World Health Day today (7 April 2016) focuses on increasing the awareness on the rise of diabetes and its debilitating consequences, particularly among low- and middle-income countries (LMICs).
The World Health Organization (WHO) reports that a staggering 422 million people worldwide have diabetes and this number is likely to double in the next two decades. In 2012, WHO reported that 1.5 million deaths were attributed directly to diabetes and more than 80% of these deaths occurred in LMICs. In Malaysia, the most recent National Health and Morbidity Survey (2015) documented that a total of 3.5 million adults now have diabetes.
I interviewed Associate Professor Dr. Muhammad Yazid Jalaludin, Consultant Paediatrician and Consultant Paediatric Endocrinologist at University Malaya Medical Centre (UMMC), Kuala Lumpur to seek his expert opinion on diabetes among children and adolescents and how families can prevent diabetes.
Q1. We have all heard of Type 1 and Type 2 Diabetes. How are they different?
Type 1 diabetes, also known as insulin-dependent or juvenile diabetes occurs when the pancreas does not produce sufficient insulin, a hormone that regulates blood sugar. As such, daily dosages of insulin are required – you may have seen those needing to take insulin jabs at intervals throughout the day. Risk factors of Type 1 diabetes include genetics (or family history) and autoimmune-related causes. The increasing prevalence of Type 1 diabetes, particularly among children below 5 years of age have been reported globally. Currently, Type 1 diabetes cannot be prevented.
Type 2 diabetes, sometimes called non-insulin dependent or adult-onset diabetes occurs when the body is unable to effectively use the insulin it produces. Close to 90% of adults diagnosed with diabetes are Type 2 diabetics. The prevalence of Type 2 diabetes amongst children and adolescents varies from country to country.
According to the Malaysian Diabetes in Children and Adolescents Registry (DiCARE) 2010, approximately 20% patients were diagnosed with Type 2 diabetes while 80% patients had Type 1 diabetes. When compared to paediatric populations in Europe and the United States, the age of diagnosis typically occurs at peak puberty, around 10 years of age. However, in Asia, the disturbing trend observed was that the age of diagnosis is getting younger. Dr. Yazid shares that the number of newly diagnosed cases of Type 2 diabetes among Malaysian paediatric patients has shown an upward trend in recent years.
"In Malaysia, 1 in 5 children are diagnosed with Type 2 diabetes. An unhealthy lifestyle and strong family history are major risk factors whereby close to 80% of their parents are diabetics and most often obese." - Dr. Muhammad Yazid
Type 2 diabetes is preventable and is largely due to lifestyle factors such as being overweight or obese, lack of exercise, unhealthy diet and family history. Type 2 diabetes has been increasingly reported among children and adolescents worldwide with the global rise in childhood obesity identified as a major risk factor. The consequences of Type 2 diabetes are often debilitating and can result in cardiovascular disease, stroke, myocardial infarction and is already the most common cause of kidney failure and retinopathy in Malaysia.
Q2. What are the symptoms of Type 1 and Type 2 diabetes?
The symptoms for Type 1 diabetes include:
- Excessive excretion of urine (polyuria)
- Frequent thirst (polydipsia)
- Constant hunger
- Sudden weight loss
- Changes in vision
Delayed diagnosis of Type 1 diabetes may result in ketoacidosis characterised by abdominal pain, chronic pain, laboured breathing, loss of consciousness or even seizures.
The symptoms for Type 2 diabetes are often similar to those of Type 1 diabetes but often less pronounced. As such, diabetes may only be diagnosed several years after onset, once complications have surfaced.
Note to Parents: Check if your child has dark, velvety discoloration in body folds and creases, particularly at the back of the neck, armpits, elbows or knees. People with this skin condition known as acanthosis nigricans indicate insulin resistance and are more likely to develop Type 2 diabetes.
Q3. What are some practical steps families can take to prevent diabetes?
The key is to focus on the things you can change, like your weight, diet and exercise. Don’t dwell on things that you can’t do anything about such as your family’s medical history. Many habits (healthy or unhealthy) that children and adolescents develop begin at home and are often shaped by their environment. Here are four key pillars to prevent Type 2 diabetes:
The entire family must be involved in the prevention of Type 2 diabetes, whether it be eating healthily, exercise or getting enough sleep. Lifestyle changes will be short-lived if only a child or a parent makes the effort. Families who successfully adopted and sustained healthy lifestyle habits launched from the motivation to change and were championed by a leader (core member) in the family.
- Spend your weekends at the parks - enjoy nature and explore the outdoors!
- Have fun family outings – go cycling, hiking or rock climbing, kayaking, trampolining or even bubble football!
- Avoid getting stuck for hours in shopping malls, there is a greater tendency to eat when you’re not actually hungry or more than you need.
Further Information: As a clinician, Dr. Yazid shares that upon diagnosis of diabetes, the child involved is sent for eye and urine check. He then invites the patient’s entire family for screening (health check-up including waist circumference, body mass index, blood pressure, blood glucose, blood cholesterol levels) to prevent or manage other diabetic cases in the family. To help them manage their condition as a family, they are then enrolled in an obesity clinic or diabetic clinic and receive regular advice on nutrition and fitness as well as counselling from a clinical psychologist.
Healthy Eating Habits
- Always have breakfast – this is the most important meal to kickstart your day. Here are breakfast ideas for little ones and easy and quick breakfast ideas when you’re in a hurry.
- Skipping meals is a no-no – the body always tends to eat more the next meal. Eat balanced meals at proper times.
- Eat in healthy portions - use The Healthy Eating Plate as a guide for healthy meal portions as recommended by the Harvard School of Public Health:
- ½ with fruits and vegetables (eat a variety of colours)
- ¼ with wholegrains (eg. brown rice, wholewheat grains, chapatti, quinoa)
- ¼ with lean protein (eg. tofu, tempe, beans, lean cuts of meat)
- Snack healthily – here are healthy snack ideas to choose from.
- Have dinner at least 2-3 hours before bedtime and avoid large suppers.
- Limit sugar-sweetened beverages – these have hidden calories so make sure you hydrate healthily. Sugar-sweetened beverages include soft drinks, fruit drinks, energy drinks, flavoured milk and cordials.
- Shop wisely – choose more fresh produce and minimal processed foods. Remember “when the buying stops, the eating does, too.”
A recent study among Malaysian adolescents reported that sugar-sweetened beverage (SSB) intake was unfavourably associated with their metabolic health reflected in their increased waist circumference, elevated blood cholesterol, blood glucose and insulin levels independent of physical activity level, body mass index and dietary patterns.
When eating out, refrain from turning to fast food as the go-to option when you have no time to cook. Check out PurelyB’s directory of healthy places to eat or if you’re in Kuala Lumpur, here are seven places you can eat clean and enjoy! Alternatively, if you’re racing against time, pre-order your meals from healthy meal deliveries to ensure you don’t compromise on giving your body the fuel and nutrients it needs.
Regular Physical Activity
- Aim for 30 – 45 minutes of moderate-vigorous exercise for at least 5 days a week.
This can be done in short bouts of 10-15 minutes throughout the day.
- Limit screen time (entertainment media time spent in front of mobile phones, computers, tablets, Ipads, Playstation, etc) to a maximum of 2 hours daily (Recommendations from the American Academy of Pediatrics)
Reduce sedentary activities by encouraging interactions and active play. Let your kids play a sport they enjoy or take them on an outdoor expedition or Biology adventure – go on a treasure hunt for certain plants, insects or art-inspiration!
- Children should get 7 to 9 hours of sleep every night.
Not only do children need adequate sleep for growth, sleep affects the satiety and hunger hormones, leptin and ghrelin. A lack of sleep triggers the body to crave for high sugar foods which over time results in weight gain.
A study investigating the prevalence and risk factors of metabolic syndrome among Malaysian adolescents revealed that those with less than 7 hours or more than 9 hours of sleep had an increased likelihood of developing metabolic syndrome.
Q4. If you have an adult family member with diabetes, what are some practical ways to help?
Besides going for regular check ups, healthy eating (see 5 dietary tips for diabetics) and regular exercise, assist your diabetic family member to pay attention to:
- Foot care
- Trim nails regularly
- Inspect their feet daily – use a mirror to check for cuts or blisters
- Always use covered shoes when going outdoors
- Use padded socks or covered footwear with suction when indoors to prevent falls
- Dental Care – use a toothbrush with soft, rounded bristles and dental floss to clean away plaque and food from between teeth and below the gumline.
- Skin Care – prevent dry skin and tend to wounds right away to prevent infections and skin conditions. Moisturise often especially if you’re in air-conditioned rooms or outdoors.
- Food & Medicine Supplies - To keep your blood sugar levels in check, it’s good to always have with you:
- Healthy snacks (for in-between meals) eg. fruit, raisins, yoghurt
- Water to stay hydrated
- Medicine supplies (including blood glucose meter and/or insulin kit)
Q5. As our nation’s leading Consultant Paediatric Endocrinologist, how we can move forward as a nation in halting the rise of diabetes?
There are various on-going health initiatives in Malaysia to curb obesity and diabetes including My Body Fit & Fabulous (MyBFF), an upcoming health intervention programme in schools, workplace and homes; Jom Mama, a programme dedicated to helping women stay healthy pre-conception and during pregnancy; and SEGAK, a nationwide initiative to measure the body weight and height of school students twice annually, to name a few. As with many campaigns and initiatives, sustenance is key. Enthusiasm may die down after the hype is over or when limited by resource constraints.
Dr. Yazid further commented on the grave need for healthcare professionals (HCPs) to be equipped with the knowledge and skills to educate their patients. As frontliners, HCPs need to be aware of how to assess patients with signs, symptoms or complications of diabetes, address this through effective and timely communication and educate their patients on how to care, manage or treat diabetes.
At a national level, besides the various research projects Dr. Yazid is actively involved in (including MyBFF), he with the Science Academy of Malaysia and the National Obesity Taskforce to revisit ‘hard’ policies such as tax on sugar-sweetened beverages and reducing the import duty for fresh produce.
In conclusion, what is most important is that everyone needs to work together. Prevention of Type 2 diabetes begins at home, from families to schools to communities, town planners, the media, commercial sectors, non-government organisations and the government. Together, let's beat diabetes!