The first step in treating diabetes is diet. Second step: d-i-e-t. Third step: D.I.E.T.

Diet doesn’t mean skimping on or skipping meals, but following medical nutrition therapy (MNT), including a diabetic-specific formula (DSF), to control, and even reverse type 2 diabetes.

The inclusion of the right meal replacement can support the body’s natural process to help manage blood sugar by helping minimise glycaemic response and provide for long-lasting blood sugar control.

“It is very difficult to diet and most of us tend to rebel. If I tell you to change your dietary habits, you might listen, but mostly likely, you will not follow.

“If you have diabetes, you might listen to me, but most likely you’ll say, ‘Dr, please give me a tablet.’

“If I tell you that beyond the tablet, you still have to diet, you’ll still listen, but tell me, ‘Doctor, I love my food!’

“In this therapy, have less food and have a meal replacement. The trick in modern nutrition is in functional food science, which uses ‘medicinal food’, and it is personalised for each individual.

“For example, suppose your largest meal of the day is dinner, then have half the dinner and take a bit of this DSF so the sugar level won’t go up too high. Or replace your lunch with DSF,” says endocrinologist and diabetologist Prof Dr Shashank Joshi.

He was in Kuala Lumpur in late November 2018 in conjunction with the International Diabetes Federation Western Pacific Region Congress.

“MNT is the first step for diabetics, and if you just diet, you will see the three-month average HbA1c (measure of average blood glucose) come down by 2%. Your quality of life improves.

“Diabetics fear that tablets or injections might suddenly cause the sugar level to become very low at night and they may die.

“We then give them a bedtime meal replacement, or if there is a long gap between foods, we also give them a meal replacement.”

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‘Diabetics must eat enough to be energetic but yet, they are often told to eat less. This puts them in a dilemma,’ says Dr Low. — Photos: NORAFIFI EHSAN/The Star

Adds Dr Low Yen Ling, director of research and development at Abbott’s Asia-Pacific Nutrition Centre: “Just because patients are diagnosed with diabetes, it does not mean the nutrition intake has to go down; you still need adequate nutrition.

“Many patients are still young, working and need nutrients to lead an active life. They must eat enough to be energetic, but yet, they are often told to eat less.

“This puts them in a dilemma. Food gives us adequate nutrition, but gets the blood glucose high.

“Drugs help us control blood glucose, but do not give us nutrition, so in order to balance this dilemma, use a diabetic formula that is designed to provide complete balanced nutrition.

“The definition of ‘complete’ is that if a person were to rely only on this formula for their energy requirement, they would meet all the nutrient requirements as well.”

Normal foods or formula use rapidly digestible carbohydrates, which enter the stomach and gut, and are usually digested in the top part of it.

Due to this quick digestion, it ‘shoots’ up the blood glucose, and then afterwards, the body responds and the blood glucose goes down.

Dr Low explains, “This kind of swing is actually bad for diabetes control. With slow-digested carbs, instead of everything being metabolised in the top part of the gut, it travels down the gut and slowly releases into the system, so the blood glucose curve is a much gentler one.

“And because it’s spaced out much longer in the gut, it also helps stimulate the intestinal cells to release the hormone GLP1, which has the ability to decrease blood sugar levels by enhancing the secretion of insulin.”

Every 1% drop in HbA1c can reduce the risk of microvascular complications such as diabetic nephropathy, neuropathy and retinopathy by 40%.

“Losing weight is one thing, but losing the right kind of weight is more important because patients shouldn’t lose muscle, but fat.

“Apart from weight reduction, there is also a significant reduction of blood pressure when taking MNT,” says Dr Low, who is also an adjunct assistant professor at the Saw Swee Hock School of Public Health at the National University of Singapore.

The advanced carb system in the meal replacement contains heart healthy fats and helps control appetite, while simultaneously providing nutrition.

“Although designed for diabetes management, anyone can take this meal replacement, especially pre-diabetic patients. It makes an easy and convenient lunch or snack,” she says.

Sugar-craving Malaysians

According to the International Diabetes Federation 2017 data, the world is seeing a 48% rise in diabetics between the ages of 20 and 79. From 425 million in 2017, the figure is expected to increase to 629 million by 2045.

As for the prevalence of diabetes in the region, Malaysia is at the top with 16.9%, followed by Singapore at 13.7%. Cambodia is the lowest at 2.6%, while China ranks highest in terms of cases (114,394,800).

Prof Joshi says, “Malaysia and Singapore are both global migration hub ports and diabetes is a serious issue, along with obesity.

“The number of people dying of diabetes is distressing as it is almost four million people yearly, and in a shorter time, in younger age groups, and even in those with lower BMI (body mass index).

“This parallels the rise in obesity, as we put on fat in our abdomen, gradually become overweight and become diabetic.

“It’s a mixture of environment and genes. Defeatists will say, ‘Ok, I’ve bad genes so let me enjoy my life.’ But that’s not true.

“Type 2 diabetes is a polygenic disease. It’s not a single gene defect – multiple genes are involved in the process, but it needs a main trigger.

“It’s like a gun which is loaded but not fired. To fire the gun, you need an environment that basically ‘feeds’ inactivity and bad food habits.

“If you eat the wrong foods and become physically inactive, and if you’re predisposed, then diabetes comes on.”

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Diabetes is a heart attack equivalent, points out Prof Joshi.

Based on geography and gene pool, the chances of genetics (coming from father to son or mother to daughter) are high.

When you breed within the same community and there is consanguinity, then the chances of bad genes being propagated to the next generation are higher.

About 20% of the population will fall into this category, so no matter what you do, you will still get the disease.

Prof Joshi says that if a heart attack patient is taken to a cardiologist, the risk of that person dying is the same as a person having mild diabetes.

“Remember: diabetes itself is a heart attack equivalent,” he points out. “Heart failure is equal or more than 50% in five years, particularly in diabetics, compared to somebody having, for example, colon or prostate cancer. People need to take diabetes seriously.”

In diabetes, there are no symptoms. What kills is when the glucose causes the blood vessels to narrow, for example, the brain vessels (you might get a stroke), retina (retinopathy), coronary artery (heart attack), etc.

“The skin becomes dry and because nerves are damaged, you don’t feel the sensations.

“The blood vessels start narrowing in the periphery, and then you get ulcers, which lead to amputations.

“So, it is a silent killer and does so bit by bit because of complications.

“I’ve had patients who have been on MNT, and along with exercise, they have managed to reverse diabetes, but they need lots of motivation and discipline.

“There are no cheat days, no weekends off; they have to be regularly regular or predictably predictable.

“With just 600 calories a day, you can reverse diabetes and be free of medicines. You won’t become skinny as you get all the nutrients.

“There are plenty of diet data to show reversal of diabetes type 2 is possible,” he says.

It is difficult to change a sweet tooth, but one can eat sensibly. Dr Low chips in, “When person is hungry, fast acting sugars are more attractive.”

Prof Joshi’s advice for diabetes management: “Eat less, eat on time, and eat slowly; eat a large breakfast, moderate lunch and light dinner; and if possible, replace one of your meals with MNT to lose weight.

“Do five to 10 minutes of brisk walking, six to seven times a day. When you get a telephone call, don’t be lazy and sit there, move around when you talk… walk the talk. Sleep on time, be stress-free and smile.

“Most of the time, the person with diabetes will not read health articles, but his family members will. They will cut out the article or WhatsApp it to the patient! So, education and enforcement are important.”