YOUTH WITH TYPE 2 DIABETES AT HIGHER RISK OF DEVELOPING COMPLICATIONS DUE TO POOR BLOOD SUGAR CONTROL

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1 6 November 2014 MEDIA RELEASE YOUTH WITH TYPE 2 DIABETES AT HIGHER RISK OF DEVELOPING COMPLICATIONS DUE TO POOR BLOOD SUGAR CONTROL The face of diabetes among young adults in Singapore has changed significantly over the past 10 years, raising concerns among clinicians. A recent study on 182 young adults found that two-thirds (121 patients) had Type 2 diabetes compared to one-third (61 patients) with Type 1 diabetes. This is a sharp contrast to ten years ago when the majority of young adults with diabetes had Type I diabetes. Doctors from Khoo Teck Puat Hospital performed a cross-sectional review of all patients under 30 years old on follow-up visits at the hospital s Diabetes Centre. Those with Type 1 Diabetes had the condition for an average of 7 years compared to 3 years for those with Type 2 diabetes. Yet the patients with Type II diabetes had more complications and were on complicated medical regimes. 22 per cent of the patients with Type 2 diabetes were taking insulin. Blood sugar was generally not well controlled in both sets of patients with about 60 per cent having an HbA1C above 8.1. The HbA1C is an indicator of blood sugar levels over 3 months and readings above 8.1 are known to put patients at high risk of complications. Out of the 121 with Type 2 diabetes, 21 patients (17%) had diabetic nephropathy (diabetic kidney disease), compared to only 1 patient (1.6%) from the group with Type 1 diabetes. Study findings In relation to other studies on diabetes conducted by KTPH, the risk of developing diabetic kidney disease in people with early onset of Type 2 Diabetes Mellitus (T2DM) is heightened if they are centrally obese. These findings are consistent with reported literature on similar studies of Western diabetic patients. The study suggests that interventions for diabetes-related complications and aggressive management of diabetes and associated risk factors in youth with T2DM should be carried out earlier, in view of the prevalence of the disease in Singapore. Of particular importance is patient education on glycemic control, making lifestyle modifications (exercise, diet and smoking cessation) to helping youth with diabetes manage their conditions. KTPH started a Diabetes In Youth (DIY) programme in 2013 to monitor young patients with diabetes to reduce loss to follow-up and treatment, and to encourage them to take better control

2 of their diabetes. Another programme is the Diabetes Empowerment Programme (DEP) in Annex 1. The study led by Dr Angela Koh (Senior Consultant, KTPH s Department of Medicine) is one of 170 poster submissions by healthcare professionals that will be showcased at the Alexandra Health Forum 2014 to be launched by Health Minister, Mr Gan Kim Yong today. This biennial research forum organised by Alexandra Health System (AHS) which manages KTPH aims to provide a platform for local and overseas healthcare professionals to share research findings, best practices and ideas in improving clinical practice and patient care. The Forum runs from 6 to 8 November 2014 and features lectures, symposia and workshops by distinguished local and foreign faculty. The Alexandra Health Forum was first organised in 2012 in conjunction with the annual Alexandra Nursing Fest. This year s event attracted 170 abstract submissions in three main categories, i.e. Clinical Research, Basic Science Research, and Quality Improvement & Patient Safety, a 60 per cent increase from 2012, when there were 107 submissions. About 400 local and overseas participants have registered for Alexandra Health Forum For more information about the Alexandra Health Forum, please visit For interviews and other media enquiries, please contact: Tan Boon Leng Corporate Communications Department Khoo Teck Puat Hospital (Alexandra Health System) Tel: Mobile: tan.boon.leng@alexandrahealth.com.sg Sharon Ng Corporate Communications Department Khoo Teck Puat Hospital (Alexandra Health System) Tel: Mobile: ng.sharon.qw@alexandrahealth.com.sg Enc: Annex 1: List of featured projects/research About Alexandra Health System Alexandra Health System (AHS) offers multi-disciplinary and holistic care for the patient s total well-being. Established on 1 April 2008, Alexandra Health is a new healthcare cluster in the north that currently manages the 590-bed Khoo Teck Puat Hospital. As part of an integrated healthcare system to serve the community in the region, Alexandra Health will build and oversee the Yishun Community Hospital, the new Admiralty Medical Centre in the Kampung Admiralty integrated development, and the Woodlands Integrated Healthcare Campus (WIHC). The community hospital will be operational in end December 2015 whilst the medical centre and WIHC will be ready in 2017 and progressively in About Khoo Teck Puat Hospital Khoo Teck Puat Hospital (KTPH), a 590-bed general and acute care hospital, opened in June KTPH combines medical expertise with high standards of personalised care, set within a healing environment, to provide care that is good enough for our own loved ones. From intuitive wayfinding to logical clustering of services, KTPH s design is focused on providing a hassle-free experience for patients. KTPH serves more than 700,000 people living in the northern sector of Singapore.

3 Annex 1 List of highlighted projects Empowering greater patient s self-care with the Diabetes Empowerment Programme Learning from the highly-successful Diabetes Outpatient Intensive Treatment programme run by the renowned Joslin Diabetes Centre of the United States, the Diabetes Empowerment Programme (DEP) by KTPH s Diabetes Centre is a two-and-a-half day programme delivered by a multi-disciplinary team of diabetologist, diabetes nurse educator, dietitian, optometrist, podiatrist, physiotherapist and medical social worker. The programme, organised every quarterly in English and Mandarin, is targeted at patients and caregivers to equip them with the necessary knowledge and skills to better manage diabetes and prevent the onset of complications. The healthcare team members meet the patient individually to assess his needs, and then come together to design a comprehensive individualised care plan encompassing diet, exercise, stress management, monitoring/self-care and medication. One of the draw points of the DEP is the care given to create a relaxed, non-judgmental and interactive learning environment where patients and caregivers feel safe learning and sharing under the guidance of the team. Upon completion of the programme, the patient s primary physician will be provided a report with the team s recommendations on follow-up care plans for the patient. This team-based, integrated care model empowers patients by boosting their competency and confidence to better manage their diabetes condition, as studies have shown that self-care is a critical aspect in diabetes management, said Dr Tan Hwee Huan, Senior Consultant diabetologist with the Diabetes Centre. 120 patients with diabetes and 22 caregivers have signed up for DEP since KTPH s opening in This programme is currently offered exclusively to patients cared for in KTPH, but the Diabetes Centre has plans to open access to referrals from doctors outside KTPH. Reducing inappropriate polypharmacy and its impact on hospital readmissions Polypharmacy (use of five or more medications by patients aged over 65 years old) is common today, particularly in frequent flyer patients i.e. those with three or more hospital admissions over a six-month period. However, not all polypharmacy is bad. As patients grow older and are afflicted with more conditions, the number of medications that they are prescribed increase. It becomes difficult or even bothersome to comply to all the medications as prescribed, or they may experience side-effects or drug interactions that can render the medications less effective or even make them harmful. Side-effects may be mistaken as symptoms of disease, leading to additional medications added. In a bid to work collaboratively with clinical departments and to determine the prevalence of inappropriate polypharmacy, KTPH s Department of Pharmacy recruited 68 patients admitted to Cardiology with a mean age of 65 years old in a pilot study called Project Cutterpiller. Half were interviewed by Pharmacists, who then reviewed their medications and made recommendations to the primary team in charge. The success rates of reducing medications, and reduction in length of stay (LOS) of readmissions (90 days, pre- and post-hospitalisation), were compared.

4 The study team - led by KTPH s Chief Pharmacist Dr Doreen Tan - found that the intervention group recorded a numerically higher proportion of patients with reduced medications (36.7% vs 18.4%) and reduction in total LOS (11.7 days vs 10.6 days), vis-à-vis the control group. Patients with reduced medications recorded the greatest decrease in LOS (-16.8 days). This pilot study s findings suggest that an holistic approach, centered on patient interviews, to reduce inappropriate polypharmacy may be effective in reducing LOS and benefiting patients. There are plans underway for upscaling the Project Cuttapiller initiative to geriatric patients. The prescription of multiple medications to patients may cause more harm than good, especially if the patient is elderly and has multiple conditions. In healthcare, although we practise evidence-based medicine, there is still a need to individualise care and not to be too caught up in following treatment guidelines to a T. There is an urgent need for healthcare to confront this issue of polypharmacy, and the inception of Project Cuttapiller is the first step that KTPH is taking, said Dr Doreen Tan. Telemonitoring of frequent flyer patients with congestive cardiac failure A telemonitoring trial of 10 patients with congestive cardiac failure was started in May 2014, under the Alexandra Health System s Ageing-In-Place (AIP) Programme. These patients who were selected to go on trial have multiple medical conditions and a history of three or more admissions to KTPH over a six-month period. The AIP team worked with Integrated Health Information Systems (ihis) and equipment supplier Connected Health Pte Ltd to provide the patients each with a modem, weighing scale and blood pressure monitor. All the patient needs to do is to turn on the modem daily, take his weight and BP readings which will be transmitted via wireless to a monitoring system. The system will alert the AIP community nurse should the patient s readings fall outside the allowed range, enabling the nurse to intervene accordingly by calling or visiting the patient. Telemonitoring has enabled the AIP community nurses to become more effective by prioritising their home visits to patients with more urgent medical needs. Patients are also empowered by the simple-to-use technology to take greater ownership of their own health. The AIP team is evaluating the ongoing trial for possible expansion of the telemonitoring initiative to more postdischarge patients in future. Melatonin as a safe option for female patients in reducing anxiety and post-operative pain in wisdom teeth surgery under general anaesthesia Pain after wisdom teeth extraction may range from moderate to severe, and is often compounded by pre-operative anxiety in young patients undergoing the procedure. KTPH s Anaesthesia and Dental Surgery Departments conducted a study to explore if melatonin may be more effective in relieving post-operative pain after wisdom teeth surgery. The study team recruited 76 patients (mean age of 23 years old; 49 males and 27 females) who were randomly prescribed either 6mg of melatonin or a placebo 90 minutes prior to operation on all four wisdom teeth. The general anaesthesia and peri-operative analgesia regime were standardised across the patients who were assessed for pre-operative anxiety and postoperative pain at three- and six-timely intervals respectively.

5 The team found that female subjects experienced a faster reduction in post-operative pain and pre-operative anxiety, compared to male subjects, when prescribed melatonin to placebo. This suggests that female patients undergoing wisdom teeth surgery may potentially benefit from being prescribed melatonin as a pre-medication, as a complement to other standard painkillers e.g. non-steroidal anti-inflammatory drugs or opioids, which may have associated side-effects. Losing that beer belly may reduce risk of early-onset Type 2 diabetes patients developing chronic kidney disease More people are developing Type 2 diabetes mellitus (T2DM) at an earlier age with the rising prevalence of obesity worldwide. The early onset of T2DM may give rise to complications such as chronic kidney disease, a progressive failure of the body s two kidneys. A team comprising KTPH s Clinical Research Unit, Diabetes Centre, Department of General Medicine and National Healthcare Group Polyclinics studied 1,996 subjects to determine if abdominal obesity is a key determinant of kidney function in patients with early-onset T2DM. The participants were split into two groups early-onset T2DM (mean age of onset: 33 years old, n=643) and late-onset T2DM (mean age of onset: 52 years old, n=1,353) - to have their anthropometric and estimated glomerular filtrate rate (egfr) measurements recorded. The egfr is a test to determine the function of kidneys by estimating the amount of blood that is filtered by the glomeruli (tiny filters in the kidneys that filter waste from blood) per minute. The team found that measures of abdominal obesity i.e. visceral fat area and waist-to-hip ratio, were significantly correlated with egfr in people with early-onset T2DM but not in those with late-onset T2DM. In addition, abdominal obesity is a more effective predictor of renal function in those with early-onset T2DM than the standard body mass index (BMI) test. The study findings suggest that interventions targeting visceral adiposity (such as losing the proverbial beer belly ) may help to prevent the development of complications in people with early-onset of T2DM. ###