A PUBLICATION FOR
PRIMARY CARE PHYSICIANS
MCI (P) 097/03/2013
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& t Im d o
Jo pr f E
ur ov x
na e ce
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ca a nc
te ga e
in commemoration with
World Diabetes Day
in the news
in the news
TTSH Welcomes the First Cohort from
Lee Kong Chian School of Medicine
Official Opening of Foot Care and Limb Design Centre by Assoc. Prof. Muhammad Faishal Ibrahim (fourth from left) with the senior management, staff and a
patient of Tan Tock Seng Hospital.
Official Opening of Foot Care
and Limb Design Centre
he new Tan Tock Seng Hospital (TTSH) Foot
Care and Limb Design Centre (FLC) was officially
opened on Saturday, 31 August 2013, in
conjunction with the launch of Health City Day.
Parliamentary Secretary of Ministry of Health,
Assoc. Prof. Muhammad Faishal Ibrahim was the
guest-of-honour for this event.
The P&O team, which sees about 9,000 patients yearly,
produces high quality prostheses for varying ambulatory
potential and amputational levels such as above knee,
below knee, hip disarticulation and upper limb
amputation. P&O also offers orthosis for differing
conditions such as stroke, cerebral palsy, scoliosis and
helmet therapy for plagiocephaly.
The new centre houses both Prosthetics & Orthotics
(P&O) and Podiatry, and is the only specialised workshop
in Singapore that makes and assembles customised
prostheses and orthoses.
In FLC, the Podiatry team provides general treatment such
as corns, calluses, warts and nail or skin disorders;
biomechanics assessment of the lower limb, diabetes
management, footwear advice for patients and ulcer
treatment are also done. Dressing management are also
offered in this improved clinical environment, in addition to
in-house manufacturing and fabrication of orthotic devices.
Anchoring on the value proposition of being a true multidisciplinary centre, five different disciplines including the
Rehabilitation doctor, Prosthetists, Podiatrists,
Physiotherapists and Medical Social Workers come together
for weekly clinics to provide more coordinated and better
care for patients.
Inaugural batch of 54 students outside the heritage building at 11 Mandalay,
restored to house the headquarters of LKCMedicine.
an Tock Seng Hospital (TTSH) hosted the first
cohort of students from the newest Lee Kong Chian
School of Medicine (LKCMedicine) for their weeklong hospital and clinic orientation starting from
2 September 2013. The orientation week, which aimed to
help the students understand the clinical journey from
both the clinical and patient’s perspectives, included
visits to both the wards and clinics in TTSH and National
Healthcare Group (NHG) Polyclinics.
Team supervisor, Dr Seow Cherng Jye, taking his
team on a tour around the hospital as part of the
LKCMedicine, a collaboration between Imperial College
London and Nanyang Technological University, opened
its doors to the inaugural intake of 54 students on
5 August 2013. With NHG as LKCMedicine’s principal
clinical training partner, TTSH plays a part in shaping the
teaching methodology and developing a comprehensive curriculum for
the students with TTSH doctors forming part of the teaching faculty of
in the news
Launch of Virtual Hospital on
19 June by (fifth and sixth from
left) Assoc. Prof. Muhammad
Faishal Ibrahim, Parliamentary
Secretary of Ministry of Health,
and Ms Charlotte Beck, Senior
Director of the Elderly and
Disability Group, Ministry of
Social and Family Development,
accompanied by community
partners and management team
of Tan Tock Seng Hospital.
Bringing Care to Patient’s Home
an Tock Seng Hospital (TTSH) officially launched
the Virtual Hospital (VH) on 19 June 2013.
VH is a new service aimed at providing medical and
social support for patients with chronic conditions
and who were admitted to TTSH five times or more
in the past year. Together with community partners,
TTSH brings patient-centric care to the homes of
Patients under this scheme were each assigned a Health
Manager who will assess the conditions of the patients
with regular home visits and over the phone. Supported
by a team of healthcare professionals including doctors
and pharmacists, the Health Managers also worked
with community partners such as Home Nursing
Foundation and the Community Development Councils
to co-manage and support the patients.
in Central Singapore
VH was piloted from August last year with promising
results. Patients on the pilot scheme have shown a
reduction in their visits to TTSH’s accident and
emergency department by 60% and the hospitalisation
count also went down by 30%.
he Institute of Geriatrics and Active Ageing (IGA) was
established on 1 July 2013 to play a pivotal role in leading
geriatrics research and education in Singapore.
In the light of a rapidly ageing population, IGA aims to address
pressing needs for better understanding of medical issues
surrounding ageing, as well as the way healthcare is delivered to
this complex population and to grow expertise in the core
Led by Associate Professor Chin Jing Jih, Director of IGA and housed
in Tan Tock Seng Hospital, the new Institute seeks to embark on
geriatrics research and innovation, and attract, train and retain
healthcare workers in elderly care. IGA will also work with the three
local medical schools – Yong Loo Lin School of Medicine, Duke-NUS
Graduate Medical School and new Lee Kong Chian School of Medicine
– to enhance geriatrics care training, develop initiatives to improve
patient care as well as coordinate and fund research efforts.
August 2013 marked the start of a new future for
healthcare in Singapore.
On this day, Health City Novena, an integrated healthcare
master plan was officially launched by Mr Gan Kim Yong,
Minister for Health, Dr Amy Khor, Senior Minister of State,
Ministry of Health and Manpower, with grassroots leaders and
stakeholders. Anchored by Tan Tock Seng Hospital (TTSH) under
the National Healthcare Group (NHG) as well as with the
Ministry of Health and various healthcare partners, this master
plan is a significant milestone for Central Singapore as it is set
to cater to Singapore’s future healthcare needs and challenges.
By 2030, a land size of about 17 hectares in Novena will house a
spectrum of vibrant features. Leveraging on the existing
strengths of current institutions and integrating them with new
developments, Health City Novena will distinguish itself as a
public–partners–people centric development. From acute to
intermediate and long-term care, the Health City will offer
holistic care experiences for the residents in Central Singapore.
It will also extend beyond healthcare to encompass research and
education, commercial, leisure and public spaces to be a place
where Healthy Life is Central.
Keeping Pace with
the Ageing Population
The launch of Health City Novena is timely and imperative for
the central population as societal challenges are looming
ahead. As our population grows and ages, healthcare needs are
becoming more complex. Going forward, there will be more
frail people requiring more specialist care for increasing
conditions and for longer periods of time. Central Singapore’s
population is experiencing a faster rate of ageing at 15.1%,
which is higher than the average rate of ageing in the rest of
Singapore at about 10%.
“Health City Novena’s vision is to create an integrated community of
healthcare, medical education and translational research in a vibrant
and sustainable environment. It aims to shape the future healthcare of
Singapore, anchor the Regional Health System for Central Singapore,
and empower active and healthy living.” – Professor Chee Yam Cheng,
Group Chief Executive Officer, National Healthcare Group
Aerial view of Health City Novena.
4 Cs of Integrated Care
2. Integration by Continuous
Learning & Innovation
Integration of the healthcare master plan comprises
four key elements — Integration of Care, Integration by
Continuous Learning and Innovation, Integration with
the Community as well as Integration through
“The heart of medical education is the education
of the heart. We have come a long way, but each
of us is merely stepping on the shoulders of giants.
It is to them and to these whom we care for (our
patients) that we dedicate every single minute to.”
1. Integration of CARE
“Legacy models of care rooted in a hospital-centric
approach are no longer enough. We want to be more
patient-centred and collaborate effectively for better
outcomes. The creation of Health City Novena is a
wonderful opportunity to practise medicine in
a well-designed and aesthetically pleasing
environment. It will bring students, healthcare
workers, and the community together to fulfil our
mission to serve, care and heal our patients.”
– Professor Low Cheng Hock, Emeritus Consultant,
Tan Tock Seng Hospital
Health City Novena integrates learning for various
healthcare professionals through Lee Kong Chian School
of Medicine (LKCMedicine) and the future Health
Sciences School. TTSH plans to develop a Medical
Education and Training Building, where all new
healthcare professionals trained in various schools will
congregate and form integrated healthcare teams —
a vital ingredient for the new models of care to be
created and delivered, relevant to the changing needs
of the community.
– Associate Professor Thomas Lew, Chairman, Medical Board,
Tan Tock Seng Hospital
With healthcare needs becoming more complex from an
increasing burden of chronic diseases, there is a need
to adopt a new model of care to integrate care across
continuum and various healthcare partners to ensure a
holistic care approach.
New developments will be added to the current
landscape. They include the National Centre for
Infectious Diseases (NCID), proposed Integrated
Intermediate Care Hub (IICH), proposed National Skin
Centre Expansion and National Healthcare Group
Headquarters and proposed TTSH’s Ambulatory
The new developments, together with existing
partners such as General Practitioners (GPs),
intermediate care specialists, community and
voluntary welfare organisations, will build a strong
network of healthcare and social services for patients
and families within the central region. To better meet
the needs of an ageing population, Health City Novena
will also see more resources channelled towards
ambulatory and intermediate care including
Future South Gateway with the proposed Ambulatory Expansion.
rehabilitation, subacute and palliative care, to
facilitate the transition of patients back to the
community and health. These proposed
developments will all be purpose built and
interconnected to allow for effective and efficient
collaboration between the various partners. This will
generate more ideas and innovations in models of
care, not just within the development, but also for
care in the community.
For example, the proposed IICH will comprise the
Dover Park Hospice and a proposed second community
hospital. It will be adjacent to and connected to TTSH
and Ren Ci Hospital to allow seamless coordination of
care and patient transfers.
Another example will be the new NCID, a hospital
with isolation wards, intensive care units and support
facilities including laboratories. The centre will also
serve as a research and training ground to boost
expertise in the field. To meet a growing demand for
dermatological treatments, the National Skin Centre
will also have a new wing. The proposed block will
house outpatient and day treatment clinics, clinical
laboratories, a pharmacy, patient education rooms as
well as research and training facilities. NHG’s
headquarters will also be relocated in the new wing.
Community-based providers will also have an
opportunity to involve themselves in training.
Programmes will be offered to train and share new care
methodologies with community partners from primary
care or step down care. Synergising with our partners
can range in areas pertaining to impending new
healthcare standards or even in allied health support
services for primary care and community organisations.
Once Health City Novena is fully developed, some
estimated 600,000 square metres of space will be used
for healing, learning and research. More resources will
be channelled towards intermediate care and this
includes rehabilitation, subacute and palliative care.
Total bed capacity for the Health City is expected to
increase by 12% for acute care and 60% for intermediate
step down care. This means that for every 10 acute
beds, the number of step down beds in Health City will
increase from four to six. This facilitates patients’
transition back to the community.
The training of the community also extends to patients
and volunteers. Patients will be empowered to look after
their own health conditions, so that they can live the
best health possible. With training, volunteers as fellow
patients can better walk the journey with other patients
through support groups and thereby enhancing patient
engagements for a more holistic approach to healing.
3. Integration with
“During the Japanese Occupation,
Tan Tock Seng Hospital was known as
Hakuai Byoin – Universal Love Hospital.
It was also home to me literally. I grew up
in the living quarters allocated to my
father, Dr Benjamin Chew, who was Head
of Tan Tock Seng Hospital Medicine then
and brought my own children up there
when I became the head myself years later.
My wife, Dr Anna Hui, was also seeing
patients in the 70s and 80s at the
Tuberculosis Control Unit. After more than
50 years looking after patients in this area,
the community here is like an extended
family to me. I look forward to the
conservation of the rich legacy of care
for generations to come.”
– Adjunct Professor Chew Chin Hin,
Emeritus Consultant, Tan Tock Seng Hospital
Aligned with TTSH’s rich history as a people’s hospital,
Health City Novena brings the community into Novena.
This will be done through having a stronger patient–
volunteer presence within Novena.
Besides the array of medical facilities and expertise on
hand, Health City Novena plans to have open spaces,
lush parks, plazas, boulevards, ecological and exercise
trails to create a conducive environment for outdoor
and family activities. The development will also
maintain the area’s rich heritage with the conservation
of iconic buildings, which will be turned into public
attractions. Grassroots organisations and residents will
be invited to share their ideas and aspirations, making
the Health City a place to live, work and play for all.
4. Integration through
“As a sustainable community set within
a network of interconnected open spaces,
a lively place that co-exists within the
existing social and urban fabric is in the
midst of being born. It allows us to set aside
preconceived notions of hospitals and
creates a conducive environment that will
facilitate the evolution of new methods of
care for today and tomorrow.”
Boulevard with F&B terraces, a park and sheltered walkways to the MRT.
– Professor Philip Choo, Chief Executive Officer,
Tan Tock Seng Hospital
When the development is completed in 2030, more than
30,000 people will be expected to go through the
Health City daily. Hence, a key feature of this master
plan is connectivity, ensuring that people and traffic
flows are smooth.
Preserving a legacy of care – integrating heritage with future developments.
The master plan is designed to provide better patient
flow and accord patients the privacy they need during
their transfer from one care area to another. At the
same time, students and staff can move from one area
to the next easily as they learn and care for patients.
Accessibility will also improve for residents with
interconnected amenities within the Health City.
Some key connections include:
• A Level 3 connection between intensive care units
and the operating theatres in TTSH, with bridges to
link the new NCID and the community care hub.
• Staff facilities on Level 4 will be connected to the
Medical Training and Education Building via a sky
lobby. LKCMedicine will also be accessible via a
bridge on this same floor.
• For outpatient services, patients are connected to
both National Neuroscience Institute and the TTSH
Medical Centre through a link bridge. This will also
link up both Levels 3 and 4 to the proposed TTSH
Ambulatory Expansion and National Skin Centre.
At the same time, connected basement parking and
pedestrian walkways are being planned for. A connected
basement parking allows people to enter the basement
parking quickly and reduces the circulating traffic on
the street level. On the street level, boulevards
extending from the MRT to Mandalay Road as well as a
pedestrian-friendly park through a green carpet under
Jalan Tan Tock Seng will provide seamless connection
for residents to and from the MRT.
The launch of Health City Novena Master Plan is a groundbreaking milestone. Health City
Novena will anchor the Regional Health System for Central Singapore. With the completion of
the Health City by 2030, new models of care will transform and integrate care delivery across
our healthcare partners including primary care.
GP BUZZ spoke to Dr Eugene Fidelis Soh, Lead for Health City Novena and Chief Operating
Officer of Tan Tock Seng Hospital (TTSH) on the models of care, which will be introduced in
the Health City and how our primary care partners including our General Practitioners (GPs)
could potentially collaborate to shape the future of healthcare.
same (acute) care will not address this growing
healthcare need. We have to adapt our healthcare
delivery infrastructure to address this new need for
care centred on the health of our population.
In Health City Novena, we hope to incorporate a few
changes in the way we deliver care to our patients.
Transforming & Integrating
Specialist Care with Our
Firstly, we hope to transform the
way we deliver specialist care.
With an increasing ageing
population, not only do we have to
deliver great care in the community
through primary care and step down
care, we will also have to redesign
specialist care to collaborate and
meet the growing complexity of
chronic disease management.
The same model of fragmented
specialist care offered today may
not allow us to provide better care
in the future. There are a few
paradigm shifts in the way we want
to deliver specialist care:
a. From Organs to Persons
Today, specialist care is largely
according to the organ (e.g. heart,
lungs, eyes) and tomorrow,
specialist care must address the
Dr Eugene Fidelis Soh, Lead for Health City Novena.
When we first started out on this journey to build
Health City Novena, we envisioned a ‘public-partnerspeople development’. It was never about looking
‘within’ the public sector to deliver care. We want
Health City to connect with our healthcare partners in
Central Singapore as well as the people who represent
the community we serve.
The development of Health City Novena over the next
few years will represent the future model for
healthcare in Singapore. This is because we happen to
be in the region of Singapore where healthcare needs
are growing the fastest. 15% of the population in
Central Singapore is above 65 years of age, which is
higher than the national average of 10%. More of the
An evolving example is TTSH’s new musculoskeletal
(MSK) clinic. If a patient comes to TTSH with knee pain,
he could be referred to orthopaedics or rheumatology
as knee pain may be caused by a number of reasons.
If the patient is referred to orthopaedic and he turns
out to be a non-orthopaedic condition, the patient
would have wasted a trip here, only to be referred to
another specialist in the subsequent visit.
Now, if we can have a better integrated and patientcentred approach to diagnosis and care like the MSK
clinic, we can look at the way our patients access our
healthcare system. So, when the patient has knee
pain, he can come into the MSK clinic where our
various specialists rally around the patient, allowing
for timely diagnosis and a definitive treatment plan for
the patient. The patient can also expect to receive
treatment from our therapists, nutritionists and sports
b. From Providers to Teams
This brings us to the second paradigm shift - from
single providers to integrated care teams.
Team care is going to be an important feature for
TTSH and Health City Novena, especially in the
management of chronic diseases. This allows us to be
able to address our patients’ needs more holistically
by bringing providers (doctors, nurses, allied health
professionals and case managers) together to develop
an integrated care plan for each patient. This team
approach should not confine itself to the four walls of
TTSH, but extend to shared care programmes with
primary care and step down care partners.
c. From Episodes to Relationships
The third paradigm shift is about engaging patients in
relationships beyond episodic encounters.
When we had a younger population, episodic care
sufficed in addressing occasional illnesses. We would
access the hospital as and when we needed acute
With an ageing population, patients with chronic
diseases may require ongoing support and regular
follow-ups to monitor their conditions. A relationship
extends care beyond the clinic visit. It means that
patients need not physically come to hospital to
receive care, but that care will be coordinated with
their primary care providers such that care can be
delivered across facilities and at home through a
continuing relationship between the providers and the
d. From Inpatient to Ambulatory Care
The fourth paradigm shift will see surgical care move
from the inpatient to the ambulatory setting.
This shift is happening largely because of advances in
medical technology and better care protocols to ensure
good recovery at home. This has enabled TTSH to move
from inpatient to day surgery. Patients do not need to
stay in the hospital and can return home to a more
familiar environment for their recovery.
Today, we do about 70% of our surgeries as ambulatory,
compared to 10 years ago when it was just about 50%.
TTSH has also recently opened a Medical Day Centre,
which will cater to medical specialities, avoiding
unnecessary inpatient stays. Ambulatory care is fast
becoming the mainstay of specialist care.
Systems Thinking about Patients,
Panels & Populations
The second aspect of care delivery pertains to the idea
that we want to think about improving health outcomes
at all three levels: the patient, the panel and the
Good outcomes, at the patient, panel or population
level, depend largely on good transitions of care.
This is the idea of how we can work with our upstream
providers in primary care and downstream providers in
step down care.
The idea of moving from patients–panels–populations
means that not only do doctors look after patients, but
they are also responsible for a panel of patients across
their practice and be able to inform their practice
through their research and understanding of their
patients’ outcome of care. This allows us to look after
the population we serve; from the well to the frail in
the community, we can then better tailor the various
care programmes to meet their needs.
One new programme that TTSH is developing is the
Virtual Hospital, where we look at patients who have
frequent admissions to TTSH. Through a case
management based approach, we are able to work with
primary care and step down care providers in order to
coordinate care for these patients in the community.
For those who require inpatient care, we are also
looking at enhancing intermediate care within the
Health City to facilitate their rehabilitation and
transition back into the community.
Health City Novena is designed as an integrated care hub
for ambulatory specialist care, inpatient care and
intermediate transitional care. Our primary care partners
are an integral part of our regional health system with its
heart in Novena. They look after a panel of patients,
which is a subset of the population in Central Singapore
served by the Health City. The future development of
primary care networks will be important efforts under
our regional health system and this will apply to both
patients on Community Health Assist Scheme (CHAS) as
well as those who access our non-subsidised clinics.
Our primary care networks will connect seamlessly for
patients who require specialist care here in Novena.
For example, we are working on a real-time
appointment portal for GPs and patients, so they can
have ‘live’ access to our appointment systems just like
what we have for direct admissions in inpatient care.
These primary care networks will also include support
from our allied health professionals, case managers and
nursing teams, who will work alongside GPs and
Specialists in integrated care teams.
Today, our process of care is a hand-off by GPs and
hand-back to the GPs when acute care is completed.
Tomorrow, we can envision a continuing relationship
between the patient and his/her integrated care team,
which will include his/her GP.
enior citizens aged 65 years and above
make up about 9% of the population.
This is projected to increase to 18.7%
by 2030*. Singapore’s chronic disease burden
is expected to increase with a rapidly ageing
The situation in Central Singapore,
where Tan Tock Seng Hospital (TTSH)
serves, remains the most pressing as it is
experiencing a faster rate of ageing in its
population, as compared to other parts of
Singapore. At 15.1% in Central Singapore,
this is higher than the average rate of
ageing in the rest of Singapore, which is at
In 2011, the Ministry of Health (MOH)
introduced the Primary Care Masterplan to
establish team-based care among the General
Practitioner (GP) community, so that they are
more equipped to manage chronic diseases
within the community. To address the rising
health burden and increasing complex
healthcare needs of the ageing population in
Central Singapore, TTSH has been engaging GPs
in the co-management of chronic patients.
GP BUZZ interviewed Adjunct Assistant
Professor Chong Yew Lam, Assistant Chairman,
Medical Board (Clinical Development) and Project
Champion of the Community Right Siting
Programme (CRiSP) on this latest shared care
initiative by TTSH.
* Singapore Department of Statistics (DOS).
What is TTSH
Currently, TTSH has in place
aligned to the Primary Care
Masterplan’s aim of bringing
primary care closer to Singaporeans
to better support chronic disease
management within the
Since 2007, TTSH has been actively
forging linkages with our primary
care partners, which include the
Polyclinics, GPs and Family Medical
Clinics. TTSH has been right siting
asthmatic patients in its Asthma
Decant Programme and heart
failure patients for its Heart
Failure Programme. Through these
programmes, we identify suitable
and stable patients with these
chronic conditions for their care to
be transferred from TTSH Specialist
Outpatient Clinics (SOCs) to
About TTSH CRiSP
CRiSP is a partnership between
TTSH and our primary care partners,
where stable chronic patients from
TTSH SOCs are being appropriately
reviewed and cared for at the
primary care environment. CRiSP is
established to streamline and
integrate the TTSH right siting
programmes that were mentioned
earlier. Beyond asthma and heart
failure, CRiSP will extend to a
broader list of chronic conditions.
With CRiSP, identified patients
with specific chronic conditions
may choose to enjoy the
convenience of being cared for by
primary care partners instead of at
TTSH SOCs. By working with
Community Health Assist Scheme
(CHAS) accredited GP clinics,
patients may not need to pay more
for their routine follow-up
In August 2013, MOH announced its
plan to remove the qualifying age
for CHAS, thus younger patients
below 40 years of age and from
low-income families could soon
benefit from CRiSP.
Engagement Session with
Primary Care Partners
In June 2013, TTSH held an
engagement session for GP
Partners to solicit feedback on
CRiSP. This session aimed to
determine the key elements that
needed to be in place prior to the
launch of CRiSP and to crystalise
the programme further.
In this session, GPs shared their
thoughts and helped TTSH verify
and align the programme to the
needs of the patients and
community that we are serving.
At the end of the day, CRiSP must
be something realistic and aligned
to the needs of the community.
So far, 19 GPs have expressed their
commitment and participation in a
trial rollout of CRiSP, which will
commence in January 2014 once
TTSH establishes the relevant
structures and obtains support
from the authorities.
What is TTSH’s
vision for CRiSP?
How can CRiSP
potentially shape the
way specialist care
CRiSP is conceptualised with the
intent that we want to right site
patients with stable chronic
conditions. We believe that stable
chronic disease patients are better
managed by primary care providers
who can deal with multi-disease
conditions and in a more cost
effective way. At the same time,
the close doctor-family relationship
between the primary care provider
and the patient will make the
treatment journey a seamless and
their treatment of chronic
patients. Clinical networks and
linkages between GPs and the
hospital will also be tightened to
provide better care for patients.
relevant infrastructure to
facilitate this programme; there
must also be willing patients,
doctors and payers to kickstart
and sustain CRiSP.
Today, MOH has, to a large extent,
created platforms to care for
patients with chronic conditions
under the Chronic Disease
Management Programme (CDMP)
scheme. First introduced in
October 2006, CDMP has been
enhanced in recent years with the
addition of blue and orange CHAS,
which provide subsidised
healthcare for a series of CDMP
conditions, depending on the age
and how financially challenged the
What are the next
steps for CRiSP now
and in the future?
From January 2014, CDMP will also
be expanded to include
osteoarthritis, benign prostatic
hyperplasia (BPH) and anxiety.
TTSH is working in the Regional
Health System to facilitate
affordable patients’ consultations
in the primary care setting. We
are also evaluating support
services to be developed to
support CRiSP that forms part of
the Primary Care Masterplan.
Structures and processes will also
be forged to facilitate the right
siting process for integrated care
of patients in and out of TTSH and
With CRiSP in place, patients
under the CHAS and expanded
CDMP can enjoy affordable and
convenient treatment from their
primary care providers.
Moving forward, TTSH will
continue to explore better ways
for shared care and evolve with
the needs of the community in
Central Singapore and support our
primary care partners.
We hope that patients with chronic
conditions recognise the benefits
and be encouraged to extend their
care journey out of TTSH SOCs and
with our primary care partners.
What are the
for CRiSP to
TTSH Primary Care Partners Office
(PCPO) is the main facilitator for
TTSH CRiSP. To learn more about
CRiSP, please email PCPO at
We plan to develop structures to
support and reduce the
administrative burden of our GPs in
We will need support on all
grounds, which include support
from policymakers to build in the
Let’s work together to add years
of healthy life for your patients.
It’s time to pack your suitcase for
your long-awaited vacation again.
But before you start feeling excited,
have you ever wondered how
diabetes would affect your trip? Fret
not. Diabetic patients can have an
enjoyable and stress-free holiday.
Read on to find out more.
iabetes mellitus (DM) is a lifestyle
disease, and the prevalence of this
illness increases with age.
According to the National Health Survey
Singapore 2010, one in nine (approximately
11.3%) Singaporeans suffered from DM,
and 90 to 95% of diabetic patients were
classified as Type 2 DM. The prevalence of
this disease was 1% in young adults ranging
from 18 to 29 years of age and it peaked as
high as 29.1% among those between 60 to
69 years old. Therefore, it is not uncommon
to meet a travelling companion sharing this
medical condition during a trip.
However, how can you ensure a healthy and
hassle-free journey without compromising the fun
of travelling? Unsure of where to start? A little
homework will keep your trip as smooth as silk.
Overseas vacations require adequate
preparation. There are language barriers to
consider, luggages to pack and currencies to
exchange. With diabetes, vacation planning
involves even more homework.
1. Bring plenty. Whether you are heading
across the globe or making a cross-border day
trip, always pack more supplies than you will
need. It is even more crucial if you are heading
to a country where you do not speak the
language and may have a hard time finding
medications and supplies.
2. Visit the doctor. About six to eight
weeks before your trip, visit your doctor and ask
for prescription refills. A doctor’s note on the
chemical name of each medication you take is
important because many countries will carry
foreign versions of the brand names you are used
to. Keep in mind that your body may react
differently to the same medication obtained at a
pharmacy in another country because the
medication may have been prepared differently
or use varying additives. For trips to less
developed countries, consider visiting a travel
clinic for all vaccinations, medications and tips
for minimising health risks.
Rest stops mark the miles and fast-food joints
litter the roads right off the highway, but if you
are looking for something healthy to eat on the
road, you may end up frustrated. While it is
definitely harder to eat well and quickly on the
road, it is still feasible.
1. Pack a cooler. The most obvious solution
to the healthy-eating dilemma is to bring your
own food. Have absolute control over what to
pack and what you wish to eat. Fill a cooler with
snacks and meals containing fruits, vegetables,
nuts and seeds as well as fibre-packed
carbohydrates and lean protein, both of which
will keep you feeling full longer. Peanut butter on
whole-grain bread, vegetables and whole-grain
crackers, non-fat yoghurt with fruits and mixed
nuts all travel well.
If your snack needs to be kept cool, surround them
with ice packs or bags of ice. Even food that
requires refrigeration, such as luncheon meat and
yoghurt will be safe in a cooler for a few hours.
For longer trips, bring gallon-sized plastic bags
and fill them with ice from convenience stores
along the way when your ice packs turn warm.
2. Drink responsibly. Driving for hours will
The safest way to ensure your supplies make it to
your destination is to keep them with you while
flying. If you plan to stuff your hand-carry
luggage in your overhead compartment, keep a
smaller bag beneath the seat in front of you, so
you have easy access to your meter, test strips,
syringes and insulin, snacks and fast-acting
glucose. After all, meals may be delayed because
of turbulence. To deal with eating uncertainties,
consider dosing rapid-acting insulin after your
tire anyone, but be careful how you refuel. Soda,
tonics and coffee drinks may seem like ideal road
trip refreshments, but they are notoriously high
in carbohydrates and calories. Always stay
hydrated with water. If that is too boring for you,
try making ‘spa water’: Squeeze lemons, limes or
oranges into your water bottle.
When it comes to coffee, stick to the basic. Plain
coffee with low-fat milk is fine, but fancy coffee
drinks are loaded with sugar. A 350ml café mocha
with whipped cream contains as much as 270
calories, 13 grams of fat and 34 grams of
Up in the Air
Of all the ways to travel, air flights pose the
greatest hassle for people with diabetes. There
are airport security, questionable airline food and
the ever confusing task of altering insulin
regimes when crossing time zones. The following
pointers can help you reduce the stress of flying
1. Plan for meals. The food available on
long flights is generally unhealthy. When booking
your flight, many airlines will give you the option
of picking up a meal suited to your health
concerns, but if you do not have that option,
call the airline. Request for a diabetic-friendly or
vegetarian meal. Many airlines will offer hearthealthy or low-sodium options too.
If the thought of eating airline food turns you
off, buy snacks at the airport. You can find nuts,
seeds, fruits, yoghurt, veggies and dips,
sandwiches with lean meat and salads at various
vendors. If you did not carry glucose to treat
unexpected hypoglycemia, this is also a good
time to stock up on candy, soda or juice.
2. Carry a doctor’s letter. Your trip
through airport security will go smoother if you
plan ahead. Ask your doctor to write a letter
stating your conditions and need to carry insulin,
syringes, test strips and other supplies. Also carry
pharmacy-labelled pill bottles and insulin vials
with you. You will spend a lot less time explaining
that the gadgets attached to your abdomen are
what we call insulin pumps and continuous
3. Pack a carry-on. As heavy as the bag on
your back may be, avoid the temptation to store
all your diabetes supplies in your checked-in
luggage. The cargo storage can get pretty chilly
at 30,000 feet (not such a pleasant atmosphere
for insulin). An even bigger worry is lost luggage.
4. Mention your diabetes. If you are
travelling alone, it is important that someone on
the flight knows about your diabetes in case of an
emergency. Alert a flight attendant when you on
board. You do not have to go into details, but let
them know that you may need a soda or juice if
you become hypoglycaemic.
It is important to discuss with your doctor any
travel-related changes you may need to make to
your insulin plan. You may need to dose more or
less insulin depending on your itinerary. If you
will be walking all the time, you may also need
to adjust your insulin dose.
6. Disconnect your pump. You may want
to consider disconnecting from your pump briefly
during takeoff and landing. Some studies have
shown that the changes in pressure on a flight
can make the pump deliver more insulin. Once
the plane has reached its cruising altitude, it is
safe to connect. Before reconnecting your pump
after takeoff and landing, check for air bubbles
caused by altitude changes. Reprime the pump if
5. Adjust Insulin. Crossing time zones is
tricky for people with diabetes because it requires
adjustment to insulin injections and is highly
subjective. You may need to reduce your insulin
dose if you are travelling east as days are shorter.
On the other hand, your insulin dose needs to be
increased if you are travelling west as days are
longer. Thus, you should visit your doctor at least
a month before you leave for your trip.
For a general idea of how travelling may affect
your insulin needs, you may use various online
resources such as VoyageMD.com, which has a
flight calculator that can help you determine
what changes to make to your insulin regime. In
general, no adjustment is required for travelling
north or south and crossing fewer than five time
Dr Khor Hong Tar
Dr Khor Hong Tar is an Associate Consultant in the
Department of Endocrinology at Tan Tock Seng Hospital
(TTSH). He graduated from Fudan University, School of
Medicine, China in 2000, completed his basic medical
training across hospitals in Malaysia, and obtained his
membership in the Royal College of Physicians, UK in 2007
before joining TTSH and completing his higher specialist
training in Endocrinology and Internal Medicine.
Dr Khor is actively involved in the teaching of junior doctors and postgraduate
students. He currently serves as Clinical Teacher in the Yong Loo Lin School of
Medicine, National University of Singapore. His subspecialty interests include
diabetes mellitus, obesity and thyroidology.
1. National Heath Survey, Singapore 2010
2. Diabetes Forecast Magazine June 2013
3. Chandran M and Edelman SV. Have Insulin, Will Fly: Diabetes management during air travel and
time zone adjustment strategies. Clinical Diabetes 21: 82-85, 2003.
DR is usually asymptomatic and may only be detected by
the patient when the retinal changes have progressed to
an advanced stage, where treatment is often
complicated or impossible. Studies have shown that
almost all patients with Type 1 diabetes and over 60% of
patients with Type 2 diabetes develop DR after 20 years.
Therefore, the duration of diabetes appears to be one
of the most important correlates of DR. Aside from
vision-threatening complications of DR, studies have
also found associations of DR with stroke, nephropathy
and heart disease.
Too much D
Diabetic retinopathy (DR) is one of the most
important complications of diabetes and is a
leading cause of blindness among working adults.
Better understanding of the risk factors of DR in
Asians can pave the way for timely treatment and
intervention of diabetic patients.
iabetes affects approximately one in
twelve Singaporeans aged 18 to 69
years, and in those aged 60 to 69
years, this figure is even higher at 32.4%.
This situation is likely to worsen over time,
compounded by factors such as dietary and
Diabetic retinopathy (DR) is one of the most
important complications of diabetes and is a
leading cause of blindness among working
adults. For example, in Singapore, among
Malays with diabetes, the overall prevalence
figures of any DR was found to be around
35.0%, whereas the corresponding figures for
the severe stages of DR such as macular
edema and vision-threatening DR were
around 5.7% and 9.0%, respectively.
This represents a significant percentage of
our population with important consequences
from a potentially preventable complication
Current treatment for DR relies on widespread laser
therapy to the retina that leaves behind destructive
scars. Newer therapeutic agents that require repeated
injections into the eye are costly and carry an increasing
risk of adverse outcomes with each treatment.
detecting diabetic Retinopathy
DR will be considered present if any characteristic lesion
as defined by the Early Treatment Diabetic Retinopathy
Study (ETDRS) severity scale is present: microaneurysms
(MA), hemorrhages, cotton wool spots, intraretinal
microvascular abnormalities (IRMA), hard exudates (HE),
venous beading and new vessels.
Macular edema is defined by hard exudates in the
presence of MA and blot hemorrhage within one disc
diameter from the foveal centre or presence of focal
photocoagulation scars in the macular area. Clinically
significant macular edema (CSME) is considered present
when the macular edema involved is within 500mm of
the foveal centre or if focal photocoagulation scars are
present in the macular area.
retinopathy. Vision-threatening retinopathy is defined as
the presence of severe non-proliferative DR,
proliferative retinopathy or CSME. The following series
of illustrations describe the various stages of DR.*
Better understanding of the risk factors for DR in Asians
may enable the development of population and ethnicity
specific prevention and intervention programme, which
may decrease the morbidity and cost associated with this
* Information taken from the upcoming publication, ‘Fundus
Photograph Interpretation for Primary Eye Care Practitioners’ by
National Healthcare Group Eye Institute.
Non-proliferative Diabetic Retinopathy
Figure 1: Dot
are seen in the
of the macula.
They can look
(thick arrow) are
a distance from
the fovea (*).
Figure 2: Cotton
wool spots (thin
arrows) are also
seen in diabetic
(thick arrow) are
also visible in the
of the retina.
Veins are slightly
DR is categorised as minimal non-proliferative DR,
mild non-proliferative DR, moderate non-proliferative
DR, severe non-proliferative DR and proliferative
Non-proliferative Diabetic Retinopathy
Figure 3: Crops
of dot and blot
arrows) are seen.
Veins are engorged
tortuous (*). There
is significant hard
(thick arrows) at
the macula, and the
retina is likely to
be edematous on
Proliferative Diabetic retinopathy
Figure 5: The photo
is hazy especially in
the inferior aspect, as
a result of vitreous
numerous fine blood
arrows) seen on the
disc, and represent
at the disc (NVD)
arrows) exert forces
on the retina, causing
retinal striae or folds
(thin arrows), and
Proliferative Diabetic Retinopathy
Figure 4: There
is extensive hard
(thick arrows) at
the macula. Note
the proximity of the
hard exudates to the
fovea (thin arrow),
indicating that vision
is likely to be poor.
Also note also
the dilated veins
(*) and large blot
suggestive of active
laser scars (double
of previous laser
is seen at the disc
(NVD) (thin arrow)
and pigmented scars
outside the vascular
therapy (^). Streaks
arrows) are also
seen. Hard exudates
(*) are also seen
at the macula and
laser scars indicate
Dr Augustinus Laude
Dr Augustinus Laude is a Consultant and Deputy Head of
Research at the National Healthcare Group Eye Institute at
Tan Tock Seng Hospital. He graduated from the University
of Edinburgh, UK in 1996 and obtained his Master of Science
in Investigative Ophthalmology and Vision Science at the
University of Manchester, UK and Master of Medicine in
Ophthalmology at the National University of Singapore.
The clinical interests of Dr Laude include vitreo-retina,
cataract and general ophthalmology. He is also an adjunct
research fellow at Singapore Eye Research Institute.
1. Wong TY, Cheung N, Tay WT, et al. Prevalence and Risk Factors for Diabetic Retinopathy The Singapore
Malay Eye Study. Ophthalmology 2008;115:1869–75.
2. Abbate M, Cravedi P, Iliev I, Remuzzi G, Ruggenenti P. Prevention and Treatment of Diabetic
Retinopathy: Evidence from Clinical Trials and Perspectives. Curr Diabetes Rev 2011;7:190-200.
Gain a foothold
Diabetes is a chronic metabolic disease that affects multiple organs,
but it is easy to overlook the impact that it has on the feet. With proper
patient education, regular diabetic foot screenings and appropriate
podiatric management, we can prevent the onset of devastating
consequences to the feet. Read on to find out more about the signs
and symptoms as well as how to take care of the diabetic foot.
n the National Health Survey
2010, it was estimated that more
than one in nine Singaporeans
suffer from diabetes mellitus. This
staggering figure not only highlights
the burden of this chronic disease
on the population, but also the
growing demand for healthcare
providers to manage the
complications that arise with
When it comes to foot
complications, a great deal of
responsibility will fall on the
diabetic patients themselves to
manage their condition as no
amount of medication can solve
these problems. If not diagnosed or
managed in a timely fashion,
diabetes can lead to chronic foot
ulceration, infection and eventually,
amputation of the leg.
My feet are numb.
A very common problem with
diabetes is peripheral neuropathy.
As the foot is the furthest part of
the body from the central nervous
system, the nerves in the foot are
the first to be affected, resulting in
All diabetic patients should be
advised on these following points
on how to take care of their feet:
Diabetic patients will lose the ability
to sense high pressures, extreme
temperatures and pain, which greatly
decreases their awareness of injuries
and wounds on their feet.
There’s some hard skin on my feet.
Damage to the nerves can also lead
to muscular imbalances between the
foot muscles and alter their
biomechanics. Patients may also
begin to observe changes such as
clawing of the toes, which result in
uneven pressures when they walk.
At areas of high pressure, commonly
at the sole of the foot, the body’s
natural protective mechanism is to
thicken the skin. These skin lesions
are known as callus (large area) and
corns (concentrated in a small area).
However, as the callus and corns
become thicker and harder, the
pressure at these areas increase.
Coupled with reduced sensation in
their foot, the risk of foot ulceration
My skin is dry and cracks easily.
Yet, another symptom of peripheral
neuropathy is the reduced function
of the skin’s sweat glands. Without a
healthy dose of the body’s natural
secretions, the skin of diabetic
patients will become drier and
stiffer. In such a state, their feet are
at risk of cracking and tearing more
easily, causing open wounds.
My wounds take a long time to heal.
Diabetes also causes the small blood
vessels in the feet to narrow and
harden, reducing the blood supply to
the foot. Hence, if patients have
wounds on their feet, there are less
wound healing factors available from
the blood plasma, delaying the
healing process. There is also a higher
risk of an infection and the wound
takes longer to heal.
1. Control your diabetes by
following your doctor’s advice
2. Eat a healthy diet and maintain
a fit and active lifestyle.
3. Do not soak your feet, but
rather wash your feet every day
with soap and water, and dry
them well especially between
4. Apply a urea-based moisturiser
to your feet every day to keep
your skin soft (but avoid
applying between your toes).
5. Never go barefoot at all;
covered shoes should be worn
at all times, ensuring that the
fitting of the shoe is neither too
big nor too small.
Caring for the
6. Toenails should be trimmed in
a straight line, do not trim
down the corners to prevent
the toenails from poking into
Having explored the complications of
the diabetic foot, it is essential that
all diabetic patients are taught how
to take good care of their feet.
7. Do not cut any corns/callus by
yourself or use any corn
plasters or acid as they can be
too strong and burn your foot.
Beyond patient education and
regular follow-ups with their
physician, they should also attend a
Diabetic Foot Screening annually and
be referred to a Podiatrist for
specialised management of foot
• Annual Diabetic Foot
Diabetic patients need to be
screened for neurological,
vascular and dermatological
problems at least once a year to
keep a record of the patient’s
foot condition as well as to
provide appropriate patient
education relevant to their
Research has shown that Diabetic
Foot Screenings can reduce the
incidence of ulceration and
amputation by up to 80%, hence
the importance of these
• Specialist Podiatric
The Podiatrist, who is specially
trained in the management and
treatment of the diabetic foot,
provides a vital service to those
diabetic patients with
complicated pathologies or those
with chronic foot ulcerations.
Following a holistic assessment of
the patient’s conditions, the
Podiatrist is able to manage and
treat thickened toenails, callus
and corns, along with being able
to perform conservative wound
debridement and provide
appropriate wound dressings.
More complicated cases may
require the Podiatrist to utilise
other therapies such as
offloading insoles and specialised
footwear to assist with callus or
with two feet
Taking good care of the feet is
simple, but yet, is often neglected.
Diabetic patients must be aware of
the importance of good foot care
and take charge of their own foot
health, before ulceration and
amputation become a real risk to
At the same time, healthcare
professionals must review the
patients regularly to ensure that
they are compliant with good foot
care advice and refer for
appropriate treatment where
Podiatrist at work.
8. Check your feet every day for
any wounds, cuts and areas of
redness, swelling and warmth
(use a mirror if necessary).
9. If you have any wounds on your
foot, immediately wash them
with clean water and cover
them with plasters to reduce
the risk of bacterial infection.
Matthias Ho is a Podiatrist with the Podiatry
Department in Tan Tock Seng Hospital. He
completed his undergraduate training at
the University of Southampton, UK and
has an interest in managing diabetic foot
wounds. He is also an active member of
the Podiatry Association (Singapore), where
he is currently serving as its Honorary
10. If you observe any signs of
infection, which are redness,
swelling, warmth, pus
discharge from wounds and
fever, visit your doctor or the
emergency department for
Vascular assessment of diabetic feet.
he prevalence of diabetes in
18 to 69-year-old adults in
Singapore has increased from
8.2% in 2004 to 11.3% in 2010
according to the Ministry of Health1.
This figure does not include
individuals with prediabetes, that
is, those with impaired fasting
glucose (blood glucose = 5.6mmol/l
– 6.9mmol/l) or impaired glucose
tolerance (2-hour plasma glucose
post oral glucose tolerance test =
7.8mmol/l – 11mmol/l).
The benefits of physical activity as a
non-pharmacological treatment option
for diabetic patients should not be
underestimated. However, it is important
to exercise appropriately and consult the
doctor if the patient wishes to embark on a
new exercise regime. Dr Pria Krishnasamy,
Associate Consultant of the Sports
Medicine & Surgery Clinic, Tan Tock Seng
Hospital shed light on the potential
benefits of exercise in diabetes as well as
the potential risks and complications of
physical activity for this group of patients.
and reduction in metabolic
complications and cardiovascular
oxidative capacity and muscle
strength and is associated with
Improved blood glucose and insulin
sensitivity are mediated by a
number of mechanisms. As one ages,
decline of muscle mass (also known
as sarcopaenia) increases the risk of
developing glucose intolerance and
diabetes, as muscle is a primary site
for glucose disposal and utilisation.
A decline in muscle mass also results
in reduced metabolic rate, lipid
A mechanism by which insulin
signalling in skeletal muscle is
thought to be improved with
physical activity is up-regulation of
insulin-stimulated glucose uptake
through increased GLUT-4 protein
concentration in skeletal muscle.
Hence, improving muscle mass is
believed to improve glucose
tolerance and insulin resistance.
Given that diabetes has become
one of the biggest public health
disease, the importance of physical
activity as a powerful treatment
option cannot be underestimated.
Benefits of Physical
In patients with pre-diabetes,
increased physical activity and
a good diet can reduce the
incidence of Type 2 diabetes by
58%, compared to 31% for those
individuals taking Metformin2.
For individuals with Type 2
diabetes, there is strong evidence
that physical activity can reduce
HbA1c by approximately 0.6%, even
without associated weight loss and
can lead to reduced medication3.
The benefits of physical activity
include improved blood sugar
control and insulin sensitivity,
improved blood cholesterol level
Points to Note for
Special considerations for diabetic
patients who are physically active
include the following3:
Physical activity is also thought to
switch on enzymes that manufacture
anti-oxidants besides increasing the
number and size of mitochondria,
which is the main energy generator
Other mechanisms through which
physical activity is thought to
reduce the risk of developing
coronary heart disease are through
decreased systemic inflammation,
improved early diastolic filling
(reduced diastolic dysfunction),
improved endothelial vasodilator
function and decreased abdominal
visceral fat accumulation with
effects on lipid profile and blood
It is recommended that physical
activity should be performed daily,
with a recommendation of 150
minutes of physical activity a
week. For those unaccustomed to
exercise, starting at 15 minutes a
day and building towards the
recommended dose of physical
activity is recommended.
A period of warm up and cool down
for about 10 minutes should be
incorporated before and after the
exercise sessions. Exercise should
be performed to at least moderate
intensity and gradually progressed
to vigorous intensity (as able where
it is safe after medical clearance)
to maximise health benefits,
particularly changes to HbA1c and
The types of exercise suitable for
individuals who are prediabetic or
those who have diabetes include a
combination of aerobic and
resistance exercises in the absence
Aerobic exercises involve large
muscle group activities like walking,
• If blood sugar is ≤ 3.9mmol/l,
exercise should be postponed
until carbohydrate has been
taken and blood sugar is
≥ 4mmol/l. When you are starting
to exercise, aim for blood sugar
• In the event of hypoglycaemic in
individuals on insulin and oral
hypoglycaemics, exercise should
be delayed for 24 hours as the
risk for hypoglycaemia is
• During exercise, a source of
rapid-acting carbohydrate (that
ideally does not also contain
fat) should be readily
available. In general, one
hour of moderate exercise
requires 15g of carbohydrate
(vigorous activity may require
30g). Requirements may be
higher in Type 1 diabetics.
• Ensure adequate
fluids should be
consumed before, during
and after exercise.
• Good foot care should be
practised by wearing
proper shoes and cotton
socks and inspecting feet
every time after exercise.
Keep feet dry.
• Medical identification
should always be carried
• General safety measures
such as avoiding
exercising alone or going
into remote areas should
cycling and swimming. Resistance
exercises are those that improve
muscle strength and can be body
weight exercises or those that
involve weights. Other exercises
that help general conditioning and
in the prevention of falls include
balance, proprioception and
flexibility exercises, such as yoga
and Tai Chi.
However, prior to commencing any
new exercise regime, especially in
diabetic individuals who are
unaccustomed to exercise, a
medical consultation with a doctor
is required to identify any factors
that may require modification to
These precautions are necessary
especially in diabetics, mainly
due to the high prevalence of
cardiovascular diseases and other
secondary organ damage including
retinopathy, peripheral and
autonomic neuropathy and
Other co-existing risks that should
be kept in mind when initiating an
exercise regime in individuals with
diabetes include arrhythmia in the
background of coronary artery
disease, which can be fatal and
autonomic dysfunction, which can
manifest as inappropriate blood
pressure response to exercise,
orthostatic hypotension and silent
Some specific contraindications
for exercise in diabetics include
the presence of active retinal
hemorrhage, treatment for
retinopathy within three months
(e.g. laser treatment), current
illness or infection, when blood
glucose is > 14mmol/l and ketones
are present and when blood glucose
is < 3.9mmol/l4.
Diabetics with both peripheral
neuropathy and foot ulcers should
not undergo weight bearing
activity, but can participate in
non-weight bearing activity such
as cycling or swimming4. Diabetics
with autonomic neuropathy are
not recommended to undertake
vigorous activity and light to
moderate activity should be
limited to sessions of shorter
In conclusion, tackling the rising
trend of diabetes is a priority in
modern Singapore and physical
activity can be a powerful nonpharmacological treatment option
for diabetic patients with due
consideration to the points listed
above and with medical guidance
from a doctor.
Dr Pria Krishnasamy
Dr Pria Krishnasamy is
the Associate Consultant
of the Sports Medicine
& Surgery Clinic of Tan
Tock Seng Hospital. She
graduated from Queen’s
University of Belfast, UK
and obtained a Masters
of Science in Sports
and Exercise Medicine from the University
of Nottingham in 2007. Dr Pria Krishnasamy
has worked in the National Health Service
(NHS) and many other sports organisations in
the UK including the London 2012 Olympics
and Paralympics. Besides musculoskeletal
medicine, Dr Pria Krishnasamy has clinical
and research interests in physical activity in
chronic disease and is involved in projects
related to physical activity prescription.
2. The Diabetes Prevention Program (DPP): Description
of Lifestyle Intervention,Diabetes Care. 2002; 25(12):
3. Thomas, D., Elliot, E.J. & Naughton, G.A. Exercise
for Type 2 Diabetes Mellitus. Cochrane Database of
Systematic Reviews 2006, Issue 3 Art. No.: CD002968.
4. Diabetes Mellitus and Physical Activity. In MY BEST
MOVE. Intelligent Health Public Health England:
5. Hilsted J et al Impaired Cardiovascular Responses to
Graded Exercise in Diabetic Autonomic Neuropathy.
Diabetes 1979; 28 313-319.
Apple Yoghurt Salad
Serving size: 8
Large Fuji apples 3
Fresh lemon juice
Non-fat plain yoghurt 200g
Low calorie sweetener (e.g. EqualTM)
Small ginger (3cm X 2cm), finely grated
1. Cut apples into cubes (about 1cm thick) and drain the excess juice with
2. Add lemon juice to the apple cubes immediately to prevent browning.
3. Mix the yoghurt, sweetener and grated ginger together.
4. Add the apple cubes, grated carrot and raisins with the yogurt mixture.
Stir well and ready to serve.
Cook’s Tip: Add celery or capsicum instead of raisins to reduce the
carbohydrate portion so that it is more suitable for people with diabetes.
Serving Size: 1 serving
Amount Per Serving
Calories 60 Calories from Fat 0
% Daily Value*
Total Fat 0g
Saturated Fat 0g
Trans Fat 0g
Total Carbohydrate 15g
Dietary Fibre 2g
* Percent Daily Values are based on a
2,000 calorie diet.
Recipe was designed by the Nutrition & Dietetics
Department and Hospitality & General Services of
Tan Tock Seng Hospital.
Photo courtesy of Mr Henry Lim, Photographer,
Tan Tock Seng Hospital.