Advancing treatment
Speaking at the recent virtual launch of the CPG, Prof Chan, who is also the chairperson of the CPG Development Committee, highlighted what the new CPG brings to diabetes care: “Recent research has shown that losing 7-10% of body weight with diet and lifestyle can prevent pre-diabetic people from becoming diabetic.
“In addition, people newly diagnosed with T2DM (less than three years) can reverse their diabetes by losing 15% of their body weight and keeping it off.
“Such weight loss can be facilitated with the help of meal replacement products, very low calorie diets, or bariatric surgery and regular exercise.”
One of the key points in the CPG is that a patient has a 50% chance of reversing their T2DM by following a radical diet for three to five months, and losing at least 10kg.
If the patient can shed 15kg during the same period, they have a 90% chance of reversing their T2DM.
“The weight reduction would also benefit the liver by improving non-alcoholic liver disease, which, if left untreated, may lead to liver scarring and cancer,” adds Prof Chan.
Checking the gums
Perhaps one of the lesser talked about effects of diabetes is its association with periodontal or gum disease.
This condition affects the gums and bone surrounding the teeth, eventually leading to tooth loss.
In diabetics, the increase in blood sugar level can cause damage to the nerves, blood vessels, heart, kidneys, eyes and feet.
Similarly, the patient’s gums can also be affected.
Evidence shows that severe periodontal disease can increase blood sugar levels in not only people with diabetes, but also in those who do not have diabetes.
In other words, periodontal disease and diabetes are linked both ways.
“People with T2DM with periodontitis have two times more severe periodontal destruction than those without T2DM.
“The elevated levels of proinflammatory mediators within the inflamed periodontal tissues of poorly controlled diabetics causes increased periodontal destruction and contributes to insulin resistance and worsening glycaemic control,” says consultant endocrinologist Prof Dr Norlaila Mustafa.
The early symptoms of periodontal disease are bleeding during tooth-cleaning or eating, redness and swelling of the gums, and bad breath.
If these symptoms are not treated, the disease progresses to involve the deeper tissues and results in bone destruction.
Recession of the gums may occur, making the teeth appear longer.
Gaps can also appear between the teeth and the teeth may start to drift apart.
As the disease progresses, the teeth become loose.
“This disease is a chronic inflammatory condition that is underdiagnosed in patients with T2DM.
“Therefore, oral health education should be provided to all diabetic patients as the management of periodontal disease will improve metabolic parameters in T2DM,” Prof Norlaila adds.
She suggests that physicians and medical health professionals investigate the presence of periodontal disease as an integral part of T2DM follow-up visits.
“For newly diagnosed T2DM, referral for a periodontal examination should occur as part of their management.
“Even if there is no periodontitis diagnosed initially, annual periodontal review is still recommended.”
Affected patients are usually given periodontal therapy, which has been proven to improve their condition, even in poorly controlled T2DM.
She says, “With the therapy, we can bring the HbA1c level down by 0.27% to 0.48%.
“Also, adjunctive use of antibiotics doesn’t enhance HbA1c reduction beyond scaling and root surface debridement.
“Even in poorly controlled diabetic patients, root canal and scaling can be beneficial.”
Keto diet is a no-no
On the fad of T2DM patients following the keto diet, the experts say that the diet is unbalanced.
Ketogenic or keto is a term for a specific low-carb diet.
The idea is to get more calories from protein and fat, and less from carbohydrates.
Carbs that are easy to digest, like sugar, soda, pastries and white bread, are cut back the most.
Prof Chan says, “The keto diet is totally unbalanced.
“If you do it according to the recommendation of having almost zero carbs, the patient will become ketotic (where the body burns fat for fuel due to lack of carbohydrates), and then, acidotic (too much acid in the body fluids).”
Subsequently, they become very lethargic.
“This diet is discouraged because in some individuals, particularly those with renal impairment who are taking alternative proteins, it can adversely affect their kidney function.
“And if the patient is on the new class of drugs, the keto diet worsens ketosis.
“Basically, we don’t encourage diabetic patients to go on the keto diet due to the side effects they could suffer,” she says.
Consultant endocrinologist Datuk Dr Zanariah Hussein chips in, “A lot of patients need a lifestyle coach to give them incentives and motivate them to control their diabetes, so perhaps we need to consider giving them the right education and continuous motivation.”
Ethnic differences
The 2019 NHMS also showed that among ethnic groups, Indians had the highest prevalence of known diabetes (18.5%), followed by Malays (11%), Chinese (8.5%) and Sarawakian Bumiputeras (7.9%).
Among those with known diabetes, 25.7% claimed they were on insulin therapy; 85.6% claimed to be on oral antidiabetic drugs within the past two weeks; 88% had received specific diabetes diet advice from healthcare personnel; 75.4% claimed to have been advised by healthcare personnel to lose weight; and 23% opted for traditional and complementary medication.
While the differences in percentages could be partly due to genetic factors, Dr Zanariah points out that other background risk factors should also be looked at, e.g. obesity and physical inactivity.
“We must also recognise that in the Asian population, visceral adiposity and insulin resistance are factors to be considered,” she says.
Visceral adiposity is a type of fat that is stored deep within the abdominal cavity, where it pads the spaces between our internal organs such as the liver, pancreas and intestines.
This fat has been linked to metabolic disturbances and increased risk for cardiovascular disease and T2DM.
“Some East Asians may have more problems with pancreatic beta cell function, i.e. they cannot produce enough insulin, whereas southern Asians may have more problems with insulin resistance.
“We in Malaysia stand somewhere in between,” says Dr Zanariah, who is one of the co-chairpersons of the CPG Development Committee.
The CPG also provides guidance on managing acute illness or infection, says Prof Chan, quipping that diabetes does not take a holiday, even during a pandemic.
“People with diabetes tend to experience more severe Covid-19 infection and have a higher risk of death than non-diabetics.
“If other chronic diseases are also present, the risk of severe Covid-19 infection has been found to increase by two to three times.
“This is why the best course of action is to closely manage their glucose, blood pressure and cholesterol while taking every precaution to avoid catching Covid-19.
“Unfortunately, many patients are missing their follow-ups,” she remarks.
The CPG was jointly produced by a team of 69 experts under the auspices of MEMS, the Health Ministry, the Academy of Medicine Malaysia, Diabetes Malaysia and the Family Medicine Specialists’ Association of Malaysia.
It can be downloaded from