Critical to improve health literacy

People must learn to modify diets to prevent lifestyle diseases such as diabetes

Image Credit: Created with the assistance of DALL·E 3

 

PRIME Minister Datuk Seri Anwar Ibrahim’s reminder to the people to take health knowledge seriously is timely.

At the launch of the 2024 National Wellness Month celebration last weekend, he reminded people to understand the dangers of excessive sugar consumption, saying that campaigns on health literacy or sugar reduction, as well as health literacy policies, would only be effective if people began changing their eating habits now.

For a start, let’s recall what we ate and drank in the past 24 hours, just to have a perspective of our sugar consumption.

From roti canai to teh tarik and the myriad of kuih, these foods all contain sugar.

When people say that they have cut sugar from their diets, I wonder if they realise that their bodies convert the carbohydrates they consume into sugar.

Staples like rice, bread, noodles and fruits are also high in carbohydrates, so maybe we need to take a good look at our food portions too.

Not long ago, the Health Ministry introduced the Malaysian Healthy Plate campaign with the hashtag #sukusukuseparuh

My friends were talking about it and I thought it was a clever way of introducing the concept of meal portions to the public.

The campaign encourages the public to limit their carbohydrate intake to fit a quarter segment of the plate. Another quarter of the plate should be filled with protein and the remaining half, with fruits and vegetables.

Now the key is making this meal formula part of our lifestyle.

Growing up, I watched my paternal grandmother suffering from diabetes.

She had her first stroke a day before I turned one. She must have been about 53 years old then.

However, I remember my paternal grandmother having a healthy diet. She took me along for her evening walks, took her medications on time and never skipped doctor’s appointments.

Over time, she became bedridden, before she passed away at the age of 70 in 1994.

She was an attractive woman in her youth but everything went downhill when she became sick.

After the stroke, her mobility was limited, preventing her from maintaining her active lifestyle.

My maternal grandmother also suffered from diabetes and her mobility, too, was limited after a stroke.

She had never cared about her diet and was a teh tarik addict. There was always an unlimited supply of condensed milk from my grandfather’s grocery store.

I dare say her enjoyment of this popular drink and her eventual poor physical mobility contributed to her eventual death.

As a child, I watched my grandmothers become weak, lose their speech and become bedridden before their deaths.

They were both diabetics and would have had poor health literacy in their younger days.

Thankfully, both my parents are healthy and my dad just turned 80. I believe this can be attributed to their balanced diets.

I’m also conscious of my own family’s consumption and manage this through my cooking.

Besides food, physical exercise is also necessary. It is no longer an option to say that we have no time to exercise.

A walk in the park may be possible depending on the weather.

However, I believe it is time that more public gyms are created. These gyms could be open from morning to midnight and made accessible to the public for a minimal fee.

The Bangsar Sports Complex at in Bangsar, Kuala Lumpur, has a public gym and it is managed by Kuala Lumpur City Hall. The entrance fee is just RM2.

I hope local councils, especially the ones with city status, will create public gyms with cardio and weight-training equipment.

Cardio activities such as Zumba could also be held at public spaces and should be promoted to the community.

More community-based sports for children, such as football and netball, should also be spearheaded by elected representatives.

Prevention of non-communicable diseases such as diabetes, hypertension and high cholesterol will reduce taxpayers’ funding of the nation’s healthcare services.

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Diabetes is a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces. Insulin is a hormone that regulates blood glucose.

Diabetes and insulin

Summary

Read the full fact sheet

• People with type 1 diabetes must inject insulin every day, often up to 4 or 5 times per day.
• There are different ways to inject insulin ranging from a syringe and needle, to an insulin delivery pen, to an insulin pump.
• Your doctor or diabetes nurse educator will teach you about how, where and when to inject insulin, and how to store it safely.
• Even with the help of your doctor and diabetes nurse educator, it may take a while to find the right insulin dose to reduce your blood glucose to your target levels.
• What is Type 2 Diabetes?

Type 2 diabetes is a common metabolic condition that develops when the body fails to produce enough insulin or when insulin fails to work properly, which is referred to as insulin resistance. Insulin is the hormone that stimulates cells to uptake glucose from the blood to use for energy.

Image Credit: Created with the assistance of DALL·E 3

When this is the case, cells are not instructed by insulin to take up glucose from the blood, meaning the blood sugar level rises (hyperglycemia).

Prevalence and Risk Factors

People usually develop type 2 diabetes after the age of 40 years. However, people of South Asian origin are at an increased risk of the condition and may develop diabetes from age 25 onwards. The condition is also becoming increasingly common among children and adolescents across all populations. Type 2 diabetes often develops due to overweight, obesity, and lack of physical activity, and diabetes prevalence is on the rise worldwide as these problems become more widespread.

Heterogeneity and Genetic Factors

Type 2 diabetes is a heterogeneous disorder characterized by varying degrees of beta cell dysfunction in concert with insulin resistance. The strong association between obesity and type 2 diabetes involves pathways regulated by the central nervous system governing food intake and energy expenditure, integrating inputs from peripheral organs and the environment. Genetic susceptibility and environmental factors, including the availability of nutritious food and other social determinants of health, play significant roles in the development of diabetes and its complications.

Global Impact In 2021, the global prevalence of diabetes mellitus was estimated to be 6.1%, representing 529 million people, with prevalence estimates in certain regions as high as 12.3%. Type 2 diabetes accounts for 96% of cases, and greater than 50% of type 2 diabetes is attributable to obesity. The trajectory of the diabetes pandemic is concerning, with an estimated 1.31 billion individuals projected to have diabetes by 2050.

Types of Diabetes

Also known as juvenile diabetes, type 1 diabetes usually occurs in childhood or adolescence. In type 1 diabetes, the body fails to produce insulin, so patients have to be given the hormone. This is why the condition is also known as insulin-dependent diabetes mellitus (IDDM).

Type 2 diabetes mellitus is also called non-insulin-dependent diabetes mellitus (NIDDM) since it can be treated with lifestyle changes and types of medication other than insulin therapy. Type 2 diabetes is significantly more common than type 1 diabetes.

Symptoms of Type 2 Diabetes

The increased blood glucose level seen in diabetes can eventually damage a person’s blood vessels, nerves, and organs. The body attempts to remove the excess glucose through urination, and the most common symptoms of type 2 diabetes include the following:

• Polydipsia (increased thirst)
• Polyphagia (increased hunger)
• Polyuria (increased frequency of urination), especially during the night
• Extreme fatigue, weight loss, and sudden loss of muscle bulk.

Some of these symptoms are also seen in type 1 diabetes, but type 2 diabetes symptoms tend to develop more gradually and can take months or years to manifest. This can make it more difficult for people to tell they have an underlying health condition, and often, people have had type 2 diabetes for a long time before it is finally diagnosed.

Risk Factors

Several factors can increase a person’s risk of developing diabetes. Examples include:

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• Overweight or obesity
• Unhealthy diet
• A waist measurement of 31.5 inches or more among women
• A waist measurement of more than 37 inches among men
• Low levels of physical activity
• Raised cholesterol
• High blood pressure
• South Asian ethnicity
• Smoking

A family history of diabetes also increases a person’s risk of developing the condition. Studies have shown that the offspring of families where one parent has diabetes have a 15% increased risk of developing the condition and that offspring born to two parents with diabetes have a 75% increased risk.

Complications of Type 2 Diabetes

The high blood glucose seen in diabetes can damage blood vessels, nerves, and organs, leading to a number of potential complications. Some examples of the complications caused by diabetes include the following:

Cardiovascular Disease

Persistently high blood glucose levels can lead to atherosclerosis, increasing the risk of heart disease and stroke. This includes narrowing and clogging of blood vessels with fatty plaques, which can disrupt blood flow to the heart and brain.

Nervous System Damage

Excess glucose in the blood can damage small blood vessels in the nerves, causing a tingling sensation or pain in the fingers, toes, and limbs. Nerves outside of the central nervous system may also be damaged, a condition known as peripheral neuropathy. If nerves of the gastrointestinal tract are affected, vomiting, constipation, and diarrhea may occur.

Diabetic Retinopathy

Damage to the retina may occur if tiny vessels in this tissue layer become blocked or leak. The light then fails to pass through the retina properly, which can cause vision loss.

Kidney Disease

Blockage and leakage of vessels in the kidneys can affect kidney function. This usually happens due to high blood pressure, and blood pressure management is an integral part of managing type 2 diabetes.

Foot Ulceration

Nerve damage in the feet can mean minor cuts are not felt or treated, leading to a foot ulcer developing. This happens to around 10% of people with diabetes.

Prevention, Treatment, and Care

Blood sugar should be regularly monitored to detect and treat any problems early. Treatment involves lifestyle changes such as eating a healthy and balanced diet and regular physical exercise. If lifestyle changes alone are not enough to regulate the blood glucose level, anti-diabetic medication in the form of tablets or injections may be prescribed. In some cases, people who have had type 2 diabetes for many years are eventually prescribed insulin injections.

Maintaining a healthy blood glucose level, blood pressure, and cholesterol is essential to preventing the complications of type 2 diabetes. Overweight or obese individuals with diabetes often significantly reduce the extent of their symptoms by making adjustments to their lifestyle.

Recent Therapeutic Advances

Maintaining a healthy blood glucose level, blood pressure, and cholesterol is essential to preventing the complications of type 2 diabetes. Recent advances in therapy include the use of GLP-1 receptor agonists, which have shown positive effects beyond glycemic control, such as weight loss and reduced cardiovascular mortality. These therapies represent a new era in diabetes treatment, impacting both metabolic control and cardiorenal complications.

Gut Microbiota and Type 2 Diabetes

The gut microbiota (GM), comprising trillions of microorganisms in the gastrointestinal tract, plays a crucial role in the development of obesity and related metabolic disorders, such as type 2 diabetes. Studies show that GM dysbiosis is linked to increased energy extraction, altered metabolic pathways, and inflammation, contributing to obesity, metabolic syndrome, and type 2 diabetes. The GM influences nutrient absorption, immune regulation, and energy metabolism.

Impact of Diet and Lifestyle

Dietary habits significantly influence GM composition and microbial metabolites that regulate host metabolism. A Western diet, rich in fat and sugar but low in fiber, is associated with GM dysbiosis. Conversely, adherence to a Mediterranean diet increases short-chain fatty acid (SCFA) levels, promoting metabolic health.

Microbial Diversity and Health

The human GM consists of approximately 100 trillion cells, with the highest diversity found in the colon. A diverse GM is rich in number and variety, playing a key role in maintaining metabolic health. Disruptions to GM diversity due to diet or medication can lead to metabolic diseases.

Emerging Therapies Targeting GM

Potential therapies targeting GM include dietary modification, prebiotics, probiotics, and fecal microbiota transplantation (FMT). These interventions aim to restore a healthy GM composition, improving metabolic health and reducing the risk of type 2 diabetes and obesity.

Sources

1. NHS. “What Is Type 2 Diabetes?” NHS, NHS, 18 Aug. 2020, www.nhs.uk/conditions/type-2-diabetes/.
2. National Institute for Health and Care Excellence. (2022, June 29). Overview | Type 2 diabetes in adults: management | Guidance | NICE. Nice.org.uk; NICE. https://www.nice.org.uk/guidance/ng28
3. http://www.diabetes.ca/files/Prediabetes-Fact-Sheet_CPG08.pdf (no longer active)
4. Diabetes UK. “Type 2 Diabetes.” Diabetes UK, Diabetes UK, 18 May 2023, www.diabetes.org.uk/diabetes-the-basics/types-of-diabetes/type-2.
5. “Type 2 Diabetes - Symptoms and Causes.” Mayo Clinic, www.mayoclinic.org/diseases-conditions/type-2-diabetes/home/ovc-20169860.
6. Sasidharan Pillai, S., Gagnon, C. A., Foster, C., & Ashraf, A. P. Exploring the Gut Microbiota: Key Insights into Its Role in Obesity, Metabolic Syndrome, and Type 2 Diabetes. The Journal of Clinical Endocrinology & Metabolism. DOI:10.1210/clinem/dgae499, academic.oup.com/.../7718329?login=false
7. Diabetes mellitus—Progress and opportunities in the evolving epidemic Abel, E. Dale et al. Cell, Volume 187, Issue 15, 3789 - 3820, https://www.cell.com/cell/fulltext/S0092-8674(24)00703-7

Further Reading

• All Type 2 Diabetes Content
• Diabetes Mellitus Type 2 Pathophysiology
• Type 2 Diabetes Symptoms
• Type 2 Diabetes Diagnosis
• Type 2 Diabetes Screening and Prevention

More...

Don’t put your health at risk

Stay vigilant: A person looking at possibly fake supplements on an ecommerce platform. — YAP CHEE HONG/The Star

\ Fake health supplements slip through on ecommerce platforms

PETALING JAYA: Don’t jump for joy if your usual supplements are being sold at knockdown prices on ecommerce websites, because they could be fake or counterfeits that could pose a health risk.

A check on these ecommerce websites revealed that many commonly used supplements are being sold at dirt-cheap prices of up to 70% cheaper by overseas sellers.

The “bogus” supplements bear the real brands and existing labels from the United States, United Kingdom or Australia, which are not that common in Malaysian .

ALSO READ: Suspicious supplements have consumers on high alert

They include popularly consumed supplements like multivitamins and those for joint health, heart health, anti-inflammatory, anti-ageing, antioxidants, probiotics and enzymes.

Buyers are, however, unable to view or verify where these sellers are based.

From the parcel delivery label and information, the products seem to have come from overseas with the parcels delivered through a shipping and consolidating company based in Selangor.

ALSO READ: ‘Ecommerce sites should be held accountable’

While many Malaysians have purchased these products from such sellers, some noticed differences between the original product in terms of product label, design and packaging, and the actual supplement’s look, form and smell.

Malaysian Community Pharmacy Guild (MCPG) Kuala Lumpur and Selangor chairman Rachel Gan said the cheap pricing does not “make sense.”

“It’s quite impossible for these supplements to go so cheap,” she said in an interview.

Questioning the content of such products, she said they could be made with powders used as “filler.”

“But the concern is that they could be made of something else that is unknown and which could damage your kidneys or liver in the long run,” said Gan.

MCPG president Foon Hwei Foong said these products could have been adulterated with unknown substances that could be dangerous to a person’s health. 

 Finding out what these substances are poses another challenge as it is costly to do so, said Gan, adding that consumers who suspect something amiss could send the supplement to a lab to test its ingredients.

“It may cost a few thousand ringgit. That’s why consumers usually don’t bother and just throw the products away since they spent so little to buy them in the first place,” she said.

She added that consumers were likely to only take action when their health is affected.

Despite existing laws and controls to ensure the safety of medicines and supplements in the market, Gan said the emergence of online sellers poses a challenge.

“Any sellers, either from Malaysia or overseas, are allowed to sell online, offering all kinds of unregistered products.

“It could be any overseas brand and the products can pass through Customs checks and reach Malaysian consumers.an let it go through.

“This sounds scary as any supplement can come into Malaysia without being regulated. Online platforms also do not control who can sell what, and they don’t filter what products are on their platforms,” she said.

Gan said a concerted effort from several ministries and agencies is needed for greater enforcement to stop fake supplements from reaching consumers.

For example, she said the Health Ministry can tighten its rules and enforcement through the National Pharmaceutical Regulatory Agency (NPRA), while the Malaysian Communications and Multimedia Commission (MCMC) can require ecommerce platforms to filter their sellers and products, requiring them to have authorisation letters from the concerned brands or the Customs Department.

“The Domestic Trade and Cost of Living Ministry could also play its part in creating awareness among online consumers,” she said.

Gan noted that the NPRA required all medicines, cosmetics and supplement products sold in the Malaysian market to be registered with the Health Ministry.

“The registered products will have a hologram sticker on the item and a registration number beginning with MAL issued by the Health Ministry.

“Consumers can run a check on the hologram by using the FarmaChecker app,” she added.

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OUR MANY APPETITES: Figuring out the right amount of protein we need could be the key to weight management

People follow various diet fads, hoping to unlock the secret to weight management. — Photos:123rf.com 

This dia­gram indic­ates the out­come of a diet­ary “chase” (res­ult­ing in the “excess Cal­or­ies”) from an ini­tial inad­equate to a more optimal level of pro­tein con­sump­tion.

 

How much pro­tein a per­son needs depends on his life­style too. - 123rf.com
 
 

Figuring out the right amount of protein we need could be the key to weight management.

MANY would have enjoyed the 15-day Chinese New Year season of bingeing on food and drink, and some would have added on a few spare kilos of weight as a result. My own Body Mass Index (BMI) is heading back towards 27 (again) which means I am significantly overweight (again) and this simply implies some immediate weight loss is needed.

At my advanced age, being overweight confers no momentous benefits, but can present several potential negatives, so weight control in such circumstances is quite important. And this is why a 2013 published study into a single wild female Chacma baboon named Stella in South Africa may be relevant.

Researchers from various anthropological and veterinary science institutes embarked on analysing in detail the food consumption of Stella over a 30-day window, breaking down her diet into the three macronutrients: carbohydrates, fats and proteins.

The study was done in South Africa in a region where there was a diverse range of foods available for baboons, and the original purpose was to establish if baboons can (a) regulate their intake of macronutrients, (b) cope with dietary restrictions, and, (c) establish a timescale for nutritional demands.

The data surprisingly indicated that Stella’s diet was driven primarily by the amount of protein eaten. Regardless of food availability, the ratio of calories from non-protein energy to energy from proteins was remarkably steady at 5:1, and this ratio was maintained every day. The wet mass of food varied considerably with an average of 1.9 kilos a day, and may fluctuate by 800 grams daily.

Stella’s average daily calorie intake was 940 calories, which varied up or down by 426 calories a day. The study found that the other two macronutrients, fats and carbohydrates were interchangeable with each other as far as Stella was concerned, and the overriding driver of total calories consumption was solely the amount of protein in Stella’s diet.

Protein leverage

The astonishing outcome of the study on Stella was actually predicted much earlier, by two Australian researchers, Simpson and Raubenheimer, in their 2005 paper, ‘Obesity: the protein leverage hypothesis’ where a simple mathematical model was presented which offered a plausible explanation for the global human obesity epidemic.

Summarised, the Protein Leverage Hypotheses (PLH) is simple. Like baboons, people eat to satisfy their need for protein, and they will eat potentially enormous amount of carbohydrates and fats until the food

eaten finally fulfills their protein requirement. And if people do not get enough protein, then they will simply eat more and more foods (which often contain carbohydrates and fats) in a forlorn quest for protein.

The body’s need for a relatively small amount of protein can therefore hugely “leverage” the consumption of other foods. And as such other foods contain more calories than proteins, the final result is often the accumulation of body fats resulting in obesity.

The obvious and significant difference between Stella and humans is that baboons appear able to restrict the overconsumption of fats and carbohydrates, even in the absence of protein. There may be several reasons for this. Perhaps there is a “protein switch” in baboons, or more probably, the range of foods available for baboons is simply limited, unlike for most humans.

Modern food production techniques use all sort of chemicals and flavouring compounds to mimic the texture and taste of protein-rich foods, resulting in processed foods that taste remarkably like proteins, but actually have very little or zero protein content. These foods have lots of cheap carbohydrates and fats instead, as protein is an expensive ingredient to include in processed foods.

Classic example are potato-based snacks and crisps, which come in all sorts of “meaty” flavours, even though there is usually no meat or protein content. According to the PLH, humans can easily consume many thousands of calories from meat-flavoured crisps in a futile attempt to satisfy the need for protein. Their taste senses will be fooled into erroneously provoking the consumption of such fake foods.

The amount of proteins needed by humans vary with age, with older people needing more protein content in their diets. And this includes both vegetable-based and animal sources of protein as there is little difference in the way the body processes proteins in general. Proteins are linkages of amino acids which the body disassemble into various smaller amino acids and molecules and recombine into other compounds to create enzymes, hormones and other tissues.

The main differences between animal and vegetable proteins are that meat proteins are considered “complete” proteins as they contain all 9 of the essential amino acids, and additionally they have some micronutrients (eg, certain minerals) which may not be present in plant proteins. However, these variances are easily resolved by adding or cooking/preparation with various added ingredients.

Our five appetites?

Leading from the PLH, where it seems that baboons and humans can detect the protein content of food, Simpson and Raubenheimer further proposed a theory that humans may actually have five different appetites, one each for protein, fat, carbohydrate, calcium and salt. Note that these are appetites which may reflect a physical need and not the same as taste sensors in the mouth, which are reflective of eating pleasures and displeasures.

There may be an element of truth involved, though the science is still unclear. Certainly, salt and some carbohydrates such as sugar can be detected by taste buds in the mouth. Fats can apparently be detected by specialised sensors in human digestive tracts, calcium may be detectable via a protein known as NCS-1 encoded by the FREQ gene in humans, and the real puzzle is how humans can detect proteins in the diet. Some papers have suggested that humans may have amino acid chemoreceptors, but it is far from clear that these receptors are involved in creating an “appetite” for protein as there are no neural linkages associated with these receptors.

Therefore, it is plausible that proteins are complex foods which require more processing for digestion and hence the lack of protein may be inferred by the body from the lack of digestive effort (and continued feeling of hunger) when insufficient protein has been ingested. We do not know for certain, even though the effect of humans eating inadequate amounts of proteins appears to be observable.

Regardless, of all the five appetites proposed, by far the most dominant appetite is for protein. The other may be in place to remind the body to also consume other macro- and micro-nutrients.

Too much protein is bad too

However, too much dietary protein can also be bad. The muchhyped keto diet is basically a meal plan comprising of primarily proteins and fats, which is quite odd, if one thinks about it.

Here is some simple maths. A gram of fat contains nine calories, a gram of sugar (carbohydrate) contains 4 calories, and protein is roughly the same as sugar. So if one wants to lose weight, it would make sense to ingest only proteins and carbohydrates, and skip the fats. However, the inclusion of carbohydrates would preclude the onset of ketosis, which is the phase when the body begins to burn stored body fat, instead of deriving energy from the carbohydrates.

This may be good for short-term weight loss, but it is also likely to have an effect on the kidneys because any diet too high in protein ends up building acid in the bodily fluids. This causes the kidneys to excrete the excess acid which is extracted using the calcium from the bones, resulting in excessive calcium loss.

The kidneys themselves may be damaged, especially if there is not enough water in the diet. There are also other side effects which can impact the liver and the heart, but it seems that the keto diet can work with healthy, younger adults, though it is probably less suitable for older people.

The right amount

Although it is a subjective matter, the amount of protein needed daily generally depends on physical activity and age. For a healthy adult, the minimum requirement is 0.8 grams per kilo of weight. So an adult weighing 70 kilos would need a minimum of 56 grams of protein daily. For younger, growing people and people who are more active, the requirement rises to 1 gram to 1.6 grams per kilo of body weight.

Older people, aged 65 or more, generally require around 50% more protein than someone younger, so an inactive pensioner should aim for 1.2 grams of protein per kilo of body weight, rising to perhaps 2 grams per kilo for a reasonably active pensioner.

Translated into food, 56 grams of protein is obtainable from around 200 to 250 grams of meat or fish, or 160 grams of dry soybeans.

Once the daily protein requirement is established, aim to consume the right amount of protein daily and vary the calories from the rest of food to a point where one feels comfortable, especially if the target is weight loss. One can also increase the daily protein amounts if hunger pangs persist. Cravings for overeating should be reduced once the right amount of protein has been found, according to the PLH. 

 

By  Curious cook CHRIS Chan - The views expressed here are entirely the writer’s own. 

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