the truths will set you free

The Truths Will Set You FreeEight Life-threatening MythsSWeeT SurrenderResisting Unhealthy Temptations

Hunger PangSSatisfying Healthy Substitutes

SPurring THe World onFootball Legend Gary Mabbutt

Stroke rehabilitationAn Overview of the JourneydiFFerenT STrokeSManaging Emotional Difficulties

STriking THe rigHT BalanceEating Healthy to Cut Stroke Risk

More THan aBleExercising with Limited Mobility

工作压力

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30-1113 DIABETES NEWSLETTER NO.indd 1 7/12/10 10:01 AM

DSS MANAGEMENT COMMITTEE 2008/2010

PATRON:Prof Arthur Lim

ADVISOR:Dr Warren Lee PRESIDENT: Mr Yong Chiang Boon

VICE-PRESIDENTS:Dr Kevin Tan Eng KiatHj P.M. Mohd Moideen

HONORARY SECRETARY:Ms Esther Ng

HONORARY TREASURER:Mr Stanley Lim

ASST HONORARY TREASURER:Ms Zann Lim

COMMITTEE MEMBERS:Dr Yeo Kim TeckMr For Wei ChekMr GreIg Price

3

2012 15 22co

nten

tsNews Buzz6 Map to Diabetes Care

7 Bready Bunch

8 Retreat for Adults with Type 2 Diabetes

10 Get Up and Go

Care Corner11 Insulin therapy

12 Different Strokes: A Guide for Patients and Caregivers

14 工作压力

Healthy Makan15 Lotus Seed & Gingko Sweet Dessert

16 Spinach & Tofu Soup

18 Strike the Right Balance

In Shape20 More than Able

Insight22 Stroke Rehabilitation – An Overview of the Journey

Special Feature24 Bolehkah Pesakit Diabetis Berpuasa di bulan Ramadan? Diablogue26 Running the Race of Life


editor’s message

DiabetesSingapore

Editorial Team

Editor : Dr Yeo Kim Teck

Managing Editor : Charlotte Lim

Editor (Medical) : Dr Elaine Huang

Editor (Dietetics) : Janie Chua

Editorial Consultants : DSS Management Committee

Charlotte’s Web Communications

Contributors : Dr Effie Chew, Henry Lew, Janie Chua, Joan Choo,

Chionh Lay Keng, Kohila Govindaraju, Rohanah Binte Pagi, Marco Aizawa

Production/Advertising Manager :

George Neo

Advertising Coordinator : Esther Ng

Publishing Services : Stamford Press Pte Ltd

Booking for Advertisements : Tel: 6842 3382

Email: [email protected]

Address feedback to:

Managing EditorDiabetes Singapore

Diabetic Society of SingaporeBlk 141 Bedok Reservoir Road #01-1529 Singapore 470141

Fax: 68423118Email: [email protected]

For past issues of Diabetes Singapore, log onto:http://www.diabetes.org.sg/publication.html

Disclaimer

The views, opinions and recommendations given by the contributors of Diabetes Singapore or are merely for general reference. All materials in this newsletter are for informational purposes only. The individual reader should consult his own doctor or specialist for his personal treatment or other medical advice. Diabetic Society of Singapore and Diabetes Singapore Editorial Board disclaim all responsibilities and liabilities for content expressed in this newsletter including advertisements herein. All contents of the newsletter are the copyright of the contributors and newsletter. Reproduction in any form is strictly prohibited unless with written permission.

4

diabetes singapore july - september 2010editor’s message

The four-yearly contagion is on. For a month or so, the world is at a virtual standstill. The shopping malls and restaurants are deserted, come football time. Yes, it is the FIFA World Cup Pandemic. Whether you are a fanatic who breathes, lives and talks football for a month or you think of the game as just “22 silly men running after a silly ball”, there is no denying its impact. Yes, its aftermath has included broken marriages, suicides, murders, heart attacks and even strokes. So, if you have diabetes or are at risk, you will do well to check out this “stroke” issue. The ball is in your court.

On a sombre note, this “stroke” issue is an emotive one. My own dad passed on from a stroke three years ago. I remember all too well how he collapsed suddenly before my eyes one night while my mum and I were with him. I had to climb onto the hospital bed and resuscitate him while the presumably overstretched on-call doctor took a full 15 minutes before coming by. My dad lived on for another year or so before another stroke fell him. He remained alert but was robbed of his mobility and his speech. I wonder sometimes if I should have done what I did but that is another issue.

While we cannot help certain risks factors like age or/and race, knowing and controlling these nine avoidable and modifiable risk factors for strokes will help you or your family members reduce the risk of a stroke. A stitch in time saves nine indeed.

AVOIDABLE AND POTENTIALLY MODIFIABLE RISK FACTORS FOR STROKES

1. High blood pressure 2. Diabetes 3. High cholesterol 4. Smoking5. Obesity6. Certain heart disease (such as atrial fibrillation) 7. Intravenous drug abuse 8. Carotid or neck artery disease9. Certain blood disorders

AVOIDING A STROKE IN TIME SAVES LIVES

Dr Yeo Kim TeckSenior ConsultantApple Eye Centre


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diabetes singapore july - september 2010Vice-president’s message

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diabetes singapore july - september 2010

THE RIGHT TRACKIn the last issue of Diabetes Singapore, our DSS president Mr Yong Chiang Boon gave an uplifting illustration of our society’s spirit. It is my pleasure now to focus on our society’s community involvement in raising diabetes awareness and other related programmes. In Singapore alone, it is estimated that there are about 300,000 diabetic patients. Many more are still undiagnosed. The number of DSS members hardly reflects the pervasiveness of diabetes here, and we are stepping up efforts to ensure that the word about diabetes control and prevention gets out as fast, and as wide, as possible.

Our mission to educate the masses runs deep in our many programmes but our means are limited. We currently depend greatly on the generosity and active support of a few religious organisations, corporations and grassroots organisations. Yet more can be done. Even shopping centres can play their part and disseminate our message, and enlighten the public about diabetes by distributing our newsletter, Diabetes Singapore, as well as flyers about our talks, seminars and support groups. We hope that such collaborations, DSS will continue to prod the masses make that all important move to lead a healthy lifestyle.

We also hope that people will understand that good health is in their own hands, that they will overcome whatever indifference they may have to start exercising and eating healthy. Our three Diabetes Education Care Centres have trained diabetes nurse educators and a wealth of resources to make it easier for you to get on the right track – physically, emotionally and psychologically. Early diagnosis can prevent many complications such as heart disease, blindness, kidney failure and even amputation. Don’t wait till it is too late.

Hj P.M. Mohd Moideen PBS Vice-President, DSS

© Lane Erickson


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diabetes singapore july - september 2010news buzz

MAP TO DIABETES CAREThere were some burning questions at the DSS Public Forum on 22 May - “What’s so important about diabetes self-m a n a g e m e n t education and s u p p o r t ? ” , “What should I know about managing my d i a b e t e s ? ”

and “How can I adopt appropriate nutritional management in my

lifestyle?” Thankfully, Rohanah Bte Pagi, CDE, and Sarah Shamila Sinaram, Dietitian, National Healthcare Group Polyclinics (NHGP), had all the right answers to these hot topics.

Nurses from the Association of Diabetes Education (Singapore) (ADES) also conducted an interactive session using the Diabetes Conversational Map, a tool to give diabetics many opportunities to clear their doubts by asking any diabetes-related question pertaining to diet, blood glucose monitoring and its interpretation, insulin – its action and side effects –

as well as signs and symptoms of hypoglycaemia and hyperglycaemia, foot care, etc.

Watch out for our next public forum in English on 17 July 2010 at KK Women’s and Children’s Hospital. It will be on “Behavioural & Psycho-Social Issues Related to Diabetes plus the Latest Developments in Diabetes”.

*To find out more about the Diabetes Conversational Map, please ring any of DSS centre to speak to our Diabetes Nurse Educators.

6

Online contributions to Diabetic Society of Singapore

can now be made through a new charity donation portal called

SG Gives (www.sggives.org)

Go to www.diabetes.org.sg and click on the link to donate today!

Donations Made Easy

JOIN US FOR World Diabetes Day 2010

14 November 2010

The Grassroots Club

(beside Yio Chu Kang MRT station)

By Joan Choo


diabetes singapore july - september 2010diabetes singapore july - september 2010news buzz

BREADY BUNCH

Who can resist the sweet aroma and taste of freshly baked bread, even with the scorching sun beating down on you? Certainly not our members and their families. They relished every bit of the DSS-organised trip to the Gardenia Bakery on 5 May, including the video presentation on bread making Gardenia style, the tour of the production plant and an enlightening talk by Mrs Kalpana Bhaskaran from Temasek Polytechnic (Nutrition Department) on dietary management and the effects of a low Glycaemic Index (GI) diet for people with diabetes.

According to Mrs Bhaskaran, a low GI diet consists mainly of low GI foods. GI stands for Glycaemic Index and is a measure of the impact of food on your blood sugar. Foods with a low GI tend to raise your body’s blood sugar levels more

7

By Joan Choo

slowly and over a longer period. This helps to improve the well being of people with diabetes by lowering their blood sugar levels and even control weight gain.

The day ended with members and their families buying exclusive Gardenia premiums and products at special prices and receiving a goodie bag comprising a Nutri multigrain loaf. I hear that many of the members are looking forward to another DSS outing. Well, wait no longer. Our next excursion has been scheduled for 26 September. Watch this space to find out our next destination!


Program HighlightsAn interactive workshop titled “My Journey with Diabetes” by Ms Yang Su-Yin,

Senior Psychologist, Psychology Services, Tan Tock Seng Hospital

An Educational Talk by Dr Kevin Tan Eng Kiat Consultant Diabetologist and EndocrinologistMt Elizabeth Medical Centre

Work it out with Eric Senior Physiotherapist

Singapore General Hospital

Understand the effects of diet on blood sugar and diabetes control. Realise how eating healthy rather than dieting can help you better manage your weight and allow food to be

enjoyable again byMrs Kalpana Bhaskaran, Dietitian

An interactive session with the doctor, diabetes nurse educator, dietitian, psychologist and physiotherapist

BBQ Dinner by the poolside with fun interactive games. Prizes to be won!

Buffet Lunch at Salt Water Café

Big Walk by the Beach

Free goodie bag for all participants

Take Charge, Be In Control!A Retreat for Adults with Type 2 Diabetes

Date : 31 July – 1 AugustRetreat Begins : 1.30pm on 31 July 2010Retreat Ends : 5.00pm on 1 August 2010Venue : Changi Village Hotel, 1 Netheravon Road S 508502 Tel: 63797111Cost : $150 (Member) $170 (Non-Member)

Note: Registration is on a first-come, first-served basis, so register early! Please send registration forms, as well as camp fees, no later than 10 July 2010.

Payment by cheque to “The Diabetic Society Of Singapore”.

Please send to:Diabetic Society of Singapore, Blk 141 Bedok Reservoir Road, #01-1529, Singapore 470141. Please write your name and contact number at the back on the cheque or you may proceed to any of our centres to pay by cash. Please visit our website at www.diabetes.org.sg for the registration form.

Call 6842 3382 / 9711 0132 to find out more.


8


Get Up and Go! By Joan Choo

10


Johnson & Johnson (J&J) and DSS jointly organised a public forum for One Touch users at Suntec City Exhibition and Convention Centre on 20 March. DSS members enjoyed free pre-prandial blood glucose testing and a scrumptious lunch, courtesy of J&J. DSS Nurse Educator Praveen Gosal talked about “The Importance of Self-Monitoring of Blood Glucose” while dietitian Lock Poh Leng (KK Hospital) emphasised “The Importance of Diet and Exercise” and physiotherapist Ms Katherin Huang (SGH LIFE Centre) waxed lyrical about “Exercise in Prevention and Management of Diabetes”. Poh Leng and Katherin conducted a food labelling and an exercise workshop respectively to empower participants not only with knowledge but also knowhow. Participants went home with a goodie bag consisting of an exercise mat, a good reminder to put into action the exercise tips they would have picked up.

10


According to an article by Craig W Spellman, Assistant Dean, Professor of Medicine, Head of Endocrinology, and Director of the Diabetes Center, University of North Texas Health Science Center, titled ‘Advancing Beyond Basal Insulin Therapy in Patients with Type 2 Diabetes’, people with type 2 diabetes will eventually need insulin therapy because oral agents fail over time.

Many patients, however, are needle-phobic and may reject insulin therapy which requires multiple daily injections. They would be pleased to know that twenty-first century needles are now so fine that the level of pain is tolerable, and hurts no more than an ant bite.

So, what then is insulin and why do we need it in the first place? In simple terms, the pancreas produces insulin to convert the sugar from our food to generate as energy. But for type 2 diabetes patients, the pancreas does not secrete enough insulin or are insulin resistant. They experience high blood sugar, which causes damage to blood vessels. Uncontrolled diabetes can lead to serious complications of the eye and kidneys as well as amputations and nerve damage.

Most type 2 diabetes patients rely on oral hypoglycaemic agents to control their blood sugar. As years pass, the pancreas may decline with age and cannot cope with the high sugar from the food consumed. When oral hypoglycaemic agents are no longer effective on their own, insulin therapy must then be initiated in combination with oral diabetes medications to prevent glucose toxicity.

What happens when your doctor suggests that you need insulin therapy? For a start, it is a commitment, not a mere guideline. Firstly, you must follow strict eating and exercise plans. Secondly, you need more frequent blood sugar tests than before so as to achieve better blood sugar control. Thirdly, and this depends on different individuals, some might need short-acting insulin in combination with a long-acting insulin while others may need just one long-acting insulin to last the day.

Success stories among our DSS members who had gone on insulin therapy after years of taking oral medicines reveal marked improvements in their HbA1C reading. A case in point is Sarah* who had been taking oral medications for diabetes for 12 years. After just one month on insulin, her HbA1C improved from 9.1% to 7.6%! Another member, Elizabeth* was equally delighted and more energetic when her HbA1C dropped from 8.1% to 6.9%, after combining insulin therapy with diet control and exercise.

Be aware that non-compliance to the insulin regime will affect the outcome of blood sugar control, thus it is very important to follow your insulin regimen closely as directed by your doctor. Getting support from your health care team, family and friends is crucial. Joining a support group may also help motivate you to control your diabetes better.

* Not their real names.

References: http://www.touchendocrinology.com http://www.webmd.com/

INSULIN THERAPY: TO START OR NOT TO START?

diabetes singapore july - september 2010care corner

11

© Scott Rothstein

It is a common perception that insulin represents the last therapeutic measure and should be postponed for as long as possible. Chionh Lay Keng, diabetes nurse educator, Diabetic Society of Singapore, sets the record straight on the benefits of insulin therapy.


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care corner

DIFFERENT STROKES: A GUIDE FOR

PATIENTS AND CAREGIVERS

Stroke can cause many physical effects such as speech problems and memory loss. It can also trigger psychological changes. Henry Lew, psychologist, National Healthcare Group Polyclinics, reports.

diabetes singapore july - september 2010

© Eduardo Jose Bernardino

When stroke damages the brain cells, the sensations and parts of the body controlled by these cells no longer function properly. Along with the physical damage to the brain, stroke can cause emotional, psychological and behavioural changes. Each stroke is different and, to a large extent, the psychological problems that someone may experience will vary, depending on the part of the brain affected and the extent of the damage.

In addition, the person who has had a stroke may have to come to terms with the loss of many of their hopes and plans for the future, as well as having to adapt to a changed role in the family, and possibly the loss of a career. Some of them may feel anxious or depressed, frustrated, angry or bewildered. All these feelings are common and, although they usually fade with time, they may persist in some people.

Treatment of psychological difficulties faced by patients is often through medication by medical doctors and psychiatrist, and referral to psychological interventions by mental health professionals like psychologists, medical social workers and counsellors.

Emotional Difficulties: What Stroke Patients Can Do

In addition to seeking help from your doctors and mental health professionals below are some points you could consider. Not all of these suggestions will suit everyone, but you may find some helpful. Do bear in mind that these do not replace professional help.

InformationA lack of knowledge about stroke can lead to uncertainty. Misunderstandings can arise and that can add to your worries. Do not be afraid to ask your doctor to explain.

Social ContactMeeting people regularly, every day, if possible, is an important source of well-being. Talking to others can be a big help, too. If you are able to, keep talking to family and friends, and try not to push people away or assume you are a burden.

Support GroupsMany people find support groups useful. They provide a chance to meet people who have been through a similar experience, and many arrange social activities.

Hobbies and InterestsReturning to hobbies and interests after a stroke is an important part of the rehabilitation process. You could even look at trying new things. Try not to be put off by thoughts that you are unable to do things as well as you could before the stroke. Many activities can be adapted to enable you to carry on enjoying them.

ExerciseRecent research shows that regular physical activity or exercise, however gentle, can help improve one’s mood.

CounsellingAcknowledging what has happened, and accepting how life has changed is an important step in the recovery process and talking treatments can help with this. Psychological and counselling services aim


diabetes singapore july - september 2010care cornerto encourage you to talk about your thoughts and feelings and help you to come to terms with what has happened to you. You will gain a clearer picture of what lies ahead and help you feel more in control of life by working out and trying to find solutions to problems. Many people benefit from talking through their difficulties, but if your stroke has left you with problems communicating or understanding others, it may not be the best option, or you may require the specialist skills of a speech and language therapist.

Managing Your DiabetesDiabetes is progressive and, if left untreated or uncontrolled, it increases the risk of developing and complicating your stroke.

Take regular exercise, eat a healthy and balanced diet, manage your weight and don’t smoke.

Emotional Difficulties: What Family Members Can Do

Communication: • Slow down and speak in short, clear sentences. • Ask direct questions that can be answered with “yes” or “no”. For example, “would you like a cup of tea?”• Give the person plenty of time to answer. • Don’t shout at the person – they’re not deaf! • When starting to speak, give the person time to tune in. Touch the person and pause. Say their name first. • Place the key word at the end of a sentence, such as “What do you want for dinner?” and “It’s time for your bath.”.

Managing emotional difficulties

• Don’t tell the patient not to cry; this will not help him or her. People often feel upset or embarrassed about being too emotional or helpless.• Distract the patients by changing the subject of conversation, or try some deep breathing to help them relax.• Don’t ignore the person. Do not leave them, unless they say they want to be alone, when they are emotional.

Managing personality changes

Family and friends of stroke survivors often find changes to personality in the stroke patients hard to deal with. Some people find that the challenging behaviour, e.g. aggressiveness is aimed only at them and that the person affected by the stroke is reasonable with other people. This kind of situation is harder to manage so it is important to try and get support from other members of your family. You should also avoid confrontational situations and walk away if a situation is becoming too hot to handle.

Each patient and family is affected by stroke differently, hence it is important to seek professional help to assess and help you and your family cope with these new challenges.

References:http://www.strokensw.org.auhttp://www.strokesurvivors.orghttp://www.stroke.org.uk.

© Philip Lange13


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care corner diabetes singapore july - september 2010

工作压力有短暂的，如发表工作报告到超时工作。它也有长时期累积的，如面对诸多要求的上司或工作时间长。

压力与糖尿病

面临工作压力时，我们的身体会以增加体内的葡萄糖(glucose)和脂肪(fats)来控制压力。对糖尿病患者来说，却没有这么好的反应效果。这是因为体内常常没有足够的胰岛素(insulin)来应付因压力而增加的葡萄糖，因此糖分就累积在血液中。

研究显示精神和肉体上的压力往往会导致血糖上升，尤其对属于2型糖尿病患者。肉体上的压力，如病痛或受伤，都会使糖尿病患者的血糖增加。

况且，受压力的人可能不会好好的照顾自己。他们很有可能借酒消愁，多喝酒少运动。他们也可能健忘或没时间，忘了检查血糖或好好的计划他们饮食起居。因此，学会如何应付压力和改进血糖的控制是很重要的。

减低精神压力的良方

改善日常生活

压力无法根除，但却能让我们把它控制到自己能应付的水平。如果上下班的繁忙交通使您烦躁，不妨找另一条顺畅的路走或早点出门，以避免交通阻塞。如果工作使您觉得快发疯了，试试申请换个部门，或和上司商量如何改善工作上的程序。以下还有一些对抗压力的方法：

• 参加一些体育活动或参加体育队• 学舞蹈或参加舞蹈俱乐部• 培养一项嗜好或学习一门新手艺• 到医院或慈善机构做义工

学习放松

深呼吸

以坐下或躺着，手脚放松伸直，慢而深地呼吸，再透过嘴巴慢慢地把气呼出来。

重复吸气吐气，在吐气时尽量放松肌肉。

每次连续的深呼吸及放松5到20分钟，每天至少做一次。

运动

另一种放松身心的方式是让身体活动。放松的三种动作有：旋转，伸展，及摇摆身体的部分。要使这项活动更有趣，去找个朋友配合音乐一起活动。

无论您选择哪种放松方式，一定要纳入日常的生活里，就如学新的运动项目要经常长期的锻炼，才能把它炼好, 学放松也是要练的。

支持小组

有些压力来源，不管您怎么做，都不会消失。尽管如此，仍有些办法来减轻这些压力。支持小组和朋友们都能帮助您。去认识和您处在类似状况的人不仅能让您感到少些寂寞，也能让您从他人的经验中学习如何应付困境。

辅导

有时候，您可能被巨大的压力压倒。在这种情况，辅导或心理治疗都有可能会有帮助。和治疗师倾诉烦恼也许能找到解决的办法，学习新的应付方法或改善对事情的看法。

参考American Diabetes Association

工作压力妥善处理每日承受的工作压力，不仅能帮您改进糖尿病的

病情，也能预防和延缓病发症。国立保健集团综合诊所的

心理学家, Henry Lew, 教您如何放松减压。

© mayangsar

Approx. 300 - 400 applications for 1 BIG toenail per pen

Website: www.imexlink.net


healthy makan diabetes singapore july - september 2010

Ingredients

2 bunches of spinach, chopped½ tsp salt¼ tsp ground pepper1 block soft tofu, drained, cubed3 cups chicken stock1 tsp light soy sauce1 tsp sesame oil12 prawns, shelled, deveined and diced½ carrot, sliced thinly1 tbsp cornstarch, dissolved in 2 tbsp water

Method

1. Combine stock, soy sauce and sesame oil in a pot. Bring to boil over high heat.

2. Add carrots and cook for 1 to 2 minutes.3. Add prawns, spinach and tofu, mix well for

another 1 to 2 minutes until all ingredients are cooked.

4. Add cornstarch solution and stir until slightly thickened.

5. Serve hot.

Spinach & Tofu SoupServes 4

Nutrition InformationEnergy 134 Kcal

Carbohydrate 8 g

*Carbohydrate Exchanges = ~ 0.5

Protein 13 g

Fat 6 g

Saturated Fat 0.7 g

Cholesterol 29 mg

Dietary Fibre 1.2 g

Sodium 613 mg

by Janie Chua, dietitian, National Healthcare Group Polyclinics

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Spinach & Tofu SoupServes 4

Ingredients

15 red dates 50g dried longan200g lotus seed, soaked in hot water, drained100g lily bulb, soaked in hot water, drained30 ginkgo nuts, canned, drained8 cups water 100g sugar 3 pandan leaves

Method

1. Put red dates, dried longan and pandan leaves in a pot of water.

2. Boil under medium heat for 30 minutes. 3. Add lotus seed and lily bulb. Add sugar to

sweeten.4. Once cooked, turn off flame and add

gingko nuts.5. Serve hot.

Nutrition InformationEnergy 165 Kcal

Carbohydrate 33 g

*Carbohydrate Exchanges = ~ 2

Protein 6 g

Fat 1 g

Saturated Fat 0.2 g

Cholesterol 0 mg

Dietary Fibre 1.6 g

Sodium 57 mg 17

Lotus Seed & Gingko Sweet DessertServes 10by Janie Chua, dietitian, National Healthcare Group Polyclinics

diabetes singapore july - september 2010healthy makan


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The brain needs oxygen and nutrients, the life sustaining products delivered via blood, in order to function properly. A stroke occurs when there is a lack of blood proportionate to the brain that results in loss of brain function. The stroke can be caused by a ruptured blood vessel (aneurysms) or by a floating clot that interrupts or blocks the blood flow to the brain. Depending on which area the brain is affected, the stroke can cause speech impairment, paralysis, unconsciousness or even death.

Narrowing, furring, hardening or weakening of blood vessels or thickening of the blood flow will end up in stroke. Haemorrhagic strokes occur when a blood vessel in the brain breaks or ruptures. Ischaemic stroke can occur when too much plaque (fatty deposits and cholesterol) clogs the brain’s blood vessels.

The most common causes of haemorrhagic stroke are high blood pressure and brain aneurysms. Older people and those with strong family histories of hypertension, heart disease, and strokes have a higher risk of stroke than people without these histories. These risk factors, however, can be controlled.

Risk factors to watch for and control:- High blood pressure: If there is a high blood

pressure, we need to keep it under control. High blood pressure increases the risk of a haemorrhagic stroke.

- Heart disease: The causes of heart attacks are the causes for strokes too. Strokes are called brain attacks.

- Smoking: Smoking doubles the risk of having a stroke because it causes the arteries

STRIKE THE RIGHT BALANCEStroke prevention involves minimising risk factors, such as controlling high blood pressure, elevated cholesterol and tobacco abuse. Kohila Govindaraju, a nutritionist in private practice, shows you how to keep stroke at bay with a balanced diet.


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to fur up and makes the blood more likely to clot that increases the risk of stroke.

- Diabetes: Diabetes has an adverse affect on our arteries that reduces or blocks blood flow to the brain.

- Alcohol: Drinking too much alcohol can raise blood pressure and lead to heart failure or stroke [American Heart Association].

It is wise to institute good, healthier practices early in life. Eating and exercise habits need to be improved at younger age. Sitting for hours before the television and chowing down fat-foods like hamburgers, fries, and sugary soft drinks will increase the likelihood of premature heart attack or stroke.

Healthy tips to stay stroke-freeThe food we eat influences our risk of having a stroke. Consuming different food groups, such as fruits, vegetables, and whole grains cereals, protects us against stroke. High cholesterol and too much of salt in the diet will increase our risk of getting stroke early in life.

Make healthier choices:• Two servings each of fruits and vegetables

daily will provide sufficient potassium, folate, and antioxidants that protect against stroke. One serving is equivalent to:

1 small apple, orange, pear or mango (130g) 1 wedge papaya, pineapple or watermelon (130g) 10 grapes or longans(50g) Raw leafy vegetables (150g) ¾ mug cooked vegetables (100g) [ABCs of Healthy Eating, HPB]

• Reduce salt intake: Avoid processed foods as they can be high in salt. Excess salt raises the blood pressure. Always check the sodium content in the food label. Go for low salt foods that contain less than 120mg/100g of sodium.

• Food rich in soluble fibre, such as whole grain products (barley, oats, rye), fruits (apples, citrus) and legumes are associated with protecting

against heart disease and diabetes by lowering blood cholesterol and glucose level.

• Foods rich in calcium. Milk and milk products, almonds, oysters, small fish with bones such as sardines, mustard greens, bok choy, watercress, broccoli are good sources of calcium.

• Soy products – tofu, tempeh, soymilk, reduces Low Density Lipoprotein (LDL) cholesterol and raises HDL cholesterol level.

• Fish (grilled or baked) three times or more per week. Omega-3 fatty acids in fish are good for heart . Eating one to two servings of fish a week, reduces the risk of heart attack. Omega-3, a type of unsaturated fatty acid reduces the inflammation throughout the body. Salmon, herring and tuna are good sources of omega-3 fatty acids. Those who eat fish high in omega-3 fatty acids, three times or more per week, have a lower risk of silent brain lesions that can cause dementia and stroke. Flaxseed and oil, walnuts, canola oil, soybeans and soybean oil are the non-fish food options that are good sources of omega-3 fatty acids. Soy products – tofu, tempeh, soymilk, reduces LDL cholesterol and raises HDL cholesterol level.

• Limit the amount of fat you eat. Too much of fat can clog the arteries and add to weight problems. Choose vegetable, seed and nut oils rather than margarine and butter. Snack on fruit and vegetables.

STRIKE THE RIGHT BALANCE

Be flexible: Balance what you eat with physical activity. Research has shown that 30 minutes of physical activity every day will help to lower the blood pressure, lower cholesterol and to maintain a healthy weight. Obesity leads you to a risk of high cholesterol, high blood pressure and insulin resistance. People under stress may overeat. Having a regular physical activity will reduce the stress.

“PREVENTING LITTLE THINGS FROM BECOMING BIG THINGS, KEEPS US ENJOYING LIFE AND STAYING HEALTHY.”


diabetes singapore july - september 2010in shape

MORE THAN ABLE

Sources:“Having Limited Mobility Does Not Mean You Can’t Exercise.” Lehigh Valley Hospital and Health Network. Lehigh Valley Hospital and Health Network. 27 Sep 2007 <http://www.lvh.org/lvh/Your_LVH|1196>.

Rowett, D. “Exercise Concerns for People with Diabetic Neuropathy.” Yahoo! Health. 29 Sep 2004. Yahoo! Health. 27 Sep 2007 <http://health.yahoo.com/ency/healthwise/tf4724>.

“Physical Activity/Exercise and Diabetes.” Diabetes.org. 2004. American Diabetes Association. 9 Sep 2007. <http://care.diabetesjournals.org/cgi/content/full/diacare;27/suppl_1/s58>.

Balducci, S., G. Iacobellis, L. Parisi, N. Di Biase, E. Calandriello, F. Leonetti, and F. Fallucca. “Exercise Training Can Modify the Natural History of Diabetic Peripheral Neuropathy.” (2006). Journal of Diabetes Complications 20:216-223.

“Warm Up Exercises.” Tansun. (2006) Kinetix. 9 Sep 2007 < http://www.exercisechairs.com/warm-up.htm >.

This article was written by Jennifer Hicks of LifeWire (www.LifeWire.com)http://diabetes.about.com/od/benefitsofexercise/a/mobility.htm

Having limited mobility does not have to mean exercise is out of the question. For the person with diabetes, able-bodied or not, exercise is essential.

Remember to practise proper foot care during exercise. An air or silica gel midsole inside shoes will provide protection. Polyester or cotton-polyester socks will help keep feet dry.

ADA Exercise RecommendationsFor a person with limited mobility caused by neuropathy, the American Diabetes Association (ADA) recommends the following activities:• Swimming• Bicycling• Rowing

• Chair exercises• Arm exercises• Other non-weight-bearing exercise, such as yoga

or tai chi

Exercise has many benefits. It can help keep weight down and build muscle. It can strengthen bones and improve circulation. Exercise can also help:• Stabilise blood sugar levels• Increase insulin sensitivity

• Lower blood pressure• Slow the progression of neuropathy (nerve disease)

Warming Up Before ExerciseNo matter the exercises or level of ability, a warm-up period is essential. Even those with extremely limited mobility can do slow and gentle range-of-motion exercises with their unrestricted body parts. Their doctors can demonstrate these exercises.Here’s an example of a good warm-up routine. Each of the following exercises should be repeated six to 10 times. Those who are unable to stand should talk to their doctors about accommodations.

• Neck rolls: Tuck chin into chest and roll chin from side to side by trying to touch ear to shoulder. Can be done standing or sitting.

• Shoulder circles: Stand with feet apart. Raise right shoulder toward right ear; lower shoulder back down in a smooth motion. Repeat on the other side.

• Overhead arm swings: Stand with feet slightly wider than shoulder-width apart. Keep back straight and knees slightly bent. Swing both arms up overhead, then back down past hips.

• Crossover arm swings: Stand as for overhead arm swings. Swing both arms out to side at about shoulder height and then across chest.

• Side bends: Stand as in overhead arm swings. Rest hands on hips. Lift torso up and bend smoothly to left, then back up straight, then to the right. Try to keep a smooth slow rhythm and spread out while bending to the side. Inhale while returning to the upright position.

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© arekmalang tai chi


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diabetes singapore july - september 2010insight

Stroke Rehabilitation – An Overview of the Journey

I THINK I HAVE A STROKEOccasionally, over dinner, someone will casually ask me, “I have this numbness in my arm on and off for years. Do you think it is a stroke?”

There are a few things wrong with this scenario:1. Stroke is a medical emergency. If you think you are having a stroke, it is not the topic of casual dinner conversation. You should rush to the hospital immediately.

Strokes are also known as ‘brain attacks’. The blood supply to part of the brain is cut off abruptly. Other strokes are caused by burst blood vessels bleeding into the brain.The sooner you get to a hospital equipped to manage your stroke, the higher your chances of limiting the damage that is done to your brain and, consequently, the disability that you will suffer from your stroke.

2. The symptoms of stroke come on suddenly. If the symptoms are gradually getting worse over months to years, chances are it is some other problem, not a stroke.When symptoms of a stroke resolve within an hour, it is called a ‘mini-stroke’ (transient ischaemic attack). These episodes should not be ignored as they indicate an increased risk to having another stroke.

The most common warning sign of a stroke is sudden weakness of the face, arm or leg on one side. Stroke can also manifest as

sudden numbness on one side of the body, sudden confusion, sudden trouble speaking or understanding speech, sudden trouble seeing, sudden trouble with balance or coordination.

Once you arrive at the hospital, the doctors will administer treatment according to the type of stroke you had. They will investigate the likely causes of the stroke and look for underlying risk factors. Treatment will be targeted at the results of these investigations. We will not go into detail on these treatments here.

REHABILITATION – THE ROAD TO RECOVERY AFTER A STROKEThe process of rehabilitation usually starts in the hospital as soon as possible, oftentimes, the very next day after diagnosis. The goal of rehabilitation is to achieve the highest functional abilities possible, given each person’s individual disabilities and environment. There are those who would rather be assisted and waited upon, but by and large, most people want to be as independent as possible. Through rehabilitation, the stroke survivor relearns the skills of everyday living to regain as much independence as possible.

The earlier stroke rehabilitation is started, the better the outcomes will be. Rehabilitation is the only way to help in the recovery of function after the stroke has occurred. Brain cells damaged by stroke, or other injuries, do not replace themselves easily, particularly in adults. It is through rehabilitative training

Time is of the greatest essence when a stroke strikes. It hits you like a bolt of lightning out of the blue but you can limit its damage and any subsequent disability by getting immediate help. Dr Effie Chew, consultant, Rehabilitation Medicine, National University Health System, tells you why, and walks you through the process of stroke recovery.


diabetes singapore july - september 2010insight

Stroke Rehabilitation – An Overview of the Journey

that the brain is able to reorganise its connections, a process termed neuroplasticity, so that some of the lost function may be regained.

Early rehabilitation also decreases complications that can happen after a stroke, such as infections of the lung and urinary tract, pressure sores and development of fixed stiffness in the limbs (contractures).

A number of options for continuation of rehabilitation after the acute phase are available, depending on the severity of the disabilities and individual factors

1. Inpatient rehabilitation is appropriate for those who have significant disabilities and can engage in one to two hours of therapy a day at the rehabilitation unit of a hospital, or a community hospital.

2. Home rehabilitation or early supported discharge may be appropriate for those who can be cared for at home.

3. Outpatient rehabilitation at a hospital or day rehab centre may be appropriate for those with milder deficits, or for maintenance of function.

WHAT HAPPENS DURING STROKE REHABILITATION?Stroke rehabilitation is an interdisciplinary team effort. The team usually involves the stroke survivor, his or her family, the physiotherapist, the occupational therapist, the speech therapist, nurses and the doctor, often a rehabilitation physician. The stroke survivor is at the centre of this team.

A number of body functions may be affected by the stroke, apart from those listed above - awareness of one side of the body, language, memory and thinking abilities, swallowing, bladder and bowel control and mood problems such as depression.

An inpatient rehab programme starts with a formal assessment of the functional deficits resulting from the stroke and how these affect the patient given his particular environment and personal factors. Other medical problems and how they impact on the rehabilitation process will also be assessed. The team, including the patient, then comes to an agreement on the goals for rehabilitation. There will also be screening for early medical and rehabilitation complications, and measures will be taken to prevent and treat these complications.

Therapy will be targeted towards the functional deficits identified during the assessment. Some examples of common daily tasks that are worked on include retraining of balance, walking, toileting, dressing and bathing. Nutrition and swallowing abilities are also looked into, as are cognitive and communication abilities, and bladder and bowel function.

Prior to discharge, an assessment of the stroke survivor’s home environment will be made and the equipment necessary to assist the stroke survivor in daily activities will be prescribed. Some equipment that may be needed include wheelchairs or walking aids, grab bars, orthotics to assist with activities of daily living or walking. If necessary, caregivers will be trained in the appropriate skills to assist the stroke survivor.

WHAT HAPPENS AFTER GETTING HOME? For those with residual disabilities, rehabilitation often continues into the outpatient phase. This may take place at a hospital, a day rehab centre or in a home therapy programme. Some challenges only become apparent when the stroke survivor returns home and faces the actual demands of daily life. Which is why an outpatient review is important. For others, return to work issues, driving, and other higher-level activities, need to be addressed as an outpatient.

WHAT ELSE CAN BE DONE?Having had a stroke puts a person at an increased risk of having another stroke. So it is very important to work with the doctors to control the risk factors that can be controlled, as much as possible. This may be through lifestyle changes, diet, exercise and medications. Some important risk factors to work on include:

1. Diabetes2. High cholesterol3. High blood pressure4. Heart disease - irregular heart beat, heart valve disease

and heart failure.5. Smoking6. Obesity

Technology has been advancing in the area of stroke rehabilitation. Recent advances include the use of robotics to assist in rehabilitation training and noninvasive brain stimulation to improve responses to rehabilitation. You can learn more about participating in ongoing trials from rehabilitation physicians in any of the restructured hospitals.

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PENGAWALAN Diabetis, terutama pada bulan Ramadan sememangnya paling mencabar untuk mereka yang menghidap Diabetes. Malah dengan nasihat dokter, pesakit yang bijak pengawalan pemakanan dan pengambilan ubat ubatan yang teratur mampu meneruskan ibadah puasa.

Bolehkah Pesakit Diabetis Berpuasa di bulan Ramadan ?

© Wynter1969

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diabetes singapore july - september 2010special feature

By Rohanah Binte Pagi, Certified Diabetes Nurse Educator (Singapore), Association of Diabetes Educators Singapore (ADES)

Mengikut Perangkaan Tahun 2004 Kementerian Kesihatan Singapura (MOH), 8.2% penduduk Singapura yg berumur 18-69 tahun menghidap Diabetis. Daripada jumlah itu, kira-kira 11% terdiri daripada kaum Melayu dimana 8% terdiri dari lelaki dan 10% wanita.

Diabetis atau penyakit kencing manis adalah penyakit kronik di mana terdapat kadar gula (glukos) berlebihan di dalam darah. Ini disebabkan gangguan peranan hormon insulin secara kuantiti (insulin berkurangan) atau kualiti (insulin tidak berkesan).

Secara khusus dari pandangan agama dan perubatan, orang yang sakit dikecualikan dari berpuasa, namun banyak dari mereka yang dikecualikan mungkin ingin mengamati bulan Ramadan ini. Pesakit diabetis jatuh dalam kategori ini dan ini boleh meletakkan mereka pada risiko tinggi serta boleh mengakibatkan pelbagai komplikasi. Pesakit diabetis Jenis 1, Jenis 2 dan wanita yang hamil dengan diabetis (gestational) harus mendapatkan nasihat dokter sekiranya ingin berpuasa.

Persoalannya, bolehkah pesakit diabetes berpuasa sedangkan mereka terpaksa begantung kepada ubat-ubatan atau suntikan insulin setiap hari untuk mengawal penyakit? Boleh atau tidak seseorang pesakit itu berpuasa, telah banyak di bincang oleh sekumpulan ahli endokrin dan diabetologis dari negara negara muslim dan non-muslim. Kajian menunjukkan bahwa puasa dibulan ramadan memang cukup umum di kalangan umat Islam dengan diabetes. Ianya telah meningkatkan kesedaran bahwa berpuasa dibulan ramadan berdasarkan menepati ajaran agama serta penyakit diabetis adalah masaalah kesihatan global.

Berpuasa bagi mereka ada lah suatu cabaran yang besar. Pertimbangan dan pengurusan berpuasa terserah pada

pesakit yang terus memutuskan untuk b e r p u a s a .

Secara umumnya, mereka boleh menjalani ibadat berpuasa dengan baik, dengan syarat mereka mematuhi jadual pengambilan ubat, mengawal pemakanan dan yang penting sekali, nasihat dari dokter.

Siapa yang di larang berpuasa berdasarkan pandangan dokter?• Pesakit yang diabetis nya tidak terkawal.• Pesakit diabetis yang tidak mematuhi nasihat pengawalan

permakanan, pengambilan ubat dan insulin. • Pesakit diabetis yang mengalami komplikasi serius seperti

kerosakkan buah pinggang, penyakit jantung yang tidak stabil, dan tekanan darah tinggi yang tidak terkawal.

• Pesakit diabetis yang mempunyai sejarah atau sering mengalami hipoglisemia (kekurangan glukos dalam darah) dan hiperglisemia (berlebihan glukos dalam darah)

• Pesakit diabetes yang sedang mengalami jangkitan kuman.

• Pesakit diabetes yang lanjut usia, tinggal bersendirian dan tiada keluarga untuk membantu

• Pesakit diabetes yang mengandung dan memerlukan insulin.

• Pesakit diabetes kanak-kanak berumur di bawah 12 tahun.

Di bulan ramadan, pesakit perlu memberi lebih perhatian dengan keadaan perut yang kosong selama lebih dari 14 jam. Mereka mungkin mengalami komplikasi buruk saperti masalah dihidrasi (kekurangan cairan), hipoglisemia (kekurangan glukos dalam darah) jika kurang makan diwaktu sahur atau melakukan aktiviti yang berat ketika berpuasa. Hiperglisemia (berlebihan glukos dalam darah) juga boleh berlaku jika keadaan diabetis menjadi tidak terkawal.

Kekeliruan mengenai penjagaan di bulan ramadan saperti penukaran waktu di masa pengambilan ubat2an, salah tanggap mengenai keperluan permakanan dan nafsu ketika berbuka puasa menjadi fakta utama menyebabkan sesetengah pesakit diabetis mengalami masalah sepanjang waktu tersebut.

Tanda hipoglisemia• Rasa gelisah dan binggung• Lemah • Teramat lapar • Berpeluh • Menggeletar • Denyutan nadi terlalu laju – berdebar debar• Tidak sedarkan diri (pada peringkat serius)-Koma


Tanda hiperglisemia• Sangat letih• Terlalu dahaga• Kerap buang air kecil

Tanda dihidrasi• Teramat dahaga• Kekeringan kulit dan lidah• Fikiran terganggu

Jika mengalami hipoglisemia, anda harus:

- Segera berbuka - Minum minuman yang manis sampai tanda2 hipoglisemia hilang, dilanjutkan dengan makan- Berjumpa doktor jika tanda2 tidak hilang dan semakin lemah

DietIanya harus ringkas mengikut panduan pemakanan yang menitikberatkan pelbagai jenis makanan secara sederhana dan seimbang. Pemakanan di bulan ramadan sepatutnya tidak jauh berbeza daripada makanan seharian biasa. Buat temu janji dengan pakar pemakanan (dietitian) untuk merancang pemakanan di bulan ramadan.

Pemakanan harus dibahagi dan diatur mengikut keperluan individu bersama ubat-ubatan yang di perlukan. Kuantiti makanan harus dipertimbangkan sewaktu berbuka seperti, berbuka dengan meminum air untuk mengelakkan kekurangan air di dalam badan, makan 1-2 biji kurma untuk cepat memberi pesakit tenaga yang diperlukan dan makan ubat-ubatan yang telah disyorkan sebelum solat magrib.

Sejurus lepas solat magrib, makan makanan utama secara sederhana saja sebelum tarawih. Setelah tarawih, boleh menambah tenaga dengan memakan makanan yang agak ringan saja. Waktu Sahur perlu di perlambatkan. Makan dengan secukupnya kerana jika makan terlalu awal atau sedikit boleh mengakibatkan masaalah hipoglisemia.

UbatUbat ubatan yang selalu dimakan pada sebelah pagi pada hari tidak berpuasa ditukar masa pengambilan nya ke waktu berbuka puasa dan dos malam yang di ambil sewaktu tidak berpuasa diambil sebelum sahur. Berbincang dengan dokter tentang pengambilan ubat ubatan dan dos insulin untuk bulan ramadan kerana ianya dapat mengelakkan tahap kadar darah glukos dari terlalu turun atau naik.

SenamanSenaman yang ringan boleh di lakukan asal permakanan,pengambilan ubat ubatan serta pemantauan darah glukos dapat di lakukan dengan baik.

Panduan:• Jangan makan berlebihan ketika berbuka. Pilih makanan

yang kurang kandungan gula, lemak dan garam. • Percepatkan berbuka puasa dan lambatkan bersahur. • Mematuhi jadual pengambilan ubat-ubatan dan waktu

suntikkan insulin yang disyorkan dokter.

© Adina Chiriliuc insulin

• Berusaha mengawal diabetis secara berterusan dengan memantau darah glukos yang lebih ketat iaitu di rekomendasi pada dua jam selepas waktu sahur, 1 petang dan 4 petang.

• Mengenali tanda tanda hiperglisemai (berlebihan glukos dalam darah), hipoglisemia (kekurangan glukos dalam darah) dan dihidrasi (kekurangan cairan).

• Berbuka jika terdapat tanda2 yang boleh memudaratkan.• Selain mengawal diabetis, berusaha mengawal penyakit

sampingan lain saperti tekanan darah tinggi serta mengawasi berat badan di sepanjang bulan ramadan.

• Pembelajaran pengawalan diri sebelum ramadan mustahak. Belajar dari doktor, pakar pemakanan dan jururawat. Catat secara terperinci pemakanan, pemantauan diabetis, tekanan darah tinggi dan berat badan sepanjang ramadan dan hari hari seterusnya selepas ramadan. Ini memudahkan dokter menganalisa kawalan penyakit diabetis, darah tinggi dan sampingan lain.

KesimpulanKeputusan pesakit untuk berpuasa harus dibincangkan dengan dokter. Pengawasan , pendidikan penjagaan diri serta penyesuaian perubahan jadual pemakanan dan ubat ubatan dapat membantu pesakit mengawal diabetes di bulan ramadan. Jika panduan dan syarat dapat di patuhi, ibadah puasa dapat dilaksanakan dengan selamat dan ianya tidak menjadi halangan besar bagi pesakit diabetis.

Selamat Menyambut Bulan Ramadan

Sumber Referensi:1. Fereidoun Azizi and Behnam Siahkolah; Ramadan Fasting

and Diabetes Mellitus: Int J Ramadan Fasting Res. 1998: Endocrine Research Centre, Teheran.

2. Recommendations for Management of Diabetes during Ramadan - Diabetes Care September 2005

3. Website: Article from Assoc Prof Dr Nor Azmi Kamaruddin, Malaysia, for Novo Nordisk Pharma (M) Sdn Berhad

4. Website: Penjagaan Diabetes Musim Ramadan, Dr Norasyikin Wahab, Malaysia, August 2009

5. International Meeting on Diabetes and Ramadan, Edition of the Hassan II Foundation for Scientific and Medical Research on Ramadan, Casablanca, Morocco, 1995

diabetes singapore july - september 2010special feature

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A Singaporean born to a Japanese father, Marco Aizawa has actually scaled mountains to overcome diabetes. The staff nurse talks about his love for endurance sports and its impact on his health in this new column for diabetes patients who want to share their experiences with others.

THE RACE OF LIFERUNNING

Luck, said Aristotle, is when an arrow hits the guy standing next to you. But what happens when that arrow hits you right between the eyes?

Fifteen years ago, I was hit by a bout of breathlessness. It sent me straight to the East Shore Accident and Emergency. I thought I had asthma. But when the doctor broke the real diagnosis to me, I could hardly believe my ears.

It was D-day for me – I found out I had type 1 diabetes, also known as Insulin Dependent Diabetes Mellitus. Clueless, I began poring over brochures to find out more about this disease. The information about the ill effects of poor diabetes control, for example, hypertension, heart disease, leg amputation and kidney failure, really frightened me. I was determined not to suffer from its complications.

Growing up with diabetes is not a bed of roses. There are ups and downs, like stress, and the way people look at you when they give you insulin jabs and test your blood sugars. Keeping blood sugars in control is not easy either.

However, I look upon my condition as a test of my strength and never as an obstacle. Now 26, I have completed five Project Discoveries with Touch Diabetes Support. I have scaled Mount Kinabalu twice, reaching the summit on the second attempt; cycled 500km to Kuantan and

also Cherating; and participated in a 100km trekking expedition in Singapore.

After these projects, I started on endurance sports, inspired by Lance Armstrong, Phil Southerland of Team Type 1 and Dr William Tan. They have either cancer or diabetes and are living testimonies of people who are able to live life to its fullest despite their conditions. I hope to be able to give hope to others and encourage them in the same way with my running and cycling.

Both running and cycling allow me to know my body better and help me control my blood sugars and my HbA1c. Hyperglycaemia (high blood sugar) and Hypoglycaemia (low blood sugar) are conditions I have to take note of when I exercise.

When I experience a hyperglycaemia, I drink more water and have plenty of rest. I never exercise when I have a sugar reading of more than 14 mmol/L as it will increase my blood sugar level further. When I have hypoglycemia, I rescue it by drinking something sweet and eating (depending on my sugar level). With my experience over the years, I will make it a point to reduce my insulin dosage by 2-4 units to prevent hypoglycaemia.

There are times when my blood sugar reading will be a little low, even after I have trained harder. I am still in the process of understanding what works for me and how much insulin to reduce when I exercise. I know I still have lots to discover about myself as I run this race of life. What’s next for me? Ironman, perhaps!

diabetes singapore july - september 2010diablogue

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the truths will set you free

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