Burden of diabetes: A refocus

Diabetes mellitus is one of the most challenging health problems in the world today. In Singapore, diabetes is a growing problem. Its prevalence has risen from 9% in 1998 and 8.22% in 2004 to 12.3% in 2013. ¹

There is a need to seek out the borderline diabetic or prediabetic patient in the community. Patients with this condition have a blood glucose level higher than normal (but not high enough to be considered diabetic), and are without symptoms; the condition is detectable only through a blood test. Prediabetes affects many women in Singapore.

The National Health Survey conducted by the Ministry of Health in 2010 revealed that 14.4% of people in Singapore, between the ages of 18 and 69, had impaired glucose tolerance. The figure was higher in women (15.2%) than in men (13.5%). ² As early detection and prompt treatment may reduce the burden of diabetes and its complications, screening for diabetes may be appropriate.

The Ministry of Health has clinical practice guidelines to screen for diabetes mellitus in asymptomatic individuals. ³ The guidelines need to be re-emphasized for interns, general physicians, and general practitioners managing their daily patients, so that those who are obese, first-degree relatives, those in high-risk ethnic groups, etc., can be screened. Our endocrinologists are well acquainted with these recommendations.

Researchers at the University of Florida found that doctors in academic settings with a positive attitude toward prediabetes were more likely to follow national screening guidelines. ⁴ These guidelines are an important way to prevent diabetes. Screening for diabetes is a systematic ongoing process, and not merely a one-time effort. Follow-up is appropriate as necessary. The Health Promotion Board has a prediabetes intervention program.

The standard treatment is diet and exercise with an emphasis on weight loss of 5–10% of body weight. This will reduce the risk of developing type 2 diabetes. Some doctors also prescribe Metformin. A greater awareness of prediabetes and treatment would reduce the risk of developing type 2 diabetes, its costly complications, and its incidence. In Singapore, about 50% of all persons with diabetes are unknown and undiagnosed. ⁵

Another area of focus will be the pre-pregnancy period. Studies such as GUSTO will help lead to a better understanding of the developmental origins of health and disease, and propose that adult disease risk can be programmed by the perinatal environment.^{6, 7} Women with gestational diabetes mellitus are more than seven times as likely than other women to get diabetes. The GUSTO study found that 10% of these women developed full-blown diabetes within 5 to 10 years. The study showed that the rate of gestational diabetes mellitus here is far higher in Indian and Chinese mothers than in Malay mothers.

Asians have a strong genetic susceptibility to type 2 diabetes, characterized by early β cell failure and prominent central obesity. As such, understanding the role of the β cell in diabetes is key; with the predominant burden of type 2 diabetes shifting to developing countries, such as those in Asia, further research is needed for additional insights on the role of β cell function.

The incidence of overweight and obesity in Singapore has increased over the past few decades. Despite Singapore’s obesity rate being lower than many countries, it is still a cause for concern, as 40% of the population have a body mass index above 25 kg m². Population-based interventions, for example, lifestyle changes and exercise have helped all Singaporeans manage their weight. Yet more targeted individualized assistance is required to help those who are already overweight or obese (body mass index > 25 kg m²) achieve a healthy weight. ⁸ Doctors need to be engaged, and to identify young individuals who are obese and overweight.

Further measures are needed at the population level and in high-risk groups. The importance of repeated communication of preventive strategies to patients cannot be overemphasized. Determining children at risk of being overweight allows for early preventive intervention and treatment in childhood.

In Singapore, the Ministry of Health and Health Promotion Board have done much to influence diet, exercise, and lifestyle changes in the school system. However, the prevention of obesity must remain a high priority if we are to prevent diabetes. Singapore’s obesity prevalence among adult Singapore residents aged 18–69 years has increased from 6.9% (2004) to 10.8% (2010). At the time of writing, the Agency for Care Effectiveness, in support of the Ministry of Health “War on diabetes” campaign, has published appropriate care guides to complement the Ministry of Health clinical practice guidelines on diabetes. ⁹