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This article is adapted and translated from Lian He Zao Bao. Originally written by Kang Xiu Jin.

Diabetes can be managed by leading a healthy lifestyle, adhering to healthy dietary patterns, a healthy diet and regular exercise. Adults under 40 years old should also complete an online diabetes risk assessment to determine if they are at risk of diabetes.

Common Questions on Diabetes

Question:
Is diabetes a disease only for the elderly?

Must you lose weight in order to control diabetes?

Answer:

I believe that excessive bodyweight is one of the main factors in Singapore’s rise in pravelence of diabetes mellitus. 40-50% of the adult population are obese or overweight. Apart from lack of exercise, and sedentary lifestyle, unhealthy dietary patterns and social pressure from friends are factors that contribute to the rise in excessive body fat.

That’s why diabetes can affect both young and elderly. In the case of Type 2 diabetes, prevalence increases with age due to the increased insulin resistance and impaired pancreatic functions associated with age.

The National Health survey done in 2010 (NHS 2010) reported that 12.3% of Singaporean males and 10.4% of females are likely to develop diabetes. However, this does not mean that ladies less at risk compared to males and can ignore the warning signs.

Diabetes is still a serious chronic illness that can potentially affect one’s heart, blood vessels, kidney, legs and eyes, so do not treat it lightly. With a healthy lifestyle, proper diet and frequent exercise, diabetes can be controlled and potentially be prevented.

I would like to emphasise that you should control diabetes before it controls you!

Cytokine blocks body signal to intake Insulin

It is undeniable that excessive body weight  will worsen diabetes and make it harder to control blood sugar. Adipose tissue in people with excessive body fat are stressed as they  are required to process excessive nutrients inflammation which releases pro-inflammatory cytokines. These pro-inflammatory cytokines are associated with insulin resistance which can lead to the development of diabetes.

Furthermore, being overweight and obese increases the risk of complications such as heart disease, kidney problems, stroke and other related problems that affects one’s lifestyle. Therefore, achieving a healthy body weight will definitely improve  one’s health. A study in Finland reported that losing weight has reduced the risks of diabetes in people by 58%.

Many believe that Type 2 diabetes will definitely show some early symptoms first. Although many early-stage patients appear with early symptoms such as frequent urination, often feeling thirsty and tired. However, there are many more that do not suffer from early stage symptoms when they were diagnosed with diabetes, which is the reason for encouraging people above 40 to do a physical check with a doctor.

For those of age below 40years old, an online check will be more than sufficient to know one’s risk of being diagnosed with diabetes.

Living a healthy lifestyle using mobile applications

I often say, if one is to want to effectively achieve control diabetes, they need to start with building sustainable healthy lifestyle habits, here are a few suggestions:

• Using “nBuddy Diabetes” app to record your daily intake of food

• Ensure every day’s calorie intake is healthy and limit intake of sugar

• Choosing “nBuddy Diabetes” app function, choosing a healthy diet of food with a green thumbs up and have not more than 2 times of “red meat” a week.

• Go for a walk 4 times a week, starting with 3,000 steps at the beginning and slowly increase  10,000  steps.

• Weigh yourself twice a week (best to be Wednesdays and Sundays)

• Check your blood sugar levels twice a week

Walking is a physical activity that everyone can do anytime, anywhere. Thus it is a highly recommended activity for those diagnosed with diabetes. The recommendation would be to go for a walk 30 minutes daily, 5 times a week.  This exercise can ay, for example, splitting the 30minutes a day into 10 minutes 3 times in a day.

NUH’s “nBuddy Diabetes” app shows that frequent users of the app are likely to benefit from positive health outcomes.  Users that record their food intake daily are able to lose 6 to 8kg in overall body weight, far exceeding other users’ results when they only record their intake once a week. As for users that are able to follow the app’s instructions and limit carbohydrate intake on 6 days of the  week, they reported better long term glycemic control with lowered Hba1cPeople diagnosed with diabetes are also advised to check their Hba1c levels once every 3 months,with  normal levels range around 5% to 6%, and diabetic people should aim to have their haemoglobin level below 7%.

Sustainable lifestyle habits have been found to be dependent on the diabetes diagnosed person’s calorie and carbohydrate intake. Providing personalised dietary intake advice via mobile applications will assist  diabetics to adopt a healthy lifestyle. For example, choosing wholegrains instead of refined grains. . When dining outside, adhere to the Health Promotion Board’s “My Healthy plate” of half a plate of vegetables, a quarter plate of protein and carbohydrates each.

With the current epidemic, local medical services are heavily affected. From another perspective, this is a chance for medical professionals to adopt remote treatment for patients with chronic illnesses like diabetes. For example, usage of medically approved mobile apps, helping patients to be self-monitor and change their lifestyle habits and dietary intake on their own.

Skinny diabetes

Many believe  that only overweight or obese people can be diagnosed with diabetes, however this is untrue  For those that have successfully lost weight and can managecontrolling their blood sugars, they still have diabetes. Should they re-adopt back unhealthy lifestyle practices, the blood sugar level will rise uncontrollably leading to ketosis which results in tremendous weight loss. Other may experience rapid weight loss not due to healthy balanced diet but rather as a result of underlying chronic illness affecting their appetite , causing them to unintended weight loss.

About 10% to 15% of people with type 2 diabetes are within a healthy weight range. We call it “lean diabetes”, and it is a “mixture” of type 1 or type 2 diabetes, meaning the body doesn’t produce enough insulin.

Early lessons for children to adopt healthy eating habits

For those with a healthy weight but still diagnosed with diabetes, your skeletal muscles may have accumulated a dangerous amount of fats. 

Family history of diabetes is one of the biggest risk of diabetes, however the bigger problem  lies within one’s dietary habits. Therefore, those diagnosed with diabetes or a family history of diabetes, should bring up their kids with the right dietary intake and a healthy amount of exercise from young, reducing unhealthy lifestyle choices, such as refusing to eat vegetables or not wanting to exercise, etc.

Therefore, I recommend that people with diabetes or a family history of diabetes should raise their children not only to eat healthy and exercise from an early age but to avoid unhealthy dietary practice and sedentary lifestyles. 

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Landmark studies have shown that lifestyle interventions focusing on weight loss, dietary modification  and physical activities are able to prevent progression of diabetes. Although this is the case, the widespread implementation will be hindered due to a few limitations. In-person coaching for large areas lacks manpower, is time-consuming and very costly.

Smartphone app-based lifestyle intervention programmes are the focus of the solutions, but how effective can they be?

D’LITE Study research 

Well, according to the Diabetes Lifestyle Intervention using Technology Empowerment (D’LITE) studies where 2 groups of adults tried out 2 different programs for 6months. 148 total Adults with prediabetes were randomly allocated into 2 groups, 1 empowered by self-monitoring features of the Nutritionist Buddy Diabetes app (nBuddy Diabetes) with in-app dietician coaching for 6 months and the other group receiving standard diet counselling at baseline.

Results from the D’LITE Intervention shows that the group using the nBuddy Diabetes App were able to achieve a significantly greater weight loss, corresponding to weight loss percentage 5.2% vs 1.5% (P<0.001) with a moderate Cohen d effect size, as compared to the control group at the 6^th month. The same group also has significantly reduced calorie, carbohydrate, sugar, total fat and saturated fat intake post-intervention.

Mobile health applications prove some effect

Smartphone app-based lifestyle programme with in-app dietitian health coaching can lead to clinically significant weight loss and improved glycemia and can potentially improve the prevention of diabetes among an Asian multi-ethnic population. 

Trajectory from pre-diabetes towards type 2 diabetes can be altered by weight loss through lifestyle interventions. Landmark studies have established that interventions focusing on weight loss, diet modification and physical activity can prevent diabetes progression. Widespread implementation of traditional face-to-face diabetes prevention efforts is limited by low uptake, high attrition and withdrawal rates

To read up more on the study done:

https://www.frontiersin.org/articles/10.3389/fnut.2021.780567/full

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With the help of nBuddy Diabetes app, 70year old trainer Mr Yang Chao Zong managed to shave off 16kg and gained control of his sugar levels by making lifestyle and dietary changes.

Locally, more than 640000 Singaporeans are diabetic. Research has shown that obesity increases the risk of developing type 2 diabetes by up to 80% to 85%, thus carrying excessive body weight does not equate to prosperity. With the help of nBuddy mobile app, the 70-year old instructor has not only managed to lose about 16kg, in 1 year, but has also managed to improve his blood glucose control. 

Yang has been living for the past 12 years with diabetes. He was first diagnosed with high blood pressure, and then high cholesterol. He says that the combination of his inability to manage his appetite and obesity, contributed to his condition. He also believes that it was his own right to consume whatever he wishes leading to him reaching a weight of 92kg at one point.

In an interview with Lianhe Zaobao, together with Chief NUH Dietitian Dr Lim Su Lin, Yang confessed that it was only in the last 5-6 years that he accepted the fact that he was diagnosed with diabetes.”

Mr Yang shared that initially he did not experience any obvious symptoms and believed that by taking medications and having regular check-ups would be sufficient to manage his diabetes Furthermore, it was cultural that Chinese tend to refuse the fact that they have fallen ill, even so for their love of food.

Yang shared that he has no family history of diabetes. Even with his weight soaring to 92kg, Yang shared that he didn’t feel that there was anything wrong, furthermore, he sheepishly remarked that he used to think that being fat was a blessing. 

Results seen after 3 months

It was not until 4 August 2018, Yang’s first contact with NUH Chief Dietitian Dr Lim Su Lin, by participating in the research mobile application “Nutritionist Buddy Diabetes” (nBuddy Diabetes). Mr Yang carefully followed instructions and made changes to his diet and lifestyle, leading to him losing around 14-to 16kg in a year.

He continues: “I was told by the Doctor that if I don’t manage my condition well, it may lead to complications like proteinuria (protein in the urine), leading to chronic kidney disease, eventually leading to kidney failure which will require lifelong dialysis.

He confessed saying when he travels to Shanghai, it’s a must for him to eat braised pork. His favourite local dishes include laksa, char kway teow and tao suan. Cheesecake is another dish that is irresistible.

Yang said that when he first started using nBuddy Diabetes, almost every dish exceeded his dietary requirements; however after 3 months, he saw a gradual reduction of weight and blood glucose levels. Within half a year, he successfully lost 6 to 8kg while his HbA1c decreased from 10% to 6%. His diabetic medications were even reduced to once daily and high blood pressure medication reduced by half.

Managing your diet to manage your weight

Mr Yang shared that he weighed about 72kg before the pandemic however due to the reduction of outdoor activities and consuming lovely meals prepared by his wife, his weight has increased slightly to 75kg. However, he monitors his weight closely to prevent any further weight gain.

He said, “For the past 3 years, I have been going for a 30 minute brisk walk every morning. Food wise, I do not eat anything fried and I insist on less salt, sugar and oil. In the past, I loved to eat roasted pork, but now rarely. On occasions when I do choose to eat these foods, I tend to choose more lean cuts and select steamed or grilled fish. I used to eat Laksa weekly but now I only give it a go every 3 months or so.”

On the other hand, if he has any dishes he is a little addicted to, he will satisfy his craving with only a bite or two rather than finish the entire dish by himself Even if there was cheesecake, a dish Yang cannot resist, he will only take a bite.

Yang continues, “Now I choose to consume mainly only brown rice and high quality, lean protein like fish and skinless chicken. Fruits wise I would manage my portion size which helps me manage my blood glucose levels and also reduce my meal portions by half. A healthy diet is not about avoiding everything but rather making smart choices. ”

After losing weight, Yang found himself a lot lighter, going up and down the stairs no longer gave him any knee pains. He became much more energetic and has a reduction in his waist size by 4 inches to 34 inches now.

“To me, these significant changes has been my main source of motivation.”

Yang’s height is 173cm which means his ideal weight is 69kg. However, he is not pursuing quick weight loss, but rather is focusing on healthy dietary patterns and lifestyle. 

He says, “This app (nBuddy Diabetes) has changed my life. Actually, change in diet is about choosing healthy foods rather than food restriction. I can still choose to eat the food that I want as long as I control the portion size and make unhealthy food an occasional occurrence. If I want to eat a hamburger, I can check on the app to see if there are other healthier options that can also satisfy my cravings.”

For example, he still drinks beer occasionally and regards it as a joyous occasion. During Lunar New Year, he purchased many non-sugar and “bakkwa” that is low in sugar. For wedding banquets and dinners, he will also not eat too much.

Yang describes having nBuddy Diabetes app is like having a trusted partner around, reminding and urging him to make healthier food choices and to exercise regularly.

“I am now “graduated”, no longer under this research program. However, I will occasionally log my food choices and allow the application to suggest some healthier choices. 

Yang has completed his 2 vaccinations as well as his booster, and says, “ I’m glad NUS has launched this program and I am also happy to share with everyone how I have benefitted from it.”

A 3-year clinical trial research on the nBuddy Diabetes conducted by Dr Lim from October 2017 till march last year, showed that in 204 participants, diet and lifestyle changes lead to lower blood sugar levels and reduction of weight in diabetics, thereby reducing the risk of diabetes complication.

Having been in the medical industry for 27years, Dr Lim’s most heart-wrenching moments would be seeing a lot of Type 2 Diabetic patients suffer from further complications such as kidney failure, retinopathy and amputations. Although a healthy diet and lifestyle can delay the progression of diabetes it cannot be reversed.

At the same time, Dr Lim also found that many patients are able to control their diabetes well by adopting a healthy diet and lifestyle from the beginning, with minimal damage to their organs. This inspired her to develop the nBuddy Diabetes app.

Poor dietary habits leading to increase in medication

Dr Lim says, “Many patients with type 2 diabetes think that just with regular intake of their medicine, it will be adequate to manage their condition however this is a myth. Not changing one’s eating habits and managing their blood sugars will lead to an increase in medication that one has to take and may even lead to further complications. 

Therefore, she advises people with diabetes to avoid foods high in refined sugar while ensuring adequate fiber intake by consuming vegetables and legumes, replacing refined carbohydrates like white bread and white rice with wholegrain, consuming adequate protein, reducing saturated fat intake and adhering to a regular exercise plan.

In terms of exercise, Dr Lim recommends 150 minutes of aerobic exercises a week by choosing your favourite type of movement including brisk walking, jogging, swimming or taichi and even dividing the 30 minutes of daily exercise into 2 to 3 shorter sessions throughout the day.

“In terms of diets, the nBuddy Diabetes will provide users with healthier options to choose from, for example, replacing brown rice with white rice, Should the store not have brown rice available, the app will also suggest for you to reduce the amount of rice and increase the number of vegetables instead.”

According to Health Promotion Board’s My Healthy Plate, half of the plate should be vegetables, a quarter being lean protein and the last quarter being wholegrains. Portion control paramount. 

Compared to other mobile applications, Dr Lim says nBuddy Diabetes’ 3 biggest features are calculating calories, carbohydrate and sugar intake, alerting the user if excessive intake is detected; setting achievable goals including weight and blood sugar management and reminding users to move and exercise regularly.

 She says that it is possible to cultivate healthy lifestyles including adequate physical activity, healthy dietary patterns and limiting unhealthy food to no more than twice weekly. 

Young people should be assessed for their risk of diabetes.

Dr Lim shared that common symptoms in diabetics include frequent urination, thirst and fatigue, but most people will not be aware that they have issues with excessive blood sugar. Thus it is recommended that those above the age of 40 should go for regular check-ups and those under 40 can do a diabetes risk screen online. 

She also says, “Being obese or overweight may increase the risks of heart disease, kidney disease, stroke and joint problems, reducing the quality of life.”

Actually, change in diet is about choosing healthy foods rather than food restriction. I can still choose to eat the food that I want as long as I control the portion size and make it only an occasional occurrence. If I want to eat a hamburger, I can check on the app to see if there are other healthier options that can also satisfy my cravings.

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