Diabetes Hub: Guide to Managing Diabetes

Diabetes is Serious

Diabetes is a serious condition where your body cannot manage sugar properly

What is diabetes?

Diabetes is a condition where your body cannot manage sugar properly resulting in too much sugar in your blood.

What is pre-diabetes?

Pre-diabetes is when your blood sugar levels are higher than normal but not high enough to be diagnosed with diabetes.

Diabetes is a Serious yet Common
Condition in Singapore!

Diabetes is serious because 1 in 3 Singaporeans is at risk of developing the disease

1 in 3 Singaporeans is at risk of developing diabetes

Diabetes is serious because 1 in 9 Singaporeans has the disease

1 in 9 Singaporeans has diabetes

1 in 3 individuals with diabetes does not know he or she has it

1 in 3 individuals diagnosed with diabetes continues to have high blood sugar levels

2 in 3 individuals individuals with newly diagnosed kidney failure have diabetes

1 in 3 individuals individuals with diabetes have eye disease

About 4 individuals with diabetes undergo amputations everyday

Complications

Diabetes can Cause Complications for
Your Body

Risk Factors

What Increases Your Risk of Developing
Pre-diabetes and Type 2 Diabetes?

Having family members with the disease increase your risk of developing pre-diabetes and type 2 diabetes

Family member(s)
known to have diabetes

A history of the disease during pregnancy increases your risk of developing pre-diabetes and type 2 diabetes

History of diabetes
during pregnancy

Those who are 40 years old and above have a higher risk of developing pre-diabetes and type 2 diabetes

40 years of age
and above

Having a BMI of 23 kg/m2 or higher increases your risk of developing pre-diabetes and type 2 diabetes

Body Mass Index (BMI)
of 23.0 kg/m² or higher

Having an inactive lifestyle increases your risk of developing pre-diabetes and type 2 diabetes

Inactive
(sedentary) lifestyle

Unhealthy
eating habits

How Diabetes Develops

Blood sugar levels spike

Blood sugar levels spike when you eat food
rich in sugar and/or refined carbohydrates

White rice

Blood sugar levels spike when you eat refined carbohydrates like mee rebus

Noodles

Prata

White bread

Kueh

Blood sugar levels spike when you drink fruit juices and sweet beverages

Fruit juices and sugar-sweetened beverages

Pancreas works harder

High blood sugar levels cause
your pancreas (insulin factory) to work harder

High blood sugar levels cause your pancreas to work harder

Overworked pancreas

Frequent intake of sugar and refined carbohydrates causes stress, fatigue and eventual damage to your constantly overworked pancreas.

Insulin is a hormone that helps to control the blood sugar level in your body.

Frequent intake of sugar and refined carbohydrates causes your pancreas to work harder

Excess sugar stored as fat

Excess (unused) sugar in your body is stored
as fat

Where is the fat located?

Diabetes can develop when there are fat under your skin and fat surrounding your organs and muscles

Apple-shaped body

Consequences of excess fat in the body

High blood sugar
High blood pressure
High cholesterol

There may be excess fat in your body even if you look thin

Diabetes can develop when there are excess fat in your body even if you look thin

Excess internal fat causes damage

Excess internal fat can cause damage

Healthy organs

Having no excess internal fats keep insulin level normal

Normal insulin level

Having no excess internal fats keep blood sugar level normal

Normal blood sugar level

Fatty organs

Excess internal fat causes your pancreas to produce less insulin

Pancreas produces less insulin

High blood sugar level

Cells less sensitive to insulin

How insulin works in a healthy person

Insulin moves sugar (glucose) into the cells, which is then used to generate energy and maintain normal body functions.

In a healthy person, insulin moves sugar into the cells to generate energy and maintain normal body functions

Excess internal fat makes cells less sensitive to insulin

Body cells cannot sense insulin properly so the pancreas has to produce more insulin to do the same work.

Having excess internal fat and sugar in your blood make cells less sensitive to insulin

Managing Your Condition

Stay in the Healthy Range

Manage pre-diabetes and type 2 diabetes well

Speak with your care team as your targets may vary

Healthy eating habits and regular physical activity and exercise can help you achieve target levels of blood sugar, blood pressure and cholesterol.

Eat Healthy

My Healthy Plate

Choose meat, tofu, wholegrain and vegetables for a healthier meal to help manage diabetes

Eat 2 servings of fruit daily in between meals to help manage diabetes

Eat 2 servings of fruit daily, by having fruit with or in between meals

Choose water
Use healthier oils
Be active

My Healthy Plate

Having the right food portion for your meal helps in diabetes management

^¼ plate
Wholegrains

e.g. brown rice, multigrain bread, rolled oats

^¼ plate
Meat, tofu and others

e.g. chicken breast, fish, tofu, legumes, lean meat

^½ plate
Vegetables

e.g. leafy greens, eggplant, mushrooms

1 serving
Fruit

e.g. 1 medium apple, 1 handful of blueberries, 1 wedge of papaya

Complete your meal with 1 serving of fruit

My Healthy Plate: Chinese

Choose a healthier Chinese meal to manage diabetes

My Healthy Plate: Malay

Choose a healthier Malay meal to manage diabetes

My Healthy Plate: Indian

Choose a healthier Indian meal to manage diabetes

My Healthy Plate: Western

Choose a healthier Western meal to manage diabetes

Choose water
Use healthier oils
Be active

Get Active

Regular physical activity benefits you in many ways

Regular physical activity improves productivity and helps manage diabetes

Improves productivity Boosts attention, memory and creativity

Regular physical activity improves overall mood and helps manage diabetes

Improves overall mood Reduces stress and improves mental health

Regular physical activity increases health benefits and helps manage diabetes

Increases health benefits Reduces risk of colon cancer, heart diseases, diabetes and high blood pressure

Regular physical activity increases fitness levels and helps manage diabetes

Increases fitness levels Improves strength and stamina

First Small Steps: Food

My first small step towards My Healthy Plate

Blood sugar levels spike when you eat refined carbohydrates like Bak Chor Mee

Adding more vegetables in your Bak Chor Mee starts your first small step towards eating healthy

Bak chor mee Have more vegetables

Blood sugar levels spike when you eat refined carbohydrates like Nasi Briyani

Lessening your rice or noodles in Nasi Briyani starts your first small step towards eating healthy

Nasi briyani Have less rice or noodles

Having less gravy in your mee rebus starts your first small step towards eating healthy

Mee rebus Have less gravy, leave
the gravy behind

First Small Steps: Drinks

My first small step towards healthier drink choices

Your first small step towards drinking healthier kopi

Your first small step towards healthier drink choices

First Small Steps: Activity

My first small step towards getting
active everyday

Take the stairs instead of the lift

Do a 10-minute brisk walking as your first small step towards getting active every day

Brisk walk for 10 minutes

Walk around every hour

Take 10,000 steps daily

Get off one bus stop earlier and walk

Exercise with family and friends

T & CM

Examples of Traditional and
Complementary Medicine (T&CM)

Traditional Chinese medications and acupuncture are examples of complementary medicine

Traditional Chinese Medicine and acupuncture

Ayurveda is an example of traditional and complementary medicine

Traditional medicines like Ayurveda

Herbal medicines and supplements

What I need to do if I am on T&CM

Continue taking your Western medications when taking traditional and complementary medicine

Continue with Western medicine unless otherwise advised by your doctor

Seek advice from a traditional and complementary medicine professional before taking any herbal supplements

Seek advice from a T&CM practitioner before taking herbal medicines or supplements

Continue monitoring your blood sugar when taking traditional and complementary medicine

Continue to monitor your blood sugar as advised

What I need to know about T&CM

In Singapore, Traditional Medicine (TM) typically refers to Traditional Chinese Medicine (TCM), Traditional Malay Medicine (TMM) and Traditional Indian Medicine (TIM), while Complementary Medicine (CM) refers to all other forms of medicine that are non-mainstream, e.g. chiropractic, osteopathy, aromatherapy, etc.

Scientific studies on effectiveness of T&CM for diabetes and its complications are inconclusive or insufficient.

Only Traditional Chinese Medicine practitioners are licensed in Singapore.
List of TCM practitioners www.tcmpb.gov.sg

Caregivers and Family

Signs and Symptoms of Stress

Am I experiencing caregiver stress?

Common signs and symptoms

Finding no meaning in caregiving

Loss of appetite

Insomnia

Talk to supportive friends and family to manage caregiver stress for better diabetes management

Chronic fatigue

Feeling hopeless and helpless

Withdrawal from family and friends

Managing Stress

How can I manage caregiver stress?

Practise Self-Care

Get enough rest

Positive self-talk

Physical activities and other hobbies

Meditation, yoga, taichi, or qigong

Seek Support

Talk to supportive friends and family

Join support groups

Use respite care to manage caregiver stress for better diabetes management

Make use of respite care

Seek professional help

A healthier life together

How can I help my loved one live a healthier
life?

Help your loved one live a healthier life by cooking and having healthy meals together

Cook and have healthy meals together

Help your loved one live a healthier life by walking or exercising together

Walk or exercise together

Help your loved one live a healthier life by accompanying them to medical appointments

Accompany your loved one to medical appointments

Help your loved one live a healthier life by praising them for self-management efforts

Praise your loved one for self-management efforts

Help your loved one live a healthier life by planning social events around diverse activities

Plan social events around diverse activities

Help your loved one live a healthier life by pairing healthy food with positive events

Pair healthy food with positive events

Food Choices

Eating right by choosing healthier food helps in diabetes management

Fibre-rich food

Choose wholegrain and starchy food for better diabetes management

Wholegrain starchy food

Whole fruit

Fruit juices

Dried Fruit

Meat and alternatives

Skinless chicken breast

Beans

Lentils

Choose egg for better diabetes management

Egg

Choose prawn, white fish and salmon as meat alternatives to help manage diabetes

Prawn, white fish, salmon

Tofu

Fruit

Dragon fruit

Guava

Papaya

Pear

Orange

Apple

Vegetables

Broccoli

Eggplant

Capsicum

Cabbage

Kailan

Mushrooms

Starchy Vegetables
(counted as carbohydrates)

Potato

Sweet Potato

Starchy vegetable like yam is counted as carbohydrates

Yam

Corn

Pumpkin

Peas

Meal Choices

Consider your meal choices, whenever possible

Different food types have varied effects on how blood sugar is released
The Glycaemic Index (GI) ranks the carbohydrates in food according to how they affect blood sugar levels
Carbohydrates with a low GI value are digested slowly and cause a lower and slower rise in blood sugar levels
Carbohydrates with a high GI value are digested at a faster rate and cause a very sudden increase in blood sugar levels

Did you know?
Excess sugar in your body is converted to fat and stored in your body

Cooking Tips

How can I cook healthy and yummy meals?

Healthier cooking methods

Stir fry

Boiling or steaming is a healthier cooking method to manage diabetes

Boil or steam

Grilling or baking is a healthier cooking method to manage diabetes

Grill or bake

Reduce salt and use natural seasonings for cooking to manage diabetes

Reduce salt, instead use natural seasonings (e.g. herbs and spices)

Choose healthier cooking oil to manage diabetes

Choose healthier cooking oil (e.g. sunflower, olive or canola)

Remove all visible fat from meat before cooking to manage diabetes

Remove all visible fat before cooking

Festivities

How can I continue with healthy eating during
festivals and celebrations?

Plan meals ahead

Opt for healthier products

Use healthier cooking methods

Eat moderately to continue healthy eating during festivities and celebrations

Eat in moderation

Avoid alcohol as much as possible

Maintain medication schedule and insulin dosage

Opt for healthier products

Choose a variety of vegetables and wholegrain food

Use healthier cooking methods

Stir fry, boil or steam, bake or grill

Avoid alcohol as much as possible

Do not drink alcohol on an empty stomach.
If drinking alcohol is unavoidable – limit to 1 standard drink per day (10 g of alcohol)

Appropriate Exercises

What exercises are appropriate for me?

Step 1: Determine mobility level

1. On your own, do you have any difficulty standing up from a seated position without using your arms?	Yes	No
2. On your own, do you have any difficulty walking for about 1 bus stop (~400m) without resting and using walking aids?	Yes	No
3. On your own, do you have any difficulty climbing up 10 steps without resting, using handrails or walking aids?	Yes	No
4. On your own, do you have any difficulty getting up from the floor without using furniture or other aids?	Yes	No

Count how often you answer ‘Yes’

Full mobility
‘Yes’ 0 or 1 time
Limited mobility
‘Yes’ 2 or more times

Step 2: Determine activity level

Sedentary

seldom exercise

Semi-active

some exercise

30 minutes, 3 times per week, at less than moderate intensity (can talk but can’t sing), for past 3 months

Active

regular exercise

30 minutes, 3 times per week, at moderate intensity (can talk but can’t sing) to high intensity (can only say a few words) for past 3 months

Step 3: Get relevant handouts

Sedentary

seldom exercise

Semi-active

some exercise

Active

regular exercise

Each category refers to a set of physical exercises customised for the patient’s mobility and activity levels. This assessment tool is designed for use by individuals as a guide to calibrate their physical activity based on their mobility and activity levels. Complete steps 1 to 3 to identify the relevant category of handouts for the individual.

Exercise Recommendations

F

Frequency

3 to 7 days per week

I

Intensity (moderate)

Can talk but can’t sing while exercising

T

Time

Aim for 30 minutes per day, 5 days per week or 150 minutes per week

One way to keep FIT is enjoying 30 minutes
of brisk walking, 5 days per week

Exercise Safely

How can I exercise safely?

Start slow if you have not been physically active

Exercise safely and manage diabetes by wearing comfortable clothing and appropriate footwear

Wear comfortable clothing and appropriate footwear (well-fitted shoes with adequate support)

Check your feet for wounds before and after exercising

Exercise at a cooler time for safety precaution and diabetes management

Exercise at a cooler time (mornings or evenings, or in a cooler environment)

Bring healthy snacks or sugar-containing sweets in case of a hypoglycaemia episode during exercise

Bring along healthy snacks or sugar-containing sweets, in case of hypoglycaemia (low blood sugar)

Exercise safely and manage diabetes by keeping yourself hydrated

Keep hydrated

Exercise with family and friends

When exercising, please rest or stop if you experience

Symptoms of hypoglycaemia (low blood sugar of < 4 mmol/L)

Hunger

Hand tremors

Abnormally fast heartbeat

Fatigue

To prevent hypoglycaemia rest or stop exercising if you're having mood changes

Mood changes (e.g. anxiety, irritability, nervousness)

To prevent hypoglycaemia rest or stop exercising if you're feeling dizzy and having headaches

Dizziness or headaches

Or any of these symptoms

To prevent hypoglycaemia rest or stop exercising if you're having difficulty in breathing

Difficulty breathing

To prevent hypoglycaemia rest or stop exercising if you're feeling pain in the chest or abdomen

Pain (especially in the chest or abdomen)

To note: Delay or postpone exercise if you are feeling unwell. Always listen to your body.

Monitoring

How to monitor

Different ways to test your blood sugar level

Done at home using a glucometer

You can test your blood sugar at home using a glucometer

What is blood sugar level?

“At the moment” level of sugar (glucose) in your blood

Done at the clinic

What is HbA1c?

(Glycosylated haemoglobin)

Sugar (glucose) attached to protein in red blood cells
Shows your average blood sugar level over 3 months

Self-monitoring your blood sugar level using a glucometer helps manage diabetes

For individuals with type 2 diabetes, consider self-monitoring (using a glucometer), if you are

At increased risk of developing hypoglycaemia (low blood sugar)
Pregnant with pre-existing diabetes or Gestational Diabetes Mellitus (GDM)
Experiencing acute illness
Having difficulty achieving glycaemic goals
Fasting for religious reasons (e.g. Ramadan)

When to monitor

When to test your blood sugar level

Test your blood sugar level before a meal or after 2 hours for better diabetes management

Before a meal or 2 hours after

Testing your blood sugar level when you experience hypoglycemia helps manage diabetes

When you experience hypoglycaemia (low blood sugar) symptoms (e.g dizziness, hunger

Before or after exercise

See your doctor when you're sick and you're losing appetite to prevent complications

When you are sick and not feeling well

Monitor your blood sugar level before and after meals

Too High

Risk of hyperglycaemia

Before food

> 7.0 mmol/L

2 hours after food

> 10.0 mmol/L

Optimal

Before food

4.0 to 10.0 mmol/L

2 hours after food

4.0 to 10.0 mmol/L

Too Low

Risk of hypoglycaemia

Before food

< 4.0 mmol/L

2 hours after food

< 4.0 mmol/L

Your targets may vary depending on your condition; discuss this with your doctor or care team.

Worksheet to monitor your blood sugar level

Hypoglycaemia low blood sugar

Common signs and symptoms of
HYPOglycaemia
(low blood sugar of < 4 mmol/L)

Hunger

Hand tremors

Abnormally fast heartbeat

Fatigue

Mood changes are common signs and symptoms of hypoglycaemia

Mood changes (e.g. anxiety, irritability, nervousness)

Dizziness or headaches

Changes in behaviour is a common sign and symptom of hypoglycaemia

Changes in behaviour (e.g. confusion, weakness, unclear speech)

Drowsiness

If you experience HYPOglycaemia symptoms
or your blood sugar level is low (< 4 mmol/L)

Step 1
Drink half a glass
of sweetened drink.
OR

Eat 3 soft candies (sugar-containing)
or sugar (glucose) tablets.

Step 2
After 15 minutes, check blood sugar level.
If symptoms persist or blood sugar level is low (< 4 mmol/L), repeat steps 1 & 2 one time.

If symptoms persist after second attempt, seek medical advice (if your doctor is unavailable and it is an emergency, head to the A&E).
If symptoms resolve or
blood sugar level is ≥ 4 mmol/L, go to step 3.

Step 3
Eat a light snack (e.g. bread, biscuits) or have your next meal earlier to prevent blood sugar levels from dropping again.

Record what happened prior to experiencing hypoglycaemia. If hypoglycaemia is
frequent, do a medication check with your doctor.

How can I prevent HYPOglycaemia
(low blood sugar)

Do not skip meals even when you're busy to prevent hypoglycaemia

Do not skip meals even when busy.

Bring a few sugar-containing sweets when you go out to prevent hypoglycaemia

Bring a few sugar-containing sweets along whenever you go out

Eat extra carbohydrates before doing any exercise to prevent hypoglycaemia

Eat extra carbohydrates before any exercise or strenuous activity

Don't take diabetes medication or insulin injection in the morning when fasting for a blood test

Do not take diabetes medication or insulin injection in the morning when fasting for a blood test

Follow instructions on taking your medications to prevent hypoglycaemia

Closely follow instructions on when to take your medication, especially in relation to meals

Check with your doctor if you're experiencing hypoglycaemia frequently

If you experience hypoglycaemia frequently, check with your doctor if your medication needs adjustment

Hyperglycaemia high blood sugar

Common signs and symptoms of
HYPERglycaemia
(high blood sugar)

Increased thirst

Frequent urination

Increased hunger

Blurred vision

Headaches

Weight loss

Slow-healing cuts

A blood sugar level of greater than 15 mmol/L is a common sign and symptom of hyperglycaemia

Blood sugar level > 15 mmol/L

If you experience HYPERglycaemia symptoms
or your blood sugar level is high (> 15 mmol/L)

1

Check your blood sugar level more often

2

Drink plenty of water if you experience hyperglycaemia

Drink plenty of plain water

3

Seek medical help if your blood sugar level is persistently very high

Seek medical advice if your blood sugar level is persistently > 15 mmol/L (i.e. remaining very high for more than 24 hours)

Regular checkups

Go for your regular check up to detect and
prevent complications

The frequency of tests may vary depending on your condition

Assessment/Test
At least every 3 to 6 months

Weight and height (BMI)
Blood pressure
HbA1c (blood sugar)
Stress, emotional well-being

Assessment/Test
At least once a year

Lipid profile (cholesterol)
Kidneys
Eyes
Feet

Kidney failure

Blindness

Amputation

Heart attack

Stroke

Treatment

How medications work

Medications work in different ways, on different body parts

A

Liver, fat tissues and muscles
E.g. Pioglitazone, metformin

Reduces amount of sugar made by the liver, and increases the sensitivity of fat, liver and muscle cells to insulin

B

Liver and pancreas
E.g. Linagliptin, sitagliptin

Helps the pancreas produce more insulin and reduce amount of sugar made by the liver

C

Kidneys
E.g. Dapagliflozin, empagliflozin

Prevents the kidneys from re-absorbing sugar

D

Intestines
E.g. Acarbose

Slows down breakdown of starch and absorption of sugar from the intestines

E

Pancreas
E.g. Glipizide, tolbutamide, gliclazide

Helps the pancreas produce more insulin

Taking medications

Take your prescribed medications to help manage diabetes

Take your medication as prescribed

Take your medication(s) regularly at the correct time(s)

If you miss a dose, take it as soon as you remember to help manage diabetes

If you miss a dose, take it as soon as you remember; if it is time for the next dose, skip the missed dose

Eat meals regularly to prevent hypoglycaemia and manage diabetes

Eat meals regularly to prevent hypoglycaemia (low blood sugar)

Avoid taking alcohol if you're on medication

Avoid taking alcohol with medication

Inform your healthcare professional if you are:

Taking metformin before going for any scans (e.g. X-ray) or procedures

Pregnant or planning to get pregnant before taking medication

Experiencing persistent symptoms of hypoglycaemia (low blood sugar)

Types of tablets and their uses & side effects

Insulin therapy

Insulin injections improve blood sugar control and prevent complications

Insulin injections can help

Improve blood sugar control
Prevent or delay complications

Insulin injections may cause

Hypoglycaemia (low blood sugar)
Potential weight gain

Insulin allows sugar (glucose) into the body cell

Insulin allows sugar into your body cell

How different types of insulin affect your blood sugar level throughout the day

Legend

Mealtime insulin
Basal insulin (long-acting or intermediate acting)

How to inject insulin

Part 1: How to draw insulin from a vial

Gather your supplies

1. Vial

Gather your supplies like syringe and plunger before drawing insulin from a vial

2. Syringe and plunger

Gather your supplies like an alcohol swab before drawing insulin from a vial

3. Swab

Preparation

Follow these steps to prepare your single or mixed insulin

Gather your supplies in preparing your single or mixed insulin

1. Gather your supplies
(syringe, insulin, alcohol swabs)

Wash your hands with soap and running water then dry it when preparing your single or mixed insulin

2. Wash your hands with soap and running water then dry your hands thoroughly

To prepare an insulin injection, roll the vial between the palms of your hands to mix it

3. Roll the vial insulin (if the insulin is cloudy)
between the palms of your hands to mix it and/or warm it up to body temperature

To prepare a single or mixed insulin, clean the rubber stopper on the vial with an alcohol swab

4. Clean the rubber stopper on the vial with an alcohol swab

Part 2: How to draw a dose (single)

If you are drawing a SINGLE dose

After completing part 1 (preparation), follow these steps to draw a SINGLE dose of insulin into the syringe

Draw air into the syringe to the level prescribed for your single insulin dose

1. Draw air into the syringe to the level prescribed for your insulin dose

For injecting a single dose of insulin, inject the air does into the vial with it standing upright

2. With the vial standing upright, inject the air dose into the vial by pushing down the plunger

Turn the vial and syringe upside down if you're drawing a single dose

3. Turn the vial and syringe upside down, ensure the needle tip is covered by the liquid

Pull back the plunger to withdraw insulin if you are drawing a single dose

4. Pull back the plunger to withdraw insulin to the level of the prescribed dose

Gently flick the side of the syringe if you are drawing a single dose of insulin

5. Gently flick the side of the syringe to remove air bubbles, if needed

Part 2: How to draw a dose (mixed)

If you are drawing a MIXED (clear + cloudy insulin) dose

After completing part 1 (preparation), follow these steps to draw a MIXED dose of insulin into the syringe

1. Draw air into the syringe to the level prescribed for your cloudy insulin dose

To draw a dose of mixed insulin, insert the syringe into the cloudy vial and push down the plunger

2. Insert the syringe into the cloudy vial and inject the air dose into the vial by pushing down the plunger - remove the syringe without drawing the insulin

3. Draw air into the syringe to the level prescribed for your clear insulin dose

Draw air into the syringe to the level prescribed if you are drawing a mixed dose of insulin

4. Inject the air dose into the clear vial in an upright position

Turn the vial and syringe upside to ensure the needle tip is covered with liquid

5. Turn the vial and syringe upside down ensure the needle tip is covered by the liquid

6. Slowly pull back the plunger to withdraw clear insulin to the level prescribed

To draw a mixed dose, removed the partially filled syringe and insert the vial of cloudy insulin

7. Removed the partly filled syringe from the clear vial and insert it in the vial of cloudy insulin

8. Turn the vial and syringe upside down, and slowly withdraw to the level prescribed for total amount of insulin (clear + cloudy)

Part 3: How to inject insulin

Step-by-step guide to injecting insulin into your chosen site

Clean your chosen site with water and tissue before injecting insulin

1. Clean your chosen site with water and tissue

To inject insulin, lift the skin with your thumb and finger on the chosen site

2. Lift the skin with your thumb and finger on the chosen site. With your other hand, hold the syringe (like a pencil, keeping fingers off the plunger) close to the chosen site at a 90 degree angle

Push the syringe all the way into your pinched skin fold to inject insulin

3. Push the syringe all the way into the pinched skin fold, then push the plunger all the way down to deliver insulin into the fatty tissue

To inject insulin, withdraw the needle from your skin at the same angle that it was inserted

4. withdraw the needle from the skin at the same angle that it was inserted and then release the skin fold

How to use an insulin pen

Insulin pen

How to prepare an insulin pen for injection

1. For cloudly insulin roll the pen in between your palms in a horizontal motion 10 times

To prepare an insulin pen for injection clean the rubber membrane with an alcohol swab

2. Clean the rubber membraine with an alcohol swab before attaching the insulin needle onto the insulin pen

To prepare an insulin pen for injection dial 2 units by turning the dose selector

3. Dial 2 units by turning the dose selector

To prepare an insulin pen for injection hold it with the needle upwards and tap the cartridge gently

4. Hold the insulin pen with the needle upwards and tap the cartridge gently with your finger a few times to let air bubbles collect at the top of the cartridge

To use the insulin pen, press the push-button all the way and a drop of insulin should appear

5. With the insulin pen still pointing upward, press the push button all the way (in the dose selector should return to "0", and a drop of insulin should appear at the needle tip)

To use the insulin pen for injection, select the dose you need

6. Select the dose of insulin you need

How to inject insulin with an insulin pen

1

Wash your hands with a soap and water

2

Dry hands with a tissue paper or hand towel

3

Select the injection site at your abdominal area

4

Clean the chosen site with water and tissue

5

Wait for the site to dry

6

Pinch a skinfold using your thumb and index finger

7

Inject the insulin at 90 degrees perpendicular to the injection site

8

Inject the dose by pressing the push-button all the way in until '0'

To use an insulin pen, inject the dose by pressing the push-button

9

Keep the push-button down fully for at least 6 seconds (to ensure the full dose has been injected) and as you withdraw the needle from your skin

To use an insulin pen, keep the push-button down fully to make sure full dose has been injected

10

Place the outer needle cap on the table. Direct the needle tip into the outer needle cap without holding on to it (to prevent finger stick injury). Unscrew and dispose the needle after it covered

To unscrew and dispose of the needle from an insulin pen safely, place the outer needle cap on the table

11

Store the insulin pen at room temperature after injection, away from direct sunlight and heat

Where to inject insulin

Insulin Sites

Suitable sites for insulin injection

Visual guide to show where you can inject insulin

You can inject insulin in your abdomen, arms, buttocks and thighs

To note

Different sites absorb insulin at different rates. Insulin is absorbed the fastest in the abdomen and slowest in the thighs
Rotates sites (e.g right and left thigh) to avoid swelling as this may affect insulin absorption

Site rotation

Rotate insulin injection sites every 1 to 2 weeks to avoid swelling

Move 2 fingers along from your last insulin injection site

Rotate injection sites by moving 2 finger's breadth along from your last injection site until you have used an entire area
Move to a new injection area every 1 to 2 weeks

Storage and disposal of insulin

Insulin storage

Quick tips on storing and handling your insulin

Write the date you open the insulin vial for proper storage and handling

1. Write the date on the vial on the day you open it

Store open insulin pens or vials at room temperature for proper storage and handling

2. For open vials or pens, store them at room temperature and away form direct sunlight

Store unused insulin pens or vials in the fridge for proper storage and handling

3. For unused vials or pens, store them in the fridge, not the freezer

For proper handling, avoid shaking the insulin vial excessively to prevent air bubbles forming

4. Avoid shaking the insulin vial excessively to prevent air bubbles forming

Discard the insulin 30 days after opening, if contaminated, if there are insoluble particles or if expired

5. Discard the insulin if expired (30 days after openning), contaminated, or if there are insoluble particles

How to safely dispose of used syringes and insulin pen needles

Proper disposal protects cleaners from accidental injuries, and prevents your used syringes and insulin pen needles form falling into the wrong hands

Place used syringes and insulin pen needles in a container to safely dispose of them

1. Place used syringes and insulin pen needles in a hard puncture-resistant container with a securable lid

2. Label the container "Used syringes and insulin pen needles"

Seal the container when it is full for safety

3. Seal the container when it is full

Discard the container down the rubbish chute for safety

4. Discard the container down the rubbish chute or in a rubbish bin

To note: Discard all used syringes and insulin pen needles do not reuse them. Containers that are suitable for safe disposal must be hard plastic, metal or sharp container, such as an empty detergent bottle or metal tin

Foot and Dental Care

Foot complications

Poorly controlled diabetes can lead to foot
complications

Nerve damage can make your foot feel numb and change its shape, increasing your risk of getting calluses and ulcers.

Foot complications caused by diabetes can make wounds heal poorly

Poorly controlled diabetes can lead to amputation

Extremely poor blood circulation (vasculopathy) can cause wounds to heal poorly; an amputation may be required to save your life.

Foot care practices

Good foot care practices

Monitor feet every day
Watch out for:
•Blister, wounds, corn, callus, or toenail abnormality
•Redness, swelling, bruise, or increase warmth

Maintaining good foot care and hygiene help prevent complications

Maintain good foot care and hygiene
•Clean feet daily with mild soap and water
•Use a pumice stone or foot file to gently remove hard skin
•Avoid cutting nails too short; cut them straight across and file corners

Moisturising your foot regularly helps prevent complications

Moisturise regularly
•Avoid using harsh soap
•Apply moisturiser daily but not between each toe
•Avoid scrathing skin as it may lead wound or bleeding

Wearing well-fitting and covered footwear helps prevent complications

Wear well-fitting and covered footwear
•Wear well-fitting covered shoes with socks
•Home sandals are recommended
•Check and remove any stones or sharp object inside shoes before wearing them

Applying simple first aid for small wounds helps prevent complications

Apply simple first aid for small wounds
•Clean small wounds with saline before applying antiseptic and covering with a plaster
•Home sandals are recommended
•Seek medical help if there is no improvement after two days or if there is signs of inspection

Seeking medical help if your wound is not healing well or worsens helps prevent complications

Seek medical help if wound is not healing well or worsens
•If signs of infection are present, such as redness, swelling, increased pain, pus, fever, or the wound start to smell, seek medical help as soon as possible

Seek immediate medical attention if your foot is cold, pale, discoloured, numb, painful or unable to move

Where to go for further help

Go to your doctor for advice, and if needed you can get a referal to a podiatrist for further management
Seek early review by a podiatrist if your foot feels numb (e.g you are unable to feel your footwear properly)

Footwear

Good footwear is important

Ideal features of supportive footwear

Remember to

Choose socks with tops that are not too tight
Wear a pair of cotton socks or stockings with your shoes at all times
Wear well-fitted covered shoes
Check and remove any stones or sharp object inside your shoes before wearing them
Use suitable footwear for different activities (e.g exercise with sports shoes, do daily shopping with sandals or sports shoes, and use bedroom slippers with cushioning at home

Oral care

Keep your mouth healthy

Brush your teeth and tongue at least twice a day (in the morning and before sleeping) for 2 minutes with fluoride toothpaste

Use a soft-bristled toothbrush to keep your mouth healthy and help manage diabetes

Use a soft-bristled toothbrush; change every 3 months or when bristles spread out

If you wear dentures, clean them after every meal to keep your mouth healthy and help manage diabetes

If you wear dentures, clean them after every meal; remove, clean and soak dentures in water before sleeping

Clean in between your teeth with floss to keep your mouth healthy and help manage diabetes

Clean in between your teeth with a floss or interdental brush at least once a day

Tilting your brush at an angle while brushing is a way to keep your mouth healthy and help manage diabetes

Tilt the brush at an angle to your gum line, moving it in small circular motions across all front, back and chewing surfaces of your teeth, not forgetting the back molars

Get your teeth checked every 6 months to 1 year to keep your mouth healthy and help manage diabetes

Visit a dentist every 6 months to 1 year to have your teeth checked; inform the dentist that you have diabetes, how your blood sugar control is and what medication you are taking

When to see the dentist

See your dentist if you have ...

Persistent bleeding gums

White patches in your mouth

Receding gum lines

See your dentist if you have loose, shaky or widening gaps between your adult teeth

Loose or shaky adult teeth and/or widening gaps between your adult teeth

Pain in your mouth

Bad breath or dry burning sensation in your mouth

Self-Care

Manage stress

How can I manage stress?

Physical and mental stress can affect blood sugar levels

Eat healthy

Stay active

Get enough rest

Plan well and prioritise your activities

Make time for yourself daily

Talk to someone supportive and understanding to manage stress for better diabetes management

Talk with someone who is supportive and understanding

Diabetes can increase stress

Accepting your diagnosis
Adjusting to treatment and changes in your life
Managing relationships

Physical and mental stress can change blood sugar levels

Examples of poor social support

The significance of your condition is downplayed
You are blamed for your condition
Your life is micromanaged

What to do if you experience poor social support

Share how you feel, including what was unhelpful
If negative support persists, seek professional help

Relaxation techniques
that can help to relieve stress

Deep breathing

Progressive muscle relaxation

Listen to music as a relaxation technique to relieve stress and manage diabetes

Listening to music

Creative hobbies

Walking and other physical activities

Yoga, taichi, qigong and meditation

Relaxation Techniques: Progressive Muscle Relaxation and Breathing

Fasting safely

How can I fast safely (for religious reasons)?

Before fasting

Consult your doctor if it is safe for you to fast

Adjust your diet with your healthcare professional

Adjust your medication or insulin dose with your doctor

During fasting

Self-monitor blood sugar levels regularly and check for symptoms of hypoglycaemia (low blood sugar)

If your blood sugar level is low, stop your fasting and take a sweetened drink

If your blood sugar level is low (< 4 mmol/L), stop your fast and take a sweetened drink

If symptoms of low or high blood sugar persist, stop your fast and seek medical attention

When should I not fast?

You should not fast if you have frequent hypoglycaemia or poorly managed diabetes

Frequent hypoglycaemia (low blood sugar) or poorly controlled diabetes

You should not fast if you have other serious conditions

Serious conditions such as nerve disorders, heart problems or uncontrolled hypertension

Pregnant or breastfeeding

Sick

Not been following your prescribed medication, diet and physical activities

Falling sick

What to do when I am sick?

Feeling unwell, e.g. fever, cough, runny nose, vomitting and diarrhoea

See your doctor

Get plenty of rest

Continue taking your prescribed medication or insulin when you feel sick to prevent complications

Continue to take medication or insulin as prescribed

Check your blood sugar level more often

Drink plenty of water

Have small, frequent meals or fluids when you feel sick to prevent complications

Have small, frequent meals or fluids (e.g. soups, diluted juices or sweetened drinks)

When do I have to see my doctor?

See your doctor when you're sick and having chest pains to prevent complications

Chest pains, shortness of breath, fruity breath, dry lips or tongue

See your doctor when you're sick and experiencing severe vomiting or diarrhoea to prevent complications

Severe vomiting or diarrhoea for more than 6 hours

See your doctor when your blood sugar levels are persistently lower than 4 mmol/L and greater than 15 mmol/L

Blood sugar levels that are persistently low (< 4 mmol/L) or high (> 15 mmol/L)

Loss of appetite

Skin sores

Travelling overseas

How can I prepare for travel?

See your doctor for a vaccination, if possible

Check with your care team about medication and insulin dosage if you're travelling overseas

Check with your care team on medication and insulin dosage

Bring your medical letter or diabetes card if you're travelling overseas

Bring a medical letter or diabetes card regarding your diagnosis and medication

Get insurance coverage

Put medication or insulin items in your carry-on bag if you're travelling overseas

Put necessary medication or insulin items in your carry-on bag

How can I manage my diabetes while abroad?

Drink plenty of water

Watch your food and calorie intake

Hand carry sugar-containing sweets

Always wear protective shoes

Hand carry medication or insulin items

Take medication as prescribed

Monitor your blood sugar regularly while you're abroad to manage diabetes better

Self-monitor your blood sugar level regularly

Know where to seek help

How can I prepare for travel? A Checklist

Alcohol

Alcohol affects medications and liver
functions, and causes HYPOglycaemia
(low blood sugar)

Don’t drink!If drinking is unavoidable:

Don't skip meal if drinking alcohol is unavoidable

Do not skip meals

Limit yourself to 1 standard drink per day

Limit to 1 standard drink per day, choose light beer or wine spritzer

Choose a low-calorie light beer if you can't avoid drinking alcohol

Choose low-calorie light beer or dilute mixers with water

Only drink alcohol if your blood sugar is under control

Your blood sugar level is under control

Only drink alcohol if you don't experience low blood sugar symptoms

You do not have low blood sugar (< 4 mmol/L) or experience low blood sugar symptoms

What is 1 standard drink?

300 ml light beer

100 ml wine

A 30 ml spirit is considered 1 standard drink per day

30 ml spirit or liqueur

Where to go for further help

National Addictions Management Service (NAMS)
6732 6837
https://www.nams.sg/

HPB QuitLine
1800 438 2000
https://www.healthhub.sg/programmes/88/IQuit

Smoking

Smoking increases risk of diabetes and its
complications, and insulin resistance

Quit smoking!Managing common withdrawal symptoms

Warn family and friends of potential irritability

Keep yourself distracted to better manage withdrawal syndrome from quitting smoke

Distract yourself by doing something else

Do light exercises to better manage withdrawal syndrome from quitting smoke

Do light exercises like brisk walking to lift your mood

Take small, regular meals

Do stretching exercises

Join the I Quit 28-Day Countdown

Goals

Focus on what is important

Consider different areas of your life
and which of these are important to you

Relationships

Health and physical well-being

Work and career

Personal and spiritual growth

Recreation and leisure

Ask yourself about important areas of your life to consider in helping manage diabetes

Identify the areas of life that are important to you

What are some lifestyle changes you are thinking of making or have made?
How might/ did these changes contribute to important areas of your life?

Setting my goal

Example of healthy eating goal

Step 1: Where do you want to be?

Ask yourself where you are now to set your healthy eating goal

Where I am now:

“I love having fried chicken everyday!”

Ask yourself where you want to be to set your healthy eating goal

Where I want to be:

Manage my weight better
Eat more veggies and less fried food

Know the importance of being healthier to set your goal

This goal is important to me because:

I want to be healthier and look better

Step 2: Set your goal

I will ...

ActionStick to My Healthy Plate
Day/TimeLunchtime on Mondays and Thursdays
LocationAt work
Time periodFor the next 3 months
Start dateFrom 14 January

Step 3: Identify and work around potential barriers

1

What might get in the way
Colleagues suggest having fast food for lunch

What I can do
Suggest to try out eateries with healthier options

Person(s) who can help
My colleague James likes vegetables

2

What might get in the way
I have a particular craving for curry puffs when I’m stressed

What I can do
Unwind in other enjoyable ways, like walking or listening to music

Person(s) who can help
Walk and chat with my neighbour in the evening

3

What might get in the way
There is a stall that sells delicious fried food, on my way home

What I can do
Take an alternative path home

Person(s) who can help
NIL

Complete the handout

How important is it for you to change right
now?

How confident are you that you can make
this change?

Complete the “Setting my goal” handout to set a new goal. Use the importance and confidence rulers to check that the goal is doable. If scores are less than 7, adjust the goal.

Keeping up with my goal

Example of physical activity goal

Step 1: Write down the original goal

I will ...

ActionBrisk walk for 30 minutes
Day/TimeMondays, Wednesdays and Fridays after dinner at 8pm
LocationAlong the park connector
Time periodFor the next 4 weeks
Start dateFrom 18 June

Step 2: Solve the problem

1

What got in the way
I couldn’t get off work on time

How can I work around it?
Do lunchtime exercises or pick a day without 5pm meetings

2

What got in the way
Poor weather

How can I work around it?
Do indoor exercises

3

What got in the way
Low energy level

How can I work around it?
I can sleep earlier the night before or pick a weekend day to exercise earlier

Step 3: Revise your goal

I will ...

ActionDo lunchtime exercises and brisk walk
Day/TimeLunchtime exercise on Mondays
Brisk walk on Wednesdays and Saturdays
LocationOffice gym, park connector
Time periodAnother 4 weeks
Start dateFrom 18 July

Complete the handout

How important is it for you to change right
now?

How confident are you that you can make
this change?

Complete the “Keeping up with my goal” handout if there were any barriers to accomplishing the goal. Use the importance and confidence rulers to check that the revised goal is doable. If scores are less than 7, adjust the goal.

Finance

Outpatient Bill

How your outpatient bill may be covered

1

Government Subsidies
Available at public specialist outpatient clinics (SOCs), polyclinics and CHAS GPs
Refer to government subsidy pages for more information

2

Employee benefits/Private Medical Insurances (PMIs)

3

MediSave/Chronic Disease Management Programme (CDMP)
Refer to MediSave pages for more information

4

Out-of-pocket payment (OOP)
This is determined after deducting government subsidies, available employee benefits and private medical insurances, and the amount that the patient wishes to deduct from MediSave

Subsidies

Government subsidies

at subsidised specialist outpatient clinics (SOCs) and polyclinics

Household with income
Household Monthly Income Per Person	Subsidy at subsidised SOCs^		Subsidy at polyclinics	Additional PG / MG subsidy
	Subsidised services	Subsidised medications	Subsidised medications for adults*
$1,200 and below	70%	75%	75%	PG: Additional 50% off the remaining bill MG: Additional 25% off the remaining bill
$1,201 to $2,000	60%
Above $2,000/ Unassessed	50%	50%	50%

Households no income
Annual Value^# (AV) of Home	Subsidy at subsidised SOCs^		Subsidy at polyclinics	Additional PG / MG subsidy
	Subsidised services	Subsidised medications	Subsidised medications for adults*
$13,000 and below	70%	75%	75%	PG: Additional 50% off the remaining bill MG: Additional 25% off the remaining bill
$13,001 to $21,000	60%
Above $21,000/ Unassessed	50%	50%	50%

^{^}To receive subsidies for Public SOC visits, you will first need to be assessed and referred by a CHAS clinic or polyclinic. The doctor will refer you to a Public SOC as a subsidised patient where eligible

^*Children (18 years or younger) and elderly (65 or older) already receive 75% subsidy for subsidised medications at the polyclinics

^#The AV of your home is the estimated annual rent if it is rented out. It is assessed by IRAS.

Government subsidies at CHAS GPs

From 1 November 2019


PCHI (Per Capita Household Income)	Above $2,000	$1,201 to $2,000	$1,200 and below	All Merdeka Generation seniors receive CHAS benefits,regardless of income or AV ofhome	All Pioneersreceive CHAS benefits, regardless of income orAV of home
AV (Annual Value) of Home (For households with no income)	Above $21,000	$13,001 to $21,000	$13,000 and below
Acute (common illnesses)	-	Up to $10 per visit	Up to $18.50 per visit	Up to $23.50 per visit	Up to $28.50 per visit
Simple Chronic	Up to $28 per visit, capped at $112 per year	Up to $50 per visit, capped at $200 per year	Up to $80 per visit, capped at $320 per year	Up to $85 per visit, capped at $340 per year	Up to $90 per visit, capped at $360 per year
Complex Chronic	Up to $40 per visit, capped at $160 per year	Up to $80 per visit, capped at $320 per year	Up to $125 per visit, capped at $500 per year	Up to $130 per visit, capped at $520 per year	Up to $135 per visit, capped at $540 per year
Dental	-	$50 to $170.50 subsidy per procedure (denture, crown, root canal treatment only)	$11 to $256.50 subsidy per procedure (dependent on procedure)	$16 to $261.50 subsidy per procedure (dependent on procedure)	$21 to $266.50 subsidy per procedure (dependent on procedure)
Recommended Health Screening under Screen for Life (SFL)	A fixed fee of $5 with SFL Invitation letter, for recommended screening test(s) and first post-screening consultation, if required	A fixed fee of $2 with SFLInvitation letter, for recommendedscreening test(s) and first post-screeningconsultation, if required		A fixed fee of $2 with SFL Invitation letter, for recommended screening test(s) and first post-screening consultation, if required	Free with SFL Invitation letter, for recommended screening test(s) and first post-screening consultation, if required

Pioneer Generation eligibility

Born on or before 31 December 1949
Received citizenship by 31 December 1986

Merdeka Generation eligibility

Born from 1 Jan 1950 to 31 Dec 1959; and
Received citizenship on or before 31 Dec 1996

Born on or before 31 Dec 1949; and
Received citizenship on or before 31 Dec 1996; and
Did not receive Pioneer Generation Package

Type of visit

Acute (common illnesses)

Capped at 24 visits for common illnesses per patient per calendar year, across all CHAS clinics, from 2020 onwards

Simple

“Simple” refers to visits for a single chronic condition

Complex

“Complex” refers to visits for multiple chronic conditions, or a single chronic condition with complication(s)

Refer to MediSave pages for the list of chronic conditions under the Chronic Disease Management Programme (CDMP) for CHAS Chronic conditions

Screen for Life

Recommended health screening refers to screening for diabetes, high blood pressure, high blood cholesterol, colorectal cancer and cervical cancer

Download Finance Handouts

MediSave for outpatient bills

Use your MediSave through the Chronic Disease Management Programme for your outpatient bills

Chronic Disease Management Programme (CDMP)

Specific chronic diseases
Requires 15% co-payment
Part of MediSave500, i.e. up to $500 per year
- Patients can tap on accounts of immediate family members (i.e. spouse, parents and children)
- Patients who are SC/PR can tap on grandchildren’s and sibling’s MediSave

To start using MediSave for the Chronic Disease Management Programme (CDMP)

Visit a clinic/ doctor who is registered with MediSave for CDMP to:
- Be certified by a doctor that you have one of the listed chronic conditions
- Sign the MediSave authorisation form
If you are using multiple accounts, your family members’ consent will have to be provided

₁Patients can tap on accounts of immediately family members (i.e. spouse, parents and children); Patients who are SC/PR can tap on grandchildren’s and sibling's MediSave

₂Patient’s own and spouse’s account may be used, provided spouse is also ≥ 60 years old

Flexi-MediSave

For patients ≥ 60 years old
Can be used for the 15% co-payment under CDMP
Up to $200 per patient per year₂
Can be used at Specialist Outpatient
- Patient’s own and spouse’s account may be used, provided spouse is also ≥ 60 years old

MediSave

National medical savings scheme
Can help to pay for personal or immediate family members’ hospitalisation, day surgery, and certain outpatient expenses

MediSave500

Scheme for outpatient care

Flexi-MediSave

Can be used at Specialist Outpatient Clinics (SOC) in public hospitals and national specialty centres, polyclinics, and participating Community Health Assist Scheme (CHAS) Medical GP clinics