTION & CARE TASKFORCE MEMBERS". [Online]. Available: https://www.moh.gov.sg/content/dam/moh_web/PressRoom/Press%20releases/Annex%20B%20-%20TF%20Members.pdf. [Accessed: 1 Jun 2018].
Singapore Government, "Ideas! - War on Diabetes: Application to be a Citizens' Jury Participant", 5 Oct 2017. [Online]. Available: https://ideas.ecitizen.gov.sg/egp/process/EGOV/EideasChallenge/?challengeId=20061. [Accessed: 1 Jun 2018].
Ministry of Health, "Managing pre-diabetes - a growing health concern", Agency for Care Effectiveness, 3 August 2017. [Online]. Available: https://www.moh.gov.sg/content/dam/moh_web/ACE-HTA/public-data/our-guidance/Managing%20Pre-diabetes%20(Updated%20on%203%20August%202017).pdf. [Accessed: 1 Jun 2018].
A. Tabák, C. Herder, W. Rathmann, E. Brunner and M. Kivimäki, "Prediabetes: a high-risk state for diabetes development", The Lancet, vol. 379, no. 9833, pp. 2279-2290, 2012.
K. Wood, "Prediabetes is a label that is unhelpful and unnecessary", 16 July 2014. [Online]. Available: https://www.diabetes.co.uk/news/2014/jul/prediabetes-is-a-label-that-is-unhelpful-and-unnecessary-90977261.html.[Accessed: 1 Jun 2018].
G. Vieira, "Is the Diagnosis of "Pre-Diabetes" More Harmful than Helpful?", 31 July 2014. [Online]. Available: https://www.diabetesdaily.com/blog/2014/07/is-the-diagnosis-of-pre-diabetes-more-harmful-than-helpful/. [Accessed: 1 Jun 2018].
J. Yudkin and V. Montori, "The epidemic of pre-diabetes: the medicine and the politics", BMJ, vol. 349, no. 1524, pp. g4485-g4485, 2014.
J. Yudkin, "“Prediabetes”: Are There Problems With This Label? Yes, the Label Creates Further Problems!", Diabetes Care, vol. 39, no. 8, pp. 1468-1471, 2016.
N. Forouhi, J. Luan, S. Hennings and N. Wareham, "Incidence of Type 2 diabetes in England and its association with baseline impaired fasting glucose: The Ely study 1990-2000", Diabetic Medicine, vol. 24, no. 2, pp. 200-207, 2007.
R. Sladek, G. Rocheleau, J. Rung, C. Dina, L. Shen, D. Serre, P. Boutin, D. Vincent, A. Belisle, S. Hadjadj, B. Balkau, B. Heude, G. Charpentier, T. Hudson, A. Montpetit, A. Pshezhetsky, M. Prentki, B. Posner, D. Balding, D. Meyre, C. Polychronakos and P. Froguel, "A genome-wide association study identifies novel risk loci for type 2 diabetes", Nature, vol. 445, no. 7130, pp. 881-885, 2007.
Singapore General Hospital, "Obesity – Singapore General Hospital". [Online]. Available: https://www.sgh.com.sg/subsites/life-centre/life%20centre%20specialties/units/obesity-and-metabolic-unit/conditions-and-treatments/pages/obesity.aspx. [Accessed: 1 Jun 2018].
 Diabetes.co.uk, "Diabetes and Obesity". [Online]. Available: https://www.diabetes.co.uk/diabetes-and-obesity.html. [Accessed: 1 Jun 2018].
B. Corazon, C. Tommaso, C. Jeffery, D. Ian, D. Paul, D. Mabel, G. Tim, J. Philip, K. Garry, K. Vongsvat, K. Shikiri, K. Anura, M. Nick, H. K. Moon, N. Fumio, N. Chizuru, N. M. Ismail, R. K. Srinath, R. Elaine, J. T. Schultz, S. Japp, S. June, S. Boyd, T. Kathryn, W. Robert, Z. Wu, Y. C. S., Y. Nobuo and Z. Paul, "Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies", The Lancet, vol. 363, no. 9403, pp. 157-163, 2004.
K. Salma, "Asians 'more at risk of diabetes than Caucasians'", The Straits Times, 6 May 2016. [Online]. Available: https://www.straitstimes.com/singapore/health/asians-more-at-risk-of-diabetes-than-caucasians [Accessed: 1 Jun 2018].
K. Yoon, J. Lee, J. Kim, J. Cho, Y. Choi, S. Ko, P. Zimmet and H. Son, "Epidemic obesity and type 2 diabetes in Asia", The Lancet, vol. 368, no. 9548, pp. 1681-1688, 2006.
H. L. Chua, “ Type 2 diabetes patients getting younger (Singapore Health Issue, November-December 2015, Pg 6),” SGH Work-Life – Singapore General Hospital, 1 Nov 2015. [Online]. Available: https://www.sgh.com.sg/about-us/newsroom/News-Articles-Reports/Pages/type-2-diabetes-patients-younger.aspx. [Accessed: 1 Jun 2018].
M. M. Teh, “Essential Guide,” SingHealth, HealthXchange. [Online]. Available: https://www.healthxchange.sg/diabetes/essential-guide-diabetes/diabetes-signs-symptoms. [Accessed: 1 Jun 2018].
I. M. Stratton, “Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): prospective observational study,” BMJ, vol. 321, no. 7258, pp. 405–412, Dec. 2000.
Y. T. Lim, "Cardiovascular Disease in Adults with Type 2 Diabetes Mellitus," Diabetes Singapore, Apr - Jun 2016. [Online]. Available: https://www.diabetes.org.sg/resources/2016/0416-cardio.pdf. [Accessed: 1 Jun 2018].
Singapore National Eye Centre,"Diabetic Retinopathy." [Online]. Available: https://www.snec.com.sg/eye-conditions-and-treatments/common-eye-conditions-and-procedures/Pages/diabetic-retinopathy.aspx. [Accessed: 1 Jun 2018].
National Healthcare Group,“SINGAPORE: ONE OF WORLD’S HIGHEST FOR DIABETES - RELATED LEG AMPUTATIONS Late presentation of diabetic foot ulcers and poor public awareness of diabetes - related complications major factors,” 26 Apr 2016. [Online]. Available: https://corp.nhg.com.sg/Media%20Releases/LEA%20Singapore_FINAL_edited.pdf. [Accessed: 1 Jun 2018].
Ministry of Health,“The GI Values of Common Foods,” HealthHub, 12-Nov-2016. [Online]. Available: https://www.healthhub.sg/live-healthy/1330/the-gi-values-of-common-foods. [Accessed: 1 Jun 2018].