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Diabetes, a disease marked by high blood glucose levels, can give rise to complications in various parts of the body. THIS Quarterly looks at the various conditions associated with this illness.

Did you know that World Diabetes Day falls on 14 November?

The day was created in 1991 by the International Diabetes Federation and the World Health Organization to create awareness about the disease and the increasing health concerns it poses to health authorities. With an estimated 425 million people living with the disease all around the world, diabetes appears to be one of the biggest epidemics of this century.

Diabetes is a chronic condition, and there is no cure for it. There are three major types of diabetes: type 1, type 2, and gestational. All three affect the body’s ability to use the energy found in food.

When sugar or carbohydrates are consumed, the body breaks them down into glucose, which fuels all cells in the body. The cells need insulin to take in the glucose and convert it into energy. With diabetes, the body does not make enough insulin, or cannot use the insulin it produces, or a combination of both.

Since the cells cannot take in the glucose, it builds up in the blood. High levels of blood glucose can damage the tiny blood vessels in the kidneys, heart, eyes, or nervous system. Over time, and especially if left unmanaged, it can give rise to heart disease, blindness, and arthritic problems, to name a few. Besides suffering from disabilities, many diabetics also die from complications due to the disease.

This insidious and ‘invisible’ illness has far-reaching consequences for the patient. So serious and pervasive (one in nine Singaporeans suffer from it) is diabetes that Prime Minister Lee Hsien Loong spoke at length on it at the National Day Rally in 2017. As he pointed out then, in the early stages, there are few warning signs; by the time it has wreaked havoc on other parts of the body, it may already be too late.

That’s why it is important to learn about the complications caused by diabetes.

Associate Professor Leong Keng Hong (Rheumatologist)


Few people associate arthritis with diabetes, but the two diseases are closely connected. Research shows that diabetes increases your risk of rheumatoid arthritis (RA) and arthritis-related issues by around 20%. By the same token, having RA increases your risk of developing diabetes by 50%. There are various explanations for this.

Chronic inflammation due to diabetes may result in RA. Both RA and type 1 diabetes are autoimmune diseases, and research suggests that some people tend to have more than one type of autoimmune disease. This is partly due to genetics. Scientists have found a common gene in both individuals with type 1 diabetes and a specific subset of individuals with RA, which may contribute to the development of both conditions.

Just as the body attacks its own cells within the joints in RA, the body can also attack its own pancreatic cells that make insulin, resulting in diabetes.

RA is a disorder where your body’s immune system is unable to distinguish healthy cells from harmful ones such as bacteria and viruses. This confusion results in your immune system releasing antibodies that mistakenly attack healthy and functional cells and tissues. The disease is characterised by chronic inflammation and loss of function in the joints. Unlike osteoarthritis, which causes wear and tear to occur, RA can attack joints in various parts of the body at the same time, causing inflammation. Left untreated, RA can damage the organs and other tissues that surround the affected joints.

Risk factors for RA are:

  • Age — it’s most common between ages 20 and 50
  • Gender — women are more susceptible
  • Dental hygiene
  • Smoking

While there is no known prevention or cure for RA, lifestyle modifications such as not smoking as well as losing excess weight may help prevent diabetes. This in turn reduces the risk of RA.

If you have RA, there are ways to help control the pain, prevent disease progression and further complications. For most cases, your rheumatologist will prescribe medications based on the severity of the condition. Common ones include non-steroidal anti-inflammatory drugs, steroids, diseasemodifying anti-rheumatic drugs, and biologic agents.

Aside from medications, therapy also enables you to manage your pain better and improve the quality of your life. If medications and therapy do not help, and there is severe damage of the joints, surgery is recommended.

Leong Keng Hong Arthritis and Medical Clinic
6 Napier Road
#04-18 Gleneagles Medical Centre
Singapore 258499
Tel: 6472 4337

Dr Ann Tan (Obstetrician & Gynaecologist)


In Singapore, one in five pregnancies — that is more than 6,000 women each year — is affected by gestational diabetes. This figure is high by international standards — according to the International Diabetes Federation, only one in seven births is affected by gestational diabetes globally.

In Singapore, it has also been found that two out of three mothers with gestational diabetes will develop diabetes later in life.

Gestational diabetes is a condition that happens during pregnancy, usually in the second half. Hormonal changes predispose the mother to build up glucose in her blood. If her pancreas cannot produce enough insulin to manage this, her blood sugar levels will rise and cause gestational diabetes.

One of the complications of gestational diabetes is an increased risk of having a baby who is larger than normal, leading to possible birth injuries to the baby, or the mother faces a higher chance of requiring a C-section to deliver the baby.

Other problems include fetal abnormalities if she is an undiagnosed diabetic, perinatal death, pre-term birth, an increased likelihood of developing high blood pressure or preeclampsia. Conversely, at delivery, there could be issues of low blood sugar and delayed lung maturity in the baby, which can result in temporary breathing problems. The child is also more likely to develop type 2 diabetes as an adult.

Your chances of getting gestational diabetes are higher if you were over 35 years of age, overweight before pregnancy, or have a family history of diabetes. Other risk factors include having given birth to a large baby in an earlier pregnancy or a baby who was stillborn or had certain birth defects.

Screening tests for gestational diabetes are recommended between Week 24 and 28 of the pregnancy. If you have had gestational diabetes before, or if your doctor is concerned about your risk of developing the condition, the test may be performed before the 13th week of pregnancy.

If you are diagnosed with the condition, your doctor will want you to monitor your blood sugar levels to ensure good control to minimise complications. You may need to take insulin or other medications to assist in optimal control.

Faithfully following the treatment regimen will help you experience a healthy pregnancy as you would without gestational diabetes and deliver a healthy baby.

If you are planning to conceive, lower your risk of acquiring the disease by:

  • Keeping your weight in a healthy range
  • Eating healthily
  • Exercising regularly

3 Mount Elizabeth
#11-12 Mount Elizabeth Medical Centre
Singapore 228510
Tel: 6734 8188

Dr Eric Hong (Cardiologist)


Adults with diabetes are two to four times more likely to die from heart disease than those without. While diabetics are more likely to develop heart disease, those with type 2 diabetes are particularly at risk.

Coronary artery disease (CAD) is the cause of death in more than half the patients with diabetes. In one study, at least 68% of people aged 65 and older with diabetes die from some sort of heart disease. Other studies show that the risk of heart attack in diabetics is equivalent to that of non-diabetics with a prior history of heart attack. Women with diabetes are also more likely to die of heart disease than those without. One study showed that women with diabetes have a risk of cardiovascular death up to 7.5 times higher than women without diabetes.

Even with glucose levels under control, the risk of heart disease is present. This is because diabetes causes wear and tear of blood vessels, making the heart work harder. In Asia, type 2 diabetes usually occurs in the setting of metabolic syndrome, a cluster of conditions — hypertension, high blood sugar, excess body fat around the waist, and abnormal cholesterol levels — that occur together, raising one’s risk of developing diabetes. This is also known as insulin resistance syndrome, or Syndrome X.

The most common cause of heart disease in a diabetic is hardening of the coronary arteries, or atherosclerosis. This is caused by a buildup of plaque in the blood vessels. When the plaque breaks up, the body sends platelets to seal it. As the artery is small, more so in diabetic patients, these platelets could block blood flow and trigger a heart attack.

Heart attack symptoms include shortness of breath, feeling faint, nausea, excessive and unexplained sweating, and pain in the chest, shoulders, jaw and left arm. But diabetics may not get chest pain — it is believed that diabetes-related nerve damage blunts such feelings.

Diabetics who present with heart attacks are at an increased risk of dying from their cardiac event or developing heart failure. Heart failure is a serious condition where the heart cannot pump blood adequately, which can lead to fluid buildup in the lungs, causing breathing difficulty, fluid retention, and swelling in other parts of the body. Diabetic patients also have a higher incidence of multi-vessel disease and greater number of diseased vessels. Early screening of CAD in diabetics is important to ensure that appropriate medical treatments and interventions are carried out, particularly for diabetics participating in high-intensity sports.

To avoid diabetes-led heart disease, diabetics should:

  • Exercise regularly to better control blood sugar level. Muscles at work uses more glucose than those at rest. Exercise is also beneficial for weight control and stress management. Aim for 150 minutes a week of moderate-intensity aerobic activity that raises the heart rate and makes you perspire.
  • Adopt a heart-healthy diet by controlling portion size, limiting intake of saturated and trans fats, eating more fruits, vegetables and wholegrain products, selecting low-fat protein sources, and reducing sodium intake. Allow yourself an occasional treat and you will find that this heart-healthy diet is both possible and enjoyable.

3 Mount Elizabeth
#03-09 Mount Elizabeth Medical Centre
Singapore 228510
Tel: 6736 1068

Dr Leo Seo Wei (Ophthalmologist)


Did you know that diabetes is one of the leading causes of blindness in adults? One major eye problem in people with diabetes is diabetic retinopathy. It occurs when diabetes weakens or damages blood vessels in the eye. Particularly susceptible are those who have had diabetes for many years, have poor diabetes control and high blood pressure, or have had previous stroke and heart disease incidence.

If your blood glucose level has stayed too high for too long, it blocks off the small blood vessels that keep the retina healthy. Your eye will try to grow new blood vessels, but they will not develop well. They start to weaken, then blood and fluid leak into your retina. Nerve fibers in the retina may begin to swell. Sometimes the central part of the retina (macula) begins to swell (macular edema), causing blurring of vision. As your condition worsens, more blood vessels become blocked and closed off, causing the growth of new, abnormal blood vessels in the retina (proliferative diabetic retinopathy). Scar tissue builds up as new blood vessels grow in your eye. This extra pressure can cause your retina to detach. It also leads to glaucoma and other problems that may result in blindness.

Macula edema, or proliferative diabetic retinopathy, can be treated using anti-VEGF injection or retinal laser treatment. The injection or laser stops new vessels from leaking and growing. Although the treatment procedures cannot restore lost vision in some cases, it can — combined with follow-up care — reduce your chance of blindness by as much as 90%.

In the late stages of the disease, if the retina has become detached or a lot of blood has leaked into your eye, your doctor may suggest vitrectomy. This is a surgery to remove scar tissue, blood, and cloudy fluid from inside the eye. Keeping your blood sugar and blood pressure under control will help to slow down diabetic retinopathy, and may even prevent it. It also helps if you quit smoking.

It’s important to get an annual dilated eye examination to spot early signs of the disease. Women with diabetes who become pregnant require a comprehensive eye examination during the first trimester and a close follow-up with an ophthalmologist throughout the pregnancy.

Diabetics also have a higher risk of developing open-angle glaucoma, where the increased pressure in the eye can damage its nerves and blood vessels, causing changes in vision. There may be no symptoms until the disease is far in advance, with significant vision loss. Symptoms can include headaches, eye aches or pain, blurred vision, watering eyes, halos around lights, and loss of vision.

3 Mount Elizabeth
#10-04 Mount Elizabeth Medical Centre
Singapore 228510
Tel: 6737 8366

Dr Tan Soo Heong (Hand Surgeon)


The most common hand conditions associated with diabetics are carpal tunnel syndrome, trigger finger, limited joint mobility, and Dupuytren’s contracture. Diabetics also tend to be more susceptible to hand infections compared to non-diabetics.

Carpal tunnel syndrome (CTS)

The incidence of CTS in the diabetic population is between 11% and 21%. The mechanism is due to glycosylation of soft tissue, causing collagen cross-linking, and leading to thickening and stiffening of the transverse carpal ligament and peritendinous tissue. Furthermore, diabetic microvascular angiopathy of the nerve leads to polyneuropathy and increases the susceptibility of the median nerve to compression in the carpal tunnel. CTS presents with similar symptoms in diabetic and non-diabetic patients.

These include tingling in the hand, which affects the thumb, and index, middle and ring fingers. Tingling is often worse at night or in the early morning. It may be triggered by activities that involve strenuous or repetitive gripping.

When the condition worsens, tingling and numbness become continuous, with weakness and wasting of muscles at the base of the thumb. Patients may drop objects unknowingly and experience pain. If the condition is detected early, medications, avoiding aggravating activities, and a wrist splint can relieve symptoms. Surgery is recommended if the symptoms are severe or do not respond to other treatments. Symptoms are expected to alleviate after surgery but the improvement may not be as great in diabetics due to poorer nerve regeneration. Diabetic patients undergo carpal tunnel release surgery four to 14 times more than the general population.

Trigger finger

The prevalence of trigger finger in the diabetic population is 20%. Trigger finger in diabetic patients is more often bilateral and affects multiple digits, responds less well to corticosteroid injections, and more commonly requires surgery. Symptoms include painful swelling, stiffness, and triggering or locking of the affected finger.

While trigger finger can be treated with medication, rest, finger splint or steroid injections, those with diabetes are more likely to require surgery.

Limited joint mobility (LJM)

The prevalence of LJM in the diabetic population is 30%. Patients with LJM are unable to fully straighten the finger joints. It usually starts in the little finger and extends to the other digits. Patients are unable to place their palms flat — e.g. on the table (table top test) or together (preacher’s sign). LJM is related to the patient’s age as well as the duration of diabetes. Some studies show that LJM is associated with microvascular complications such as diabetic retinopathy.


Diabetic patients have an increased risk of infection because hyperglycaemia depresses cell-mediated immunity and white blood cell function. Peripheral neuropathy numbs the extremity to pain and sores, and injuries may be left untreated, leading to infection and complications. Furthermore, poor blood flow in diabetics impedes healing and may result in amputation or even death. In one study, diabetic hand infection was caused by several bacteria (polymicrobial), Gram-negative bacteria, and the usually common Staphylococcus aureus bacteria in 55%, 73% and 36% of the specimen respectively.

Keeping your blood glucose levels as close to normal as possible will help keep your hands healthy and free from the above conditions.

3 Mount Elizabeth
#09-07 Mount Elizabeth Medical Centre
Singapore 228510
Tel: 6737 0177