The right food choices for those with diabetes


Nutrition is the cornerstone of good health for everyone.

For those with diabetes, a common challenge is food – the type of food and the amount eaten. While eating well should be everyone’s objective, it is important to remember that food is crucial in diabetes management.

There is no “forbidden” food, but food choices are important. The easiest method to illustrate good choices is to create one’s own plate by drawing an imaginary line on the plate comprising the different food groups, with the objective of consuming large portions of non-starchy foods and a small portion of starchy foods.

New foods within each food category can then be tried without affecting the general objective.

General advice on food is available from the doctor, and specific information for the particular needs of an individual are available from a dietitian, to whom referrals should, ideally, be made at the initiation of treatment, and from time to time depending on the clinical situation.

Food groups

Food portions vary with individuals. Depending on a person’s requirements and nutritional goals such as weight loss, blood glucose control or fasting, advice on the amount of each food group will vary.

The food groups are fruits and vegetables; dairy products; proteins; starchy foods; and foods high in fat and/or sugar.

Fruits and vegetables are low in calories and fat, have large amounts of vitamins, minerals and fibre, and are useful in protecting against high blood pressure, heart disease, stroke and certain cancers.

The objective is to consume at least five portions daily – a portion being roughly what fits into the palm of the hand. Fresh fruits and vegetables are preferred. The choice of a variety of colours will provide a useful mix of vitamins.

Dairy products like milk and yoghurt contain calcium, which helps to keep the bones and teeth strong. They are also a good source of protein.

As some are high in fat, lower-fat alternatives have to be chosen, but it is important to be aware of any added sugar.

The objective is to consume three portions daily – a portion being roughly equivalent to 200ml of milk.

Meat, fish, eggs and beans are foods that are high in proteins. These are required for building and replacing muscle cells. They also contain iron needed for red blood cell production.

Omega-3 oils found in oily fish like sardines and mackeral can also help protect against heart disease. The alternatives for vegetarians are tofu, soya, beans, pulses and lentils.

The objective is to consume some proteins daily and two portions of oily fish weekly.

Starchy foods like rice, bread and pasta contain carbohydrates which are broken down into glucose, which is then used as an energy source.

Carbohydrates that are slowly absorbed in the gut are preferred as they will affect blood glucose less, and they also help keep one feeling full for a longer time. Starchy foods are low in fat. High-fibre ones like wholemeal and wholegrain also help in regular bowel action.

The objective is to consume some starchy foods daily, especially the wholegrain types.

Depending on the goals of treatment, some diabetes patients may be advised to estimate the amount of starchy foods consumed, spread the intake during the day and/or choose healthier foods.

Foods high in fat and sugar are not required by the body. However, they may be taken if controlled. Sugary drinks and food increases the blood glucose; so they should be substituted with low-calorie alternatives.

The intake of saturated fats can be reduced by replacing lard, butter and ghee with unsaturated fats like olive and sunflower oils. The objective is to avoid foods that are high in fat and sugar.

Excessive salt intake may contribute to high blood pressure, which leads to heart disease and stroke. It is also advisable to avoid or reduce the consumption of processed foods.

Fasting matters

The body enters into a fasting state about eight hours after the last meal.

Individuals may fast for a longer time for religious or cultural reasons. The bodily changes during fasting depend on the duration of the fast.

Initially, the body will use stored glucose as an energy source.

Later, stored body fat will be broken down to provide energy. Although the use of stored body fat will, in the long run, lead to weight loss, which in turn, can lead to better glucose control, it is not advisable to use fasting as a method of losing weight.

When fasting, eating patterns will vary. It is essential not to overeat and to stick to a balanced diet.

Fasting diabetics are advised to eat foods like rice, chapatti and dhal more slowly, together with fruits and vegetables, just before commencing the fast.

This will help keep one feeling full longer and keep blood glucose levels more stable during the fast.

Upon breaking fast, it is important to consume only small amounts of foods that are high in sugar and fat as excess will lead to weight gain.

It is important to avoid dehydration by drinking plenty of water and sugar-free drinks. If one has diabetes and a sweet tooth, sweeteners should be used instead of sugar.

If the fast is broken for any reason, the normal meals should be continued for the rest of the day. The fast can be made up at a later date.

Blood glucose levels need to be checked more frequently as they may drop too low (“hypoglycaemia”), especially if one is on diabetic medications and/or there is illness.

If there are symptoms of hypoglycaemia, e.g. sweats, shaking and disorientation, the fast has to be broken immediately and treatment (glucose tablets, sugary drinks, followed by a snack) commenced.

With fasting, the risk of high blood glucose levels (“hyperglycaemia”) may increase due to the change in eating patterns. This may lead to a serious complication called ketoacidosis.

The symptoms of hyperglycaemia include increased thirst, passing large amounts of urine and/or marked tiredness. Immediate medical attention should be sought whenever such symptoms arise.

Prior to the commencement of fasting, it is advisable to discuss with the doctor about medications and the maintenance of good blood glucose control.

The time, type or dose of medication may have to be altered, e.g. insulin users will require less insulin before commencing fasting and the insulin type may need to be changed.

The risk of aggravating diabetic complications such as poor vision or heart or kidney disease is increased by fasting and consideration needs to be given whether fasting is advisable.

Dr Milton Lum is a member of the board of Medical Defence Malaysia. The views expressed do not represent that of organisations that the writer is associated with.

What is Metformin


Metformin is usually the first medicine prescribed for type 2 diabetes. It reduces blood glucose by decreasing the production of glucose by the liver and making the body’s cells more responsive to insulin.

It is generally well tolerated, with mild side effects of nausea, anorexia and diarrhoea.

Unlike other oral medicines, metformin does not cause weight gain. It also has a beneficial effect on outcomes in diabetics with heart disease.

It is usually not prescribed if there is impaired kidney function, liver cirrhosis, heart failure, chronic respiratory disease, vascular disease, severe infection, terminal ileum disease or previous gastrectomy.

If you are on Metformin and still not able to manage your diabetes, perhaps you should consult a Physician for other options available.


Cholesterol Lowering Drugs – Does it mean I can eat anything?

You often hear people saying that once you have taken a cholesterol lowering drug, you can practically eat anything as you are safe. This statement is not true. Cholesterol in the bloodstream comes from certain foods while your liver makes some. Statins (class of drugs used to lower cholesterol levels) reduce the amount of cholesterol made by the liver but it does not reduce the cholesterol from the food we eat.

Doctors would always prescribed cholesterol lowering medication along with careful diet selection and lifestyle changes. Doctors would also suggest a nutritionist to assist you in the careful selection of meals that are high in cholesterol. Taking doctor prescribed medications with proper diet and lifestyle changes proves to be most effective in controlling cholesterol and reducing heart related problems.


Be hygienic Malaysians

Proper handwashing is crucial to reduce the risk of transmitting all sorts of diseases.

DURING the H1N1 outbreak in 2009, it was noticeable that the health message of clean hands was taken seriously by healthcare facilities and the public. Many members of the public used the dispensers of hand sanitisers put up by the owners or tenants of healthcare facilities, offices, shopping complexes and other buildings.


It was then cool to keep one’s hands clean.

Many doctors and healthcare professionals had then hoped that the response to the then little known H1N1 virus would be translated into a habit.

With time, it was established that H1N1 was like any other flu for most individuals and like no other flu for some individuals. There was then a noticeable decline in the practice of keeping one’s hands clean. This is reflected in the reports of food poisoning and the high percentage of bacterial contamination of food sold since then.

Keeping one’s hands clean is a beneficial behaviour as many infections are spread by touch. This article is about the why, when and how of always keeping one’s hands clean.

A clean environment

There are various modes of transmission of organisms from one person to another.

Micro-organisms are present on everyone’s skin and body as well as surfaces in our surroundings. Direct physical contact between one person and another can lead to transmission of infections like respiratory viruses, hepatitis A and B, HIV and bacterial infections. The modes include shaking hands, touching, sexual intercourse, blood and other body fluids from a patient to a doctor or healthcare professional through skin lesions.

Micro-organisms like respiratory viruses and salmonella can be transmitted indirectly from one person to another through an intermediate, usually inanimate object. The modes include touching contaminated surfaces and sharing objects.

Droplet transmission involves the spread of micro-organisms like influenza through large particle droplets through the air when one person and another are in close proximity. The modes include talking, coughing and sneezing.

Airborne transmission involves the breathing in of micro-organisms like tuberculosis and legionella evaporated from droplets or within dust particles through the air within the same area or over a longer distance.

Micro-organisms can also be transmitted through common vehicles like water, food, medicines as well as shared syringes and needles among injecting drug users. These common vehicles can lead to the transmission of micro-organisms to many people.

The hands are the most common vehicle for the transmission of healthcare associated infections (HCAI), which has been defined by the Centre for Disease Control of the United States as “any infection associated with a medical or surgical intervention”.

HCAI is a major patient safety issue worldwide. It has been found to affect about 5 to 10% of patients in the developed world and double to 20 times more in developing countries. The incidence is higher in critical care units.

HCAI can lead to an increase in the severity of an illness, an increase in antimicrobial resistance, prolongation of the stay in a healthcare facility, long term disability, increased deaths and additional financial and personal costs for those affected and their families. The more ill a person is, the more likely he or she will be at risk of HCAI and its consequences.

Although HCAI involves patients and their caregivers and/or healthcare professionals, transmission of infections also occur between people with infections and their family and friends.

The sequence of events in the transmission of micro-organisms from an infected person to others is as follows:

  • Every person’s skin sheds off tissue containing micro-organisms all the time and they contaminate the hands directly or indirectly.
  • The micro-organisms also contaminate the surfaces in our surroundings.
  • The micro-organisms survive and multiply on the hands and the surfaces. The degree of contamination is influenced by the duration of exposure and the survival time of the micro-organisms, which is variable.
  • The hands remain contaminated unless there is action taken to ensure effective hand hygiene.
  • The micro-organisms are transmitted from one person to another through the contaminated hands.

As such, hand hygiene should be the concern of everyone whether they are sick or not. It is of particular importance in the sick, their caregivers and healthcare professionals.

Everyone needs to have clean hands to protect themselves and their environment from harmful micro-organisms. There is also a need for a person providing care to the sick, whether as a caregiver or healthcare professional, to have clean hands so that the patient is protected against harmful micro-organisms on the hands of the caregiver or the patient.

Planning for effectiveness

It is pertinent that the World Health Organization (WHO) launched its Global Patient Safety Challenge, “Clean Care is Safer Care” in October 2005, with the objective of reducing HCAI globally.

WHO’s decision was evidence based.

Hand hygiene has been found to reduce the risk of cross-transmission in schools, day care centres and in the community. (Luby SP et al Lancet, 2005, 366:225-233; Meadows E & Le Saux N BMC Public Health, 2004, 4:50). Hand hygiene promotion has reduced respiratory tract infections, diarrhoea and impetigo among children in the developing world.

The effectiveness of improved hand hygiene in reducing HCAI rates is well documented (Allegranzi B & Pittet D Journal of Hospital Infection, 2009 Aug 29). The reduction in HCAI rates in various reports has been as high as 70%.

Most reports also demonstrate a temporal relationship between improved hand hygiene and reduced infection and cross transmission rates as well as decreased incidence of drug resistant bacteria.

There is an association between infection and poor hand hygiene practices, of which improvement has assisted in the control of epidemics in healthcare facilities.

The cost effectiveness of hand hygiene is well documented. Pittet and his colleagues reported that the direct and indirect costs of a hand hygiene programme were US$1.40 (RM4.20) per patient admitted to a 2,600 bed hospital. A less than 1% reduction in HCAIs observed was attributable to improved hand hygiene practices, which would lead cost savings. (Lancet, 2000; 356:1307-1312.)

The National Patient Safety Agency of the United Kingdom made an economic analysis of its “Clean your hands” campaign in 2004. It noted that the economic benefits were financial and patient-related. The former included reduced costs to hospitals and general practitioners because of reduced HCAI, patients and caregivers, reduced compensation and increased economic productivity because of reduced work days lost.

The latter included reduced deaths and benefits associated with non-fatal HCAIs. It concluded that “the intervention will be cost-saving even if the reduction in HCAI rates were as low as 0.1%.”

It’s time

Hand hygiene is necessary before, during, and after preparing food. This is because although raw food may appear clean, it does not mean that it is safe.

It has been estimated that about 2.5 million bacteria are needed to make 250ml of water appear cloudy, while it takes about 15 to 20 bacteria to cause illness.

Cleanliness involves washing the hands before handling food and often during its preparation, washing and sanitising all utensils and surfaces used for food preparation, and protecting the food and kitchen from pests or animals.

Clean hands are needed before eating food, especially for those who eat with their hands. Harmful micro-organisms are spread when contaminated hands touch food items which are then consumed by others.

Clean hands are needed before and after caring for someone who is sick. Harmful micro-organisms are spread from the sick to their caregivers and/or healthcare professionals and vice versa, through the contaminated hands of caregivers and/or healthcare professionals.

Hand hygiene is vital before and after touching a patient; before handling an invasive device for patient care, regardless of whether or not gloves are used; after contact with body fluids or excretions, mucous membranes, non-intact skin, or wound dressings; if moving from a contaminated body site to another body site during care of the same patient; after contact with inanimate surfaces and objects in the immediate vicinity of the patient; after removing sterile or non-sterile gloves; and before handling medicines.

Hand hygiene is necessary after going to the toilet or after changing diapers or cleaning up a child who has used the toilet. This will prevent contamination of the hands by excretory materials.

Hand hygiene is necessary after blowing the nose, coughing, or sneezing to prevent contamination of the hands and surrounding surfaces by micro-organisms which can be harmful to others.

Hand hygiene is also necessary after touching an animal, animal waste or garbage, all of which contain micro-organisms which can be harmful to humans.

The mechanics of washing

An effective way of reducing micro-organisms growth is to wash the hands with soap and running cold or warm water for at least 40 to 60 seconds, especially when the hands are dirty or exposed to body fluids or after going to the toilet.

Liquid, bar or powdered soap can be used. When bar soap is used, the bars have to be placed such that there is drainage so that the bars will dry.

The hands should be rubbed together to make a lather and scrubbed well.

If there is no water and soap, a hand sanitiser containing at least 60% alcohol can be used. These sanitisers can reduce the number of micro-organisms in certain instances but they cannot get rid of all types of micro-organisms.

They are ineffective when the hands are obviously dirty. The hands have to be rubbed for 20 to 30 seconds.

Soap and alcohol-based hand sanitiser cannot be used together. It is important to adhere to the manufacturers’ recommendations on the use of soap and hand sanitisers, as well as the cleansing and refilling of the dispensers.

The need for hand hygiene by washing with soap or by using alcohol-based hand sanitsers is not replaced by the use of gloves, which are worn when there is likelihood of contact with blood or body fluids, mucous membranes, non-intact skin or potentially infectious materials.

There are techniques for the wearing and removal of gloves, which should be removed to perform hand hygiene when an indication occurs.

The same pair of gloves cannot be used for the care of more than one person or to touch a contaminated site of one person followed by another site of the body. Gloves should not be reused.

Hand lotions or creams that reduce the likelihood of contact dermatitis associated with hand washing or rubbing should be made available for healthcare professionals.

We all benefit

Hand hygiene has benefits for the well, the sick and their carers. Although clean hands do not totally eliminate the transmission of infection, the evidence is that it certainly reduces the incidence considerably.

Strict adherence to hand hygiene will go a long way in reducing infections and healthcare expenditures as well as improving the health status of every person.


Dr Milton Lum is a member of the board of Medical Defence Malaysia. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organisation the writer is associated with.

Tips to consider for Haze

Haze is back. As the thick smoke drowns certain places in Klang Valley, the public have been advised to minimise their activities outdoors and take in adequate fluids.


  1. If you must go out, you should wear a mask. A good one – a surgical mask – would be fine.
  2. Drink adequate fluid to ensure that the lining of the nose and respiratory airways were well hydrated to make them less susceptible to irritation.
  3. For the eyes, the haze can cause irritation, conjunctivitis and also secondary bacterial infection through rubbing. Those who wear contact lenses should ensure optimum hygiene of their lenses.
  4. Blocked nose is quite a common problem but it can cause worsening symptoms for people with pre-existing rhinitis and sinusitis. Sore throats and coughs could result from the haze but it could cause even more problems for patients with a history of asthma.

You should seek medical help immediately should you face any problems.

Pest-ilent problems

About half the world’s population are at risk of vector-borne diseases.

A VECTOR is an organism that transmits infectious organisms – bacteria, viruses and parasites – from a host to humans and other animals.

The common vectors are blood-feeding arthropods, which are invertebrate animals with an external skeleton (exoskeleton), a segmented body, and jointed appendages. Vectors of infections in humans include mosquitoes, ticks, mites and fleas.

About half the world’s population are at risk of vector-borne diseases. Increased travel, migration and trade have aggravated the risk.

According to the World Health Organisa-tion, vector-borne diseases account for 17% of all infectious diseases worldwide.

Vector-borne diseases are difficult to predict, prevent or control. These diseases can lead to serious illness and death.

It is pertinent to note that although infectious diseases comprised 6.82% of admissions to the Health Ministry’s hospitals in 2012, they were the cause of 17.17% of deaths.

Common vector-borne diseases

The prevalent vector-borne diseases in Malaysia are dengue, malaria and Japanese encephalitis.

Dengue: Dengue is a viral infection, with four viral types. It is spread through the bite of a mosquito infected after it has bitten a person who has the dengue virus in his or her blood.

The infected person may or may not have symptoms. The mosquito transmits the infection when it bites a healthy person.

Dengue cannot be spread directly from one person to another.

The infected person gets a dengue infection or dengue haemorrhagic fever (DHF).

The symptoms in the former are self-limiting, while DHF is characterised by excessively permeable (“leaky”) small blood vessels (capillaries) that result in the leaking of blood into body cavities.

This may lead to circulatory failure, shock and death if the circulatory failure is inadequately corrected.

The associated changes in blood coagulation in DHF lead to bleeding tendencies that may aggravate the circulatory failure.

There is no specific medicine for dengue and DHF. Early diagnosis, painkillers (analgesics), rest, drinking plenty of fluids and consulting a doctor are the essentials of treatment.

Early diagnosis and adequate fluid replacement, which requires hospitalisation, are the treatment of DHF.

Malaria: Malaria is a parasitic infection, with four parasitic types. It is spread through the bite of a mosquito infected after it has bitten an infected person. The mosquito transmits the infection when it bites a healthy person.

Malaria is not contagious – one cannot get it from close contact with an infected person.

The malarial parasite is found in the red blood cells of an infected person. As such, it can also be transmitted through blood transfusion, organ transplant, or the shared use of needles or syringes contaminated with blood.

It may also be transmitted from a mother to her unborn infant before or during delivery (congenital malaria).

Malaria is characterised by fever and flu-like symptoms. It may cause anaemia and yellow discolouration of the eyes and skin (jaundice). If not treated promptly, it can cause kidney failure, fits, mental confusion, coma and death.

There are specific medicines for malaria. Early diagnosis, specific medicines, analgesics, rest, drinking plenty of fluids and consulting a doctor are the usual treatments. Complications would require hospitalisation and supportive care.

Japanese encephalitis: Japanese encephalitis (JE) virus infection is transmitted following a bite by an infected mosquito after it has bitten an infected vertebrate, mainly pigs and birds.

Most infected humans have no symptoms or mild symptoms. However, a small percentage of those infected develop inflammation of the brain (encephalitis), of which one in four cases are fatal.

There is no specific medicine for JE. Treatment is focused on supportive care and management of complications.

Chikungunya: Chikungunya viral infection is transmitted following a bite by an infected mosquito after it has bitten an infected person.

The mosquito is the same type as the one that transmits dengue.

Most infected persons recover within a week. Some may develop long-term severe joint pain. Deaths are rare.

The condition was unheard of in Malaysia until recent years, and its emergence has been attributed to international travel.

There is no specific medicine for Chikungunya infection. Treatment is focused on supportive care like analgesics and anti-pyretics.

Preventive measures

Vector-borne diseases like dengue, malaria, JE and Chikungunya are preventable.

There is currently no vaccine for dengue, malaria and Chikungunya. However, there is much research on developing an effective vaccine for both dengue and malaria, with clinical trials being carried out.

There is a vaccine for JE and yellow fever.

The best preventive measure for mosquito-borne diseases is the elimination of their breeding places, i.e. stagnant places, especially in construction sites or containers that hold water.

Containers that collect rain water or store water have to be covered or discarded properly.

Sleeping in a room that has screened windows and doors, which keep mosquitoes from coming indoors, or with a mosquito bed net, reduces the likelihood of mosquito bites.

Wearing long-sleeved pyjamas and proper application of insect repellents also decrease the risk of mosquito bites.

The control of vector-borne diseases lies in prevention, with the public having a cardinal role to play.

Dr Milton Lum is a member of the board of Medical Defence Malaysia. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organisation the writer is associated with.

Disclaimer: Nothing on this blog should be considered or used as a substitute for medical advice, diagnosis or treatment. Blog visitors with personal health or medical questions should consult their health care provider.

Nourishing your grey matter

Maintain a healthy brain by eating the right sort of foods.

DIETS are associated with lifestyle conditions like obesity, diabetes and heart disease. It is often not appreciated that what is eaten has implications not only for physical health, but also mental health. The brain is the master of the body as it controls almost all bodily function, even when one is asleep. It is very complex, and is believed to be the final frontier of science. The brain requires nutrients just like the heart, lungs or muscles do. Some foods may increase the risk of neurological and psychiatric conditions like depression and dementia, whereas other food may be protective. But which foods are important to keep our grey matter happy? Knowledge about this is still in its early days, but there are research findings that can increase the chances of maintaining a healthy brain well into the senior citizen years.

The brain requires energy for its functions. As this is dependent on the body’s blood flow, it goes without saying that cardiovascular health is crucial for mental health. An adequate and steady supply of glucose in the bloodstream enhances concentration and focus. This is achievable with the consumption of wholegrains with a low glycaemic index, ie those that release glucose slowly into the bloodstream, thereby keeping energy levels stable and enabling a person to be mentally alert throughout the day. Wholegrains with low glycaemic indexes include granary or seeded bread, brown rice or pasta, oatmeal and sweet potatoes.

Oily fish
The body cannot produce essential fatty acids (EFA); therefore, they have to be obtained from food. The omega-3 fatty acids are essential for health and normal brain function, growth and development. Research findings have demonstrated that omega-3 fatty acids reduce inflammation and may lower blood pressure, which affects brain health. They have also been shown to reduce cholesterol and triglyceride levels, the formation of plaques on arterial walls, blood pressure, and abnormal heart rhythms – all of which reduces the likelihood of cardiovascular disease. The most effective omega-3 fatty acids (polyunsaturated fatty acids) are eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA).  Both EPA and DHA are needed for functioning of the brain, heart and joints. DHA plays an instrumental role in the development of the nervous and visual systems of newborn children.

It is also important for brain function in adults. Low DHA has been found to be associated with an increased likelihood of developing memory loss and Alzheimer’s disease. It has been reported that there is a correlation between fish consumption and lower likelihood of psychotic symptoms. There is also a suggestion that fish oil may prevent psychosis in individuals at increased risk. EPA and DHA have both been shown to be of benefit in depression and postpartum depression respectively. Conversely, there is a suggestion that omega-3 deficiency may increase the risk of suicide.
The American Heart Association recommends eating fish, especially fatty fish, at least two times (two servings) a week. Oily cold-water fish like salmon, mackerel, trout, tuna, herring and sardines contain ready-made EPA and DHA for the body to use. Other sources of omega-3 fatty acids include linseed (flaxseed) oil, soya bean oil, pumpkin seeds, walnut oil and soya beans.

Berries contain anthocyanins, which have anti-oxidant and anti-inflammatory properties. The consumption of blueberries may be effective in delaying or improving short-term memory loss. Animal studies have demonstrated that a diet of strawberry, blueberry or blackberry extracts lead to a reversal of age-related deficits involving learning and memory. Other studies have reported that blueberries reduced the effects of Alzheimer’s disease or dementia, and improved the learning capacity and motor skills of aging animals. In addition, it was reported recently in Circulation, a journal of the American Heart Association, that the risk of a heart attack may be reduced by as much as one-third in women who ate three or more servings of blueberries and strawberries per week.


Tomatoes contain an antioxidant called lycopene. It is also a source of niacin, which has been used for years to increase HDL (good cholesterol) and lower LDL (bad cholesterol). There is evidence that consumption of tomatoes could provide protection against free radical damage to cells that occur in the development of dementia, especially Alzheimer’s disease.

Raised levels of homocysteine have been associated with an increased risk of stroke, cognitive impairment and Alzheimer’s disease. A trial in Oxford, England, reported that “the accelerated rate of brain atrophy in elderly with mild cognitive impairment can be slowed by treatment with homocysteine-lowering B vitamins”. These vitamins were B6, B12 and folic acid. They concluded that “since accelerated brain atrophy is a characteristic of subjects with mild cognitive impairment who convert to Alzheimer’s disease, trials are needed to see if the same treatment will delay the development of Alzheimer’s disease”. The B vitamins are found in high-protein foods like fish, meat, poultry, eggs and dairy, as well as some leafy, green vegetables, beans and peas.  Among the benefits attributed to vitamin C is an increase in mental agility. The sources of vitamin C include leafy green vegetables, cabbage, broccoli, cauliflower, papayas and citrus fruits. Broccoli is also a source of vitamin K, which is believed to enhance cognitive function. A report in the American Journal of Epidemiology suggested that an intake of vitamin E may prevent cognitive decline, especially in senior citizens.

It concluded that “decreasing serum levels of vitamin E per unit of cholesterol were consistently associated with increasing levels of poor memory after adjustment for age, education, income, vascular risk factors, and other trace elements and minerals. Serum levels of vitamins A and C, beta-carotene and selenium, were not associated with poor memory performance in this study”. The sources of vitamin E are nuts, leafy green vegetables, asparagus, olives, seeds, eggs, brown rice and wholegrains.

Zinc plays an important role in modulating spatial learning and memory. But it has to be remembered that dietary fortification and supplementation of zinc could lead to overdose, with consequent toxic effects on brain function. Animal studies have shown that high dose supplementation of zinc induces specific zinc deficiency in the hippocampus of the brain, leading to impairment of learning and memory.
As such, it is important to keep to the recommended daily allowance (RDA), which varies with age, pregnancy and lactation. Red meat and poultry are common sources of zinc. Other sources include beans, nuts, seafood like oysters, crabs and lobsters, wholegrains, fortified breakfast cereals, and dairy products.


The relationship between diet and dementia has still to be fully elucidated. However, there are important links that are worth acting on. A well-balanced diet provides the brain the best opportunity of avoiding disease. If the diet is not balanced for whatever reason, supplements of omega-3 fatty acid, multivitamins and minerals may be useful. It is advisable to discuss this with the doctor prior to commencing supplements, as excess amounts will lead to adverse effects.

Mediterranean diet
The benefits of a Mediterranean diet have been publicised often. Although there are several countries bordering the Mediterranean, the term commonly refers to the diets of Italy, Spain and Greece. This diet includes a proportionally high consumption of fruits, vegetables, nuts, wholegrains, fish and unsaturated fats (common in olive and other plant oils); moderate consumption of wine and dairy products like yoghurt and cheese; and low consumption of meat and meat products. Studies have reported that those on a Mediterranean diet are up to 30% less likely to develop depression, compared to those taking more meat and dairy products. Consumers of more olive oil have a lower risk of ischaemic stroke, mild cognitive impairment and Alzheimer’s disease, especially when they are physically active.

A low to moderate consumption of alcohol has benefits, including improved cholesterol profiles, improved platelet and clotting function, and improved sensitivity to insulin. A recent meta-analysis reported an association between limited alcohol use and lower likelihood of Alzheimer’s disease and dementia. Moderate alcohol consumption may also protect against cerebrovascular disease with the antioxidants in wine, ie resveratrol, having additional benefits. However, heavy and long-term alcohol consumption leads to alcohol abuse and dependence, impaired memory, contributes to neurodegenerative disease, and hinders psychosocial functioning.The Food and Drug Administra-tion of the United States has defined “moderate alcohol consumption” as up to one drink for women, and up to two drinks for men daily.One drink is equivalent to 12 fluid ounces of regular beer, five fluid ounces of 12% wine, or 1.5 fluid ounces of distilled spirits.

Dr Milton Lum is a member of the board of Medical Defence Malaysia. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organization the writer is associated with.

Disclaimer: Nothing on this blog should be considered or used as a substitute for medical advice, diagnosis or treatment. Blog visitors with personal health or medical questions should consult their health care provider.

Infections and Water

When standards of hygiene are compromised, there’s often an increase in the number of water-related infections.

Water-related infections are common. According to the World Health Organisation (WHO), it causes 4% of all deaths and 5% of disabilities annually.

An estimated 2.2 million people die annually from gastrointestinal infections, the majority of whom are children in developing countries. This is because of limited or no access to safe water, insufficient sanitation and poor hygiene.

The water-related infections may be sanitation- and hygiene-related or vector-borne diseases associated with water.

Adequate sanitation – toilets and latrines – allows appropriate disposal of human waste, which breaks the infection cycle of many diseases.

Hygiene refers to acts that promote good health and cleanliness, e.g. frequent hand washing, face washing, and bathing with soap and clean water.

Water plays an important role in the spread of insect-borne diseases because many insects, e.g. mosquitos, breed in water. An increase in water impacts directly on the number of mosquitoes and other insects that breed in water. Bites from infected insects transmit disease to humans, e.g. malaria and dengue fever.

According to the Health Ministry, the incidence in 2013 of food poisoning, typhoid, cholera, hepatitis A and dysentery were 47.79, 0.73, 0.58, 0.41 and 0.28 per 100,000 of the population respectively.

The mortality rate of food poisoning and typhoid were 0.04 and 0.01 per 100,000 of the population respectively.

Certain infectious and parasitic diseases are the third most common cause of hospital admissions (9.4%), and also, the third most common cause of hospital mortality (13.66%) in 2013.
There are numerous water-related infections. The causes include bacterial sources (e.g. E. coli, Salmonella sp, Shigella sp, Campylobacter sp, Vibrio cholerae, Leptospira sp); viral (e.g. hepatitis A, enteroviruses, rotaviruses, dengue); parasitic (e.g. Entamoeba histolytica, Plasmodium sp, Giardia sp, Filarioidea, hook worm, helminth); chemical (e.g. arsenic, copper, lead); and other diseases, contaminants and injuries (e.g. marine toxins, ringworm, tinea).

When there are natural disasters such as floods or earthquakes, access to safe water, adequate sanitation and hygiene are compromised.

Flood and stationary water pose various health risks. They may contain potentially dangerous materials, e.g. sewage, agricultural materials and industrial chemicals.

Exposure to flood waters can also cause infections or injuries. Buildings that have been damaged by or exposed to flood waters may also pose health risks from chemicals, electrical hazards and displaced animals or their carcasses.

Diarrhoea, which is the passage of loose or liquid stools more frequently than is normal, is a common symptom of many water-related infections, especially gastrointestinal infections. The diarrhoea may be watery (e.g. rice-water stools in cholera) or blood stained (e.g. dysentery). The duration of the diarrhoea may be a few days or several weeks.

Vomiting is another common symptom of gastrointestinal infections. Abdominal pain may be present in some cases.

Severe or persistent diarrhoea or vomiting, with its increased loss of body fluids and consequent dehydration, may be life-threatening in children and people who have poor immunity or are malnourished.

The features of dehydration include dry skin, dry mouth, thirst and feeling faint.

Leptospirosis, which is acquired skin, mucosa or conjunctival contact with water or soil contaminated with the urine of rodents, carriers or diseased animals, presents with varied features, making diagnosis difficult.

There may be a mild, influenza-like illness; jaundice, kidney failure, haemorrhage and myocarditis with heart rate abnormalities; meningitis or meningoencephalitis; and lung haemorrhage with respiratory failure.

Some of the infections are self-limiting and do not require treatment. Others, particularly those that are severe or persistent, have to be treated with the appropriate medicines and the dehydration corrected.

The primary measures to address water-related infections include providing access to safe drinking water, improved sanitation, promoting good personal and food hygiene, and health education about how infections spread.

The primary measures to address loss of body fluids include consuming more fluids than usual, including oral rehydration salts solution, to prevent dehydration; continue feeding; and seeking medical assistance when the diarrhoea or vomiting is persistent or severe, there are signs of dehydration or there are other complaints.

In short, anyone in flood-affected areas are well advised to seek early medical attention if they feel unwell.

The public health response has several challenges. They have to address the health risks of flood and stationary waters, and that from damaged buildings. Health education is crucial.

Other essential measures include the provision of emergency water and electrical supply; medical and health services; and communication facilities to the affected areas.

These responses have to be rapid and effective if control and prevention of the spread of diseases is to be kept to a minimum.

Dr Milton Lum is a member of the board of Medical Defence Malaysia. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organisation the writer is associated with.

Corporate Health Screening, Kuala Lumpur – Petaling Jaya

Over the years, our Health Screening Centre had successfully implemented Workplace Health Programs (WHP) for corporate clients based on their company criteria and industry needs. The workplace is an ideal platform for promoting health among working adults. A healthy workplace and healthy organization contributes to higher productivity and a better quality of life. Our programs can be specially customized to fit your organizational needs. From basic to comprehensive workplace health and medical screenings, we can customize the health screening packages based on your organizational needs.

Apart from that, we also offer:

  • health talks by Specialist, Medical Professional, Dieticians and etc.
  • occupational safety and health (OSHA) programs
  • industrial standard audiometric hearing assessment
  • mental health educational activities
  • employee counselling
  • workplace mental health promotion activities

For more information, please contact our Sales & Marketing Team at 03 – 6141 8533. 


E-smoke stokes controversy

ELECTRONIC cigarettes, which are also known as electronic nicotine delivery systems (ENDS) and “e-cigs”, are devices that deliver a vaporised mixture of nicotine and other chemicals to the user’s lungs.
Each device has an electronic vaporisation system and controls, rechargeable batteries, and cartridges, which contain varying amounts of liquid nicotine to be vaporised.Most ENDS also contain propylene glycol, which is an irritant when inhaled. Some ENDS have flavours that are attractive to the user, and some claim they do not contain nicotine. Although many ENDS appear like their tobacco counterparts, a match or lighter is not required for its use. All that is needed is for the user to puff on the device, and the ENDS heats up the liquid nicotine, converting it to a vapour, which is inhaled. The user appears to be smoking a cigarette or another tobacco counterpart, but there is no smell because there is no burning.

ENDS have been available in the United States since 2007. It is estimated that there are more than 250 brands available in the US, with different designs and quality, which impact upon the nature and potential danger of the vapour. As such, it is difficult to put all ENDS in the same basket. There is no information available on the number and types of ENDS available in Malaysia. According to the World Health Organization (WHO) Global Tobacco Survey 2011, the prevalence of ENDS smoking in Malaysian adults was 0.8% – an estimated 164,000 people. It is estimated that about one in five smokers in developed economies have tried the ENDS. Since the ENDS do not contain tobacco, they are not subject to laws. This means they can be purchased by anyone and can be used in public places.
Safety issues

Manufacturers claim that the nicotine vapour has advantages over traditional cigarette smoking. Some claim that ENDS is beneficial as an alternative to tobacco. However, most manufacturers of ENDS have not made specific claims about the safety of their products. Health experts and regulators worldwide are unsure about the safety or otherwise of the ENDS. Questions are being asked about the possible risks of inhaling nicotine vapour to the user and the public.

The jury is still out on the safety of ENDS. There is insufficient information from scientific studies available to make definitive conclusions about its safety. When you consider the time it took to prove the risks to health from tobacco smoking, the current state is not surprising. However, there is information already known about ENDS.

The ENDS products have been found to contain variable amounts of nicotine and other chemicals. The nicotine levels vary from what is labelled, and from batch to batch in some ENDS. The amount of nicotine delivered by an ENDS depends on the nicotine content of the cartridge in it. Some contain an amount like that of a cigarette, or a bit more. Other ENDS have nicotine levels like that of a “light” cigarette.

There are also cartridges that contain liquid, but without nicotine, for users who want to experience the sensation of smoking without the effects of nicotine. Nicotine is hazardous, whether it is inhaled, eaten or comes into direct contact with the skin. Nicotine poisoning can occur in vulnerable groups like children, pregnant women, breastfeeding mothers, young adults, senior citizens and those with heart conditions, and can lead to death in children.

Most ENDS contain a large amount of propylene glycol, which is an irritant when inhaled. It has been reported some ENDS that were tested contained other toxic chemicals as well. There is no way a user can find out about the contents of the ENDS they are using. Although ENDS do not produce environmental (second-hand) smoke, they produce second-hand vapour. There are reports that this vapour causes irritation to the eyes, nose and throat, affecting breathing and causing nausea in people with certain health conditions. Manufacturers claim that this is water vapour, and hence, harmless.

However, regulators and experts state that there is insufficient research to substantiate the manufacturers’ claims. Public health and consumer organisations have also argued that the public should not be subjected to second-hand vapour until it is proven safe for everyone, especially children, senior citizens and those with certain health conditions.

Tobacco companies
The recent involvement of tobacco companies in ENDs is pertinent.
The Wall Street Journal stated on July 31, that “giants of the tobacco industry are diving into the market”. It reported that “British American Tobacco’s first electronic cigarette, the Vype, has gone on sale. Reynolds American, the second-biggest tobacco company in the US and maker of brands like Camel and Pall Mall, recently held a flashy launch event for its Vuse e-cigarette. “Altria, the largest player and owner of Malboro maker Philip Morris, announced details of its first e-cigarette, named MarkTen, in June.” Prof Simon Chapman of the University of Sydney, Australia, wrote in the British Medical Journal that tobacco companies “want smokers to use e-cigarettes, as well as cigarettes, not instead of them. Its five goals are widespread dual use; retarding smoking cessation; re-socialising public smoking back into fashion from its forlorn exile outside buildings; conveying to young, apprehensive would-be smokers that nicotine is a benign drug; and welcoming back lapsed smokers”.

Smoking cessation and ENDS
Manufacturers and some advocates of ENDS have argued the usefulness of ENDS as an aid in smoking cessation. The WHO’s view is that “The efficacy of ENDS for helping people to quit smoking has not been scientifically demonstrated. “ENDS are often touted as tobacco replacements, smoking alternatives or smoking cessation aids. But we know that for smoking cessation products to be most effectively and safely used, they need to be used according to instructions developed for each product through scientific testing. “There are no scientifically proven instructions for using ENDS as replacements or to quit smoking. The implied health benefits associated with these claims are unsubstantiated, or may be based on inaccurate or misleading information.
“When ENDS are used as cessations aids, they are intended to deliver nicotine directly to the lungs. None of the approved, regulated cessation aids, such as nicotine patches and chewing gum, delivers nicotine to the lungs. “Therefore, the biological mechanism by which smoking cessation might be achieved by delivery of nicotine to the lungs and its effects are unknown. Delivery to the lungs might be dangerous. Therefore, independently of the effects of nicotine, it is of global importance to study lung delivery scientifically. “The dose of delivered nicotine is also unknown. It is suspected that the delivered dose varies notably by products, which contain nicotine in various quantities and concentrations.”

Consumer product or medicine
Consumer products can pose health risks and safety hazards. As such, it is the duty of regulators to protect the public by researching, assessing and collaborating in the management of the issues of health risks and safety hazards of consumer products used in daily life, including ENDS.

The regulations for medicines are considerably more stringent than consumer products. However, many consumer products are unregulated and are scrutinised by regulators when health risks and/or safety hazards are reported. Those who advocate that ENDS should be treated as a consumer product argue that there is no evidence that ENDS promote smoking. Those who advocate treating ENDS as a medicine recall the disastrous mistakes made in regulating tobacco and the time it took to do so. They point out that the dose of nicotine in the smoking cessation aids, which are regulated as medicines, is small. The pharmaceutical companies, who are aware of the health hazards of nicotine, have not produced such products in doses that would compete with the amount of nicotine in cigarettes. The question then arises as to why ENDS, where users can create their own dose of nicotine, should not be subjected to the same regulation as the smoking cessation aids produced by pharmaceutical companies. In short, the debate is about the place of nicotine in society and in the law. Regulators in some countries have already made their decisions. ENDS are banned in countries like Australia, Canada and Mexico.

It is banned from public places and subject to the same tight controls as tobacco in France. The Medicines and Health Care Products Regulatory Agency (MHRA) of the UK has announced that ENDS will be licensed as a medicine from 2016 to ensure that “standards of quality, safety and efficacy are met; monitoring safety in use, including over the long term, is provided for; and advertising is controlled through medicines provisions and any emerging risks, e.g. acting as a gateway to smoking tobacco, can be effectively managed”. Other countries consider electronic cigarettes legal, but are in the process of considering where and how people can use them.

What will be our Health Ministry’s decision?

Health message
The WHO has warned that ENDS “pose significant public health issues and raise questions for tobacco control policy and regulation”. Its health message is clear, i.e. “Until such a time as ENDS is deemed safe and effective and of acceptable quality by a competent national regulatory body, consumers should be strongly advised not to use any of these products, including electronic cigarettes.”

Dr Milton Lum is a member of the board of Medical Defence Malaysia. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organisation the writer is associated with.

Disclaimer: Nothing on this blog should be considered or used as a substitute for medical advice, diagnosis or treatment. Blog visitors with personal health or medical questions should consult their health care provider.