Managing diabetes requires an all-rounded approach

Pricking the finger daily to check blood glucose levels can be painful and cumbersome for some diabetics, but it is necessary to ensure that their blood glucose levels remain in the normal range. — Filepic

Despite the plethora of information on diabetes out there, many diabetic patients still don’t know much about the disease or its consequences.

Whether they are from rural or urban areas, their diabetic knowledge is poor and they think diabetes is a temporary problem, with the majority believing sugar is the culprit.

The result is that once their blood glucose levels go back to normal, they stop taking their medications.

Unsurprisingly, they also have many other related complications as uncontrolled blood glucose levels can wreck havoc in many of our organs.

These were some of the findings uncovered by global healthcare company Abbott when they were selecting participants to enrol in their Glucerna Lifestyle Change Programme last year (2022).

This programme was built on the success of the 2021 pilot programme that had 40 participants.

Eligible Malaysians with type 2 diabetes were selected to participate in the four-week lifestyle intervention programme to help them build diabetes resilience, i.e. achieving optimal diabetes outcomes despite the condition’s challenges.

Led by a group of trained doctors and dietitians, the programme focused on diabetes management through intake of a balanced diet and diabetes nutritional supplements, exercise, continuous glucose monitoring via a sensor-based system, and medication.

Among the eligibility criteria for the programme were that the person had to be diabetic for more than a year, was actively seeking treatment; had a body mass index (BMI) that was over or under the normal range, and had a haemoglobin A1C (HbA1c) reading of 8-9 millimoles per litre (mmol/L).

HbA1c is a blood test that shows your average blood glucose level over the past two to three months.

“We had one-to-one consultations and three doctors to screen and do the assessment.

“On average, each doctor had 25 patients that we met online and we checked their motivation to participate in the programme.

“We had to be sure they would be committed to stay till the end,” says the programme’s lead doctor Dr Manoharan Paranjothy.

Abbott Malaysia nutrition business medical director Dr Nina Mazera Mohd Said adds: “We had weekly virtual consultations and the 70 participants chosen were guided on how to eat healthy without giving up their favourite foods, how to incorporate physical activity, and how to overcome psychological challenges associated with the disease, because it’s something they have to live with for the rest of their lives.

“Managing diabetes can be an everyday challenge and cause people to feel overwhelmed and mentally stressed.”

Participants, whose ages ranged from 27 to 75, also learnt how to cope with diabetes burnout and other challenges that could derail their commitment to diabetes care.

In addition, they received peer support from other diabetic participants who shared common goals, challenges and resources to help them better manage their diabetes.

Knowledge gaps

Dr Manoharan, who is a primary care physician and pharmaceutical medicine consultant, shares: “One of the biggest challenges was that many of them were on follow-up treatment at public healthcare facilities, which are very crowded.

“Most were seeing primary care doctors and very few had access to someone beyond a medical officer.

“If their HbA1c goes up, they were just given more medications, and even if they wanted to see a specialist, they were not referred.“

For those who needed better healthcare, finances were a concern.

And during Covid-19, almost 80% didn’t go for any follow-up appointments at all.

At least 60% of the participants were overweight or obese, yet many of them did nothing to mobilise themselves – they thought housework was enough exercise.

“They didn’t know about diet, and although they had heard the dietitian talking about the food pyramid, they didn’t know what that meant.

“So they just cut out sugar and still ate regular carbohydrates like rice and noodles,” he says, adding that a third of the participants came from rural areas.

Many assumed that if they got a normal blood glucose reading, they were “cured”.

“They don’t realise that something permanent has already changed in the body, therefore medications and diet are the mainstays to prevent the disease from getting worse.

“My own patients in the city ask me the same thing: if they can stop medications once the reading is normal.

“This tells you the knowledge part seems to be lacking, even among the educated,” he points out.

Upon the completion of the programme, the average HbA1C reading of participants dropped by 0.5-1%.

Dr Manoharan observes: “Of course, one month is too short a time to see major improvements, but there were good changes for those who were really motivated.

“With the newfound knowledge, resistance is a lot less and more are willing to come forward to seek help, especially older patients.”

Happily obese

Here’s a happy Vicky enjoying one of his birthday celebrations prior to being diagnosed as a diabetic in his early 20s. — VICKY RAO

Vicky Rao’s diabetes diagnosis was an accidental discovery – it shocked him and his family as he was only in his early 20s then.

“Two decades ago, I was hospitalised with dengue and after running some bloodwork, the doctors said I also had type 2 diabetes.

“I knew very little about diabetes and the impact it would have.

“I was a happy young man, enjoying life and eating whatever I wanted, especially fast food and fizzy drinks.

“The last thing I wanted was to restrict my enjoyment of junk food that gave me so much pleasure,” divulges the project manager and one the programme’s participants.

Vicky, 40, was obese at 160 kilogrammes (kg) then.

The doctor told him that managing diabetes is a lifelong commitment, and advised him to exercise and cut back on sugar and carbohydrates.

For someone who ate banana leaf rice once a week and seldom drank plain water, Vicky found it overwhelming to make such drastic changes to his lifestyle.

On a positive note, dengue caused him to lose appetite, so he lost 20kg over the next few months.

Eventually, Vicky gradually slipped back into his old habits of eating and inactivity.

He was frustrated about pricking his finger daily, unhappy to exercise and ready to give up.

None of his immediate family members are diabetic, although his elder brother was diagnosed recently.

He admits: “Yes, it is all my own doing because I brought it on myself after moving out at 19.”

Years passed until Vicky’s concerned mother asked him to take the HbA1C test, which he had been ignoring.

To oblige her, he did.

“To my horror, the glucose reading was 19.1 mmol/L – the highest it has ever been! (A normal HbA1c reading is below 6.5 mmol/L.)

“I knew instantly that I had to make some serious changes in my life.

“However, managing fluctuating glucose levels without proper guidance and support proved challenging.

“Gradually, I found myself poorly managing my condition again, and it felt like I could make no progress, no matter how hard I tried,” he says.

The real turning point came six years ago when Vicky was admitted to hospital because his glucose levels were high – this time, it was 16.1 mmol/L.

A much healthier and trimmer Vicky after his weight loss, although he has yet to achieve his target weight of 90kg. — VICKY RAO

He says of that time: “Older, wiser and married, it’s either I made lifestyle changes or die.”

He scoured the internet for information; the more he learnt, the more excited he became and understood that diabetes is not a death sentence.

“Technology has advanced significantly since I was first diagnosed, and I found an array of tools that helped me monitor my glucose levels and understand what I need to do to stay healthy,” he shares.

Vicky was then selected for the pilot programme in 2021 and finally received proper counselling on diabetes do’s and don’ts.

Talking to people on a similar journey was also comforting and he picked up many useful pointers.

From walking daily, the once-sedentary Vicky was running on the treadmill for 45 minutes to an hour every day during the movement control order.

Results came swiftly as he was also eating healthier; he successfully lost 5kg that month.

Today, his weight is at 110kg, and while he is still considered overweight, Vicky is happy with his progress.

His blood glucose reading is averaging at 6-6.3 mmol/L.

“It’s nice to feel lighter though my goal is to hit 90kg.

“These days, I eat mostly home-cooked meals, but I still have my banana leaf rice once a month.

“Witnessing my journey has also helped my father-in-law, who has been living with diabetes for many years.

“Now he feels empowered to make lifestyle changes,” he says.

Starting young

Walking is one of the best exercises for anyone, including diabetics, but you have to walk fast enough to get your heart rate up for it to be effective. — Filepic

The types of exercises diabetics can do depend on their mobility level, age and presence of other diseases.

Dr Manoharan says: “They are encouraged to spent at least 30 minutes a day to bring up the heart rate – this could be just walking up and down flat ground.

“The simplest way is to go to the neighbourhood park with a friend or sibling for support.

“If they are immobile, the role of caretaker is to help them with passive exercises, e.g. putting sandbags on their legs or arms, and lifting them up and down.”

He also advised parents to start inculcating good habits in their children early.

“A chubby child may be cute, but he is not a healthy child!” the doctor asserts.

Often, both parents are busy so they cook less or buy takeaway food.

Many children also skip breakfast because parents have no time to prepare it for them.

“Whatever is available in the school canteen then becomes their meal and this is unhealthy.

“Make time for your kid – you’ve got to give them breakfast!

“Ensure children are eating balanced meals and give them the right knowledge so they can follow through when they grow older.

“Education really begins at home,” says Dr Manoharan.

Dr Nina chips in: “If diabetics have no time to cook, it’ll be more beneficial to take meal replacements for breakfast, lunch or dinner.

“These nutritional drinks do not require any preparation.

“The overweight and obese can use it as replacement while the underweight can use it as a supplement – it’s all individualised.”

Overall, the programme received positive feedback and the majority of the participants saw the value in leading a healthy lifestyle.

They just didn’t know how to get started and keep motivated.

“The management of diabetes is heavy into pharmacotherapy (drugs) and not so much lifestyle, but we know they have to go hand in hand.

“Making lifestyle changes is just a matter of thinking long-term from the start and making smart choices that will lead to a healthier you.

“We will continue the programme this year, plus we are also actively educating healthcare professionals to make a paradigm shift on how to better manage their diabetic patients,” reveals Dr Nina.

Dr Manoharan concludes: “We just need to tell diabetics to keep moving, guide them on the right foods to consume and make them understand that this is a disease for life.

“They’ve also got to continue taking medications and go for follow-up appointments regularly.”