A PUBLICATION FOR

PRIMARY CARE PHYSICIANS

MCI (P) 097/03/2013

OCTOBER-DECember 2013

Heal City
th
Novena
Community Righ...
contents

editor’s note

07

Brave New World
2013 is coming to an end, but the
buzz and excitement have just
started.

The...
in the news

in the news

TTSH Welcomes the First Cohort from
Lee Kong Chian School of Medicine

Official Opening of Foot ...
in the news

cover story

Launch of Virtual Hospital on
19 June by (fifth and sixth from
left) Assoc. Prof. Muhammad
Faish...
cover story

cover story

30

August 2013 marked the start of a new future for
healthcare in Singapore.

On this day, Heal...
cover story

cover story

4 Cs of Integrated Care

2. Integration by Continuous
	Learning & Innovation

Integration of the...
cover story

The training of the community also extends to patients
and volunteers. Patients will be empowered to look aft...
cover story

cover story

The launch of Health City Novena Master Plan is a groundbreaking milestone. Health City
Novena w...
cover story

d. From Inpatient to Ambulatory Care
The fourth paradigm shift will see surgical care move
from the inpatient...
SPOTLIGHT

What is TTSH
Community Right
Siting Programme
(CRiSP)?
Currently, TTSH has in place
condition-specific initiati...
feature

feature

Diabetics Can
Travel Too
It’s time to pack your suitcase for
your long-awaited vacation again.
But befor...
feature

feature

2. Drink responsibly. Driving for hours will

The safest way to ensure your supplies make it to
your des...
feature

feature

Understanding Diabetic
Retinopathy
DR is usually asymptomatic and may only be detected by
the patient wh...
feature

feature

Non-proliferative Diabetic Retinopathy
and Maculopathy
Figure 3: Crops
of dot and blot
hemorrhages (thin...
feature

feature

Comprehensive foot
care education
All diabetic patients should be
advised on these following points
on h...
fITNESS

Fitness

T

he prevalence of diabetes in
18 to 69-year-old adults in
Singapore has increased from
8.2% in 2004 to...
fITNESS

Fitness

Points to Note for
Diabetic Patients
Special considerations for diabetic
patients who are physically act...
healthy recipe

Apple Yoghurt Salad
Serving size: 8
Ingredients
Large Fuji apples	3
Carrot	10g
Raisins	30g
Fresh lemon jui...
Future South Gateway of Novena Health City
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GP Buzz October - December 2013

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GP Buzz October - December 2013

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GP Buzz October - December 2013

  1. 1. A PUBLICATION FOR PRIMARY CARE PHYSICIANS MCI (P) 097/03/2013 OCTOBER-DECember 2013 Heal City th Novena Community Right Siting Programme spotlight on diabetes Scan the QR code using your iPhone or smart phone to view GP BUZZ on the TTSH website or visit www.ttsh.com.sg/gp/. “M Aw os ar & t Im d o Jo pr f E ur ov x na e ce ls” d M lle ca a nc te ga e go zin ry es in commemoration with World Diabetes Day
  2. 2. contents editor’s note 07 Brave New World 2013 is coming to an end, but the buzz and excitement have just started. The GP BUZZ editorial team: Jessie Tay Teo Puat Wen Celine Ong ADVISORY PANEL: Associate Professor Thomas Lew Associate Professor Chia Sing Joo Associate Professor Chin Jing Jih Adjunct Assistant Professor Chong Yew Lam Dr Tan Kok Leong Mr Joe Hau This edition of GP BUZZ is a bumper issue filled with good news and exhilarating developments in the healthcare industry. 24 30 GP Buzz is a magazine by Tan Tock Seng Hospital, designed by We value your feedback on how we can enhance the content of GP Buzz. Please send in your comments and queries to gp@ttsh.com.sg. © All rights reserved. No part of this publication may be reproduced or transmitted in any form by any means without prior consent from the publisher. in every issue in this issue 030 editor’s note 07 Transforming The 040 in the news 300 fitness 340 Healthy recipe Healthcare Landscape In Central Singapore Health City Novena 17 Community Right Siting Programme (CRiSP) 20 Diabetics Can Travel Too 24 Too Much ‘Eye Candy’: The Growing Concern Of Diabetic Retinopathy Amongst the many news updates, the opening of our latest Foot Care and Limb Design Centre, and the inception of National Healthcare Group and Tan Tock Seng Hospital (TTSH) as clinical partners for Lee Kong Chian School of Medicine in August are two of our most recent achievements. The healthcare landscape in Central Singapore is set to transform with the unveiling of the masterplan for Health City Novena on 30 August. For the cover story, we share how this new development could potentially address future healthcare challenges and anchor the Regional Health System for Central Singapore. We also speak to Dr Eugene Fidelis Soh, Lead for Health City Novena and Chief Operating Officer of TTSH on the new model of care and how our primary care partners can play a part in the Health City. In the same breath, TTSH has introduced a Community Right Siting Programme, termed CRiSP, to decant TTSH patients suffering from a range of chronic diseases to and from GP clinics, polyclinics and Family Medicine Clinics (FMCs). Adjunct Assistant Professor Chong Yew Lam, Programme Champion of CRiSP and Assistant Chairman, Medical Board for Clinical Development, explains the principle behind CRiSP and how it works. In conjunction with World Diabetes Day on 14 November, we have also lined up a series of feature articles on diabetes and caring for diabetic patients. We start off with travelling tips and knowledge for patients with diabetes. This is followed by targeted articles on eye care, foot care and physical fitness for diabetic patients. Not to forget, we have a diabeticfriendly recipe to end on a delicious note. Last but not least, we are humbled to share that TTSH GP BUZZ has won the APEX 2013 Awards for Publication Excellence in the ‘Most Improved Magazines and Journals’ category. This international award is not possible without the support of our GP partners. We will continue to produce quality content and develop fresher designs to make GP BUZZ an enriching read for you. The GP BUZZ Editorial Team TTSH GP BUZZ wins APEX 2013 Award of Excellence! T an Tock Seng Hospital’s (TTSH) GP BUZZ magazine won the APEX 2013 Awards for Publication Excellence in the ‘Most Improved Magazines and Journals’ category. The award recognised GP BUZZ’s efforts to provide better quality content and fresher designs to our GP partners. APEX 2013, the 25th Annual Awards for Publication Excellence, is an international competition that celebrates outstanding publications from newsletters and magazines to annual reports, brochures and websites. It acknowledges excellence in graphic design, quality of editorial content and the success of the publication in conveying the message and achieving overall communications effectiveness. 27 Gain A Foothold Against Diabetes OCTOBER - DECember 2013 03
  3. 3. 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 T 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. The new FLC along Jalan Tan Tock Seng Road. 04 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. T 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 orientation. 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 LKCMedicine. 05
  4. 4. in the news cover story 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. Virtual Hospital Bringing Care to Patient’s Home T 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. Patients under this scheme were each assigned a Health Manager who will assess the conditions of the patients Institute to Lead Geriatrics Research and Education 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. Transforming the healthcare landscape in Central Singapore HEALTH CITY NOVENA 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%. T 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 workforce. 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. 06 07
  5. 5. cover story cover story 30 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. 08 09
  6. 6. cover story cover story 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 Connectivity. “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 Expansion. 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 10 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. 11
  7. 7. cover story 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 the Community “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 cover story 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 Connectivity “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. 12 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. 13
  8. 8. cover story cover story 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 Partners 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 whole person. 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. 14 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 physicians. 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 treatment. 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 patients. 15
  9. 9. cover story 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 population. 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. SPOTLIGHT 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. Community Right Siting Programme (CRiSP) S 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 population. 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 around 10%. 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). 16 17
  10. 10. SPOTLIGHT What is TTSH Community Right Siting Programme (CRiSP)? Currently, TTSH has in place condition-specific initiatives aligned to the Primary Care Masterplan’s aim of bringing primary care closer to Singaporeans to better support chronic disease management within the community. 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 SPOTLIGHT 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 primary care. 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 consultations. 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. 18 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 is delivered? 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 comfortable process. 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 patient is. 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 primary care. 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 essential ingredients for CRiSP to succeed? TTSH Primary Care Partners Office (PCPO) is the main facilitator for TTSH CRiSP. To learn more about CRiSP, please email PCPO at GP@ttsh.com.sg. 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. 19
  11. 11. feature feature Diabetics Can Travel Too 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. D 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. 20 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. Going Abroad 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. Road trips 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. 21
  12. 12. feature feature 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 meal arrives. 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 carbohydrates. 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 with diabetes. 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 22 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 glucose monitors. 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 necessary. 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 zones. 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. References 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. 23
  13. 13. feature feature Understanding Diabetic Retinopathy 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 ‘Eye Candy’: The Growing Concern of Diabetic Retinopathy 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. 24 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 lifestyle changes. 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 of diabetes. 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 disease. * 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 hemorrhages and microaneuryms (thin arrows) are seen in the temporal aspect of the macula. They can look very similar clinically. Yellow hard exudates (thick arrow) are also seen a distance from the fovea (*). Figure 2: Cotton wool spots (thin arrows) are also seen in diabetic retinopathy. Some blot hemorrhages (thick arrow) are also visible in the temporal aspect of the retina. Veins are slightly engorged (*). DR is categorised as minimal non-proliferative DR, mild non-proliferative DR, moderate non-proliferative DR, severe non-proliferative DR and proliferative 25
  14. 14. feature feature Non-proliferative Diabetic Retinopathy and Maculopathy Figure 3: Crops of dot and blot hemorrhages (thin arrows) are seen. Veins are engorged and slightly tortuous (*). There is significant hard exudate deposition (thick arrows) at the macula, and the retina is likely to be edematous on detailed examination. Diabetic Maculopathy Proliferative Diabetic retinopathy Figure 5: The photo is hazy especially in the inferior aspect, as a result of vitreous hemorrhage. The numerous fine blood vessels (double arrows) seen on the disc, and represent neovascularisation at the disc (NVD) consistent with proliferative diabetic retinopathy. Tractional membranes (thick arrows) exert forces on the retina, causing retinal striae or folds (thin arrows), and ultimately, tractional retinal detachments. Proliferative Diabetic Retinopathy and Maculopathy Figure 4: There is extensive hard exudate deposition (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 hemorrhages (^) suggestive of active retinopathy and laser scars (double arrows) suggestive of previous laser therapy. Figure 6: Neovascularisation is seen at the disc (NVD) (thin arrow) and pigmented scars outside the vascular arcades indicate previous panretinal photocoagulation therapy (^). Streaks of preretinal hemorrhage (double arrows) are also seen. Hard exudates (*) are also seen at the macula and laser scars indicate previous macular focal/grid laser therapy. 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. References 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. 26 Gain a foothold against diabetes 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. I 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 diabetes. 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. Common complaints 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 diminished sensation. 27
  15. 15. feature feature Comprehensive foot care education 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 will increase. 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 on medication. 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 the toes. 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 diabetic foot 6. Toenails should be trimmed in a straight line, do not trim down the corners to prevent the toenails from poking into your flesh. 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 pathologies. • Annual Diabetic Foot Screenings 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 situation. Research has shown that Diabetic Foot Screenings can reduce the incidence of ulceration and amputation by up to 80%, hence the importance of these screenings. • Specialist Podiatric Management 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 wound management. Stepping out 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 their well-being. 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 necessary. 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 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 Secretary. 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 antibiotics immediately. Vascular assessment of diabetic feet. 28 29
  16. 16. fITNESS Fitness T 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). Keeping Fit with Diabetes 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. 30 and reduction in metabolic complications and cardiovascular mortality. oxidative capacity and muscle strength and is associated with increased adiposity. 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 Activity 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 31
  17. 17. fITNESS Fitness Points to Note for Diabetic Patients 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 in cells. 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 pressure. Exercising Right 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) 32 to maximise health benefits, particularly changes to HbA1c and aerobic capacity. 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 of contraindications. 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 between 7-10mmol/l. • 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 increased. • 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 hydration. 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 around. • General safety measures such as avoiding exercising alone or going into remote areas should be taken. 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. Medical Guidance for Diabetes 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 physical activity. 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 nephropathy. 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 myocardial ischaemia. 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 duration5. 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. References 1. http://www.moh.gov.sg/content/moh_web/home/ statistics/Health_Facts_Singapore/Disease_Burden. html 2. The Diabetes Prevention Program (DPP): Description of Lifestyle Intervention,Diabetes Care. 2002; 25(12): 2165–2171. 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: London, 2012. 5. Hilsted J et al Impaired Cardiovascular Responses to Graded Exercise in Diabetic Autonomic Neuropathy. Diabetes 1979; 28 313-319. 33
  18. 18. healthy recipe Apple Yoghurt Salad Serving size: 8 Ingredients Large Fuji apples 3 Carrot 10g Raisins 30g Fresh lemon juice 1 tbsp Non-fat plain yoghurt 200g Low calorie sweetener (e.g. EqualTM) 4g Small ginger (3cm X 2cm), finely grated 1 Method 1. Cut apples into cubes (about 1cm thick) and drain the excess juice with a sieve. 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. Nutritional Value Serving Size: 1 serving Amount Per Serving Calories 60 Calories from Fat 0 % Daily Value* Total Fat 0g Saturated Fat 0g Trans Fat 0g Cholesterol 0mg Sodium 20mg Total Carbohydrate 15g Dietary Fibre 2g Sugars 12g Protein 2g Vitamin A Vitamin C Calcium Iron 0% 0% 0% 1% 5% 7% 4% 8% 6% 2% * 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. 34
  19. 19. Future South Gateway of Novena Health City

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