Mr New Boon Hwee, 57, no longer needs to take diabetes medication and is also off blood pressure medication.
ST PHOTO: NG SOR LUAN

SINGAPORE – Could you live on 800 calories a day for three months if your doctor asked you to?

This very low calorie diet is part of a new year-long, medically supervised programme at NHG Polyclinics, which aims to help patients with Type 2 diabetes achieve remission.

Diabetes is a long-term health condition which affects the body’s ability to process sugar, leading to raised blood glucose levels. Type 2 diabetes usually occurs when one does not respond well or is resistant to the body’s own insulin. It is usually found in people aged 40 or older, who are overweight and physically inactive.

A person in remission has normal blood sugar levels and no longer has to take diabetes medication.

Over a year after joining this REMI-D (REMIssion in Diabetes) programme in October 2024, Mr New Boon Hwee has lost more than 10 per cent of his body weight. He weighs 86 to 88kg, down from 99kg at his heaviest.

The 57-year-old retired accounting manager no longer needs to take the oral diabetes medication he was prescribed after being diagnosed in 2018. He is also off blood pressure medication.

His usual knee pain is gone and he sleeps better at night – all outcomes attributed to his weight loss.

But it was not an easy road, Mr New says, during an interview at NHG Ang Mo Kio Polyclinic.

For three months in 2024, he was allowed to consume only 800 calories a day under medical supervision. On average, the recommended calorie intake for healthy adults is 2,200 calories for men and 1,800 for women.

His calories came from meal replacement shakes. Any additions or substitutions, whether vegetable soup or a boiled egg, had to be cleared with the dietitian supporting him.

“In those first three months, I wanted to give up because of hunger,” Mr New says. “It was nothing but drinks.”

The lover of buffet restaurants missed eating solid food. Some days, he would consume less of the shakes so he could enjoy the single hard-boiled egg his girlfriend cooked for him.

“I would look forward to that egg,” he says. “That was the best thing. It tasted different.”

Weight loss for managing Type 2 diabetes

Mr New found the very low calorie diet difficult, but he chose to stick with it to prevent future health problems.

Diabetes can lead to other complications, says Dr Ian Koh, lead of the REMI-D programme and head of NHG Ang Mo Kio Polyclinic. Diabetic patients risk stroke, heart disease, eye problems, kidney issues and slow wound healing that can lead to the need for an amputation.

“As clinicians, we see the complications of diabetes,” he adds. “If we can get people into remission, we can minimise or delay the onset of these complications.”

A local study has found that the incidence of diabetes as well as hypertension, stroke and heart disease is expected to rise sharply among older adults by 2050. In 2021, Health Minister Ong Ye Kung said that without intervention, an estimated one million Singaporeans would have diabetes in 2050.

Lifestyle changes such as getting more physical activity and limiting ultra-processed foods are part of diabetes management.

Reducing excess body weight is also helpful. The nationally recommended body mass index (BMI) is 18.5 to 22.9, and a BMI of 27.5 and above puts one at risk of developing Type 2 diabetes and high blood pressure.

Mr New had a BMI above 30 when he was diagnosed with diabetes. He now has a BMI of around 27, after going through the REMI-D programme.

A doctor or dietitian recommends suitable patients with diabetes for the REMI-D programme. Participants must be aged 18 to 65, have a BMI equal to or above 23, and have an HbA1c reading greater than or equal to six if on medication for diabetes. The HbA1c blood test indicates the average blood glucose level over the past three months.

Participants should have had diabetes for six years or less. Reasons to exclude a patient would be diabetes-related complications, pregnancy, breastfeeding, insulin use, or a history of eating disorders, among others.

REMI-D participants spend three months taking only 800 calories a day. This can be entirely through meal replacement shakes, or by replacing at least one meal with the shake and following an individualised diet plan.

For Mr New, the all-liquid diet option took the burden of choice away. “I wanted to go all in,” he says. But he first asked for his girlfriend’s permission, since they enjoy eating out together.

Mr New had a BMI above 30 when he was diagnosed with diabetes. He now has a BMI of around 27, after going through the REMI-D programme.
ST PHOTO: NG SOR LUAN

Ms Carol Chang, 54, a retired regional financial manager, told him to go ahead. For the next three months, she encouraged him to stay on the programme even when he wanted to drop out.

The very low calorie diet phase (named the Reset phase) puts the body into mild ketosis, where the body burns fat for energy, rather than sugars. During this phase, weight drops off.

The Reset phase is succeeded by three months of reintroducing other foods (the Adapt phase), and then six months of weight management (the Sustain phase).

Mr New says: “The first thing I decided to eat in the Sustain phase was chicken rice.” Rather than avoiding his favourite high-calorie foods entirely, he learnt to enjoy them in moderation.

Mr New (centre) with his dietitian Pauline Xie (left) and Dr Ian Koh, who leads NHG Polyclinics' REMI-D Programme.
ST PHOTO: NG SOR LUAN

Working on lasting results

A total of 65 people have signed up since REMI-D was launched at NHG Ang Mo Kio Polyclinic in October 2024. NHG Hougang Polyclinic began offering it in April, and NHG Yishun Polyclinic in November.

Of the 16 people who have hit the six-month mark, 14 have achieved remission.

Some have achieved better health outcomes, even if they are not in full remission, says Dr Koh.

Principal dietitian Pauline Xie, who monitors and supports REMI-D participants, cites the example of a participant who used to have an HbA1c reading in the double digits. People with diabetes are usually asked to target readings of seven or lower.

This patient is not in remission, but her HbA1c reading has improved to around eight.

Another patient has gone from taking seven medicines a day to just one. “He told me: ‘I used to say good morning to my seven pills, and now I say good morning to my colleagues instead,’” says Ms Xie, who is also assistant director of clinical services at NHG Polyclinics.

Participants may regain some of the lost weight during the Adapt and Sustain phases. Mr New initially lost 17kg and regained about 5kg. A dietitian helps keep participants on track to maintain a reasonable weight.

Not everyone can keep up with the REMI-D programme. Ms Xie says three people ended up dropping out because they could not follow the diet. A fourth turned out to be allergic to the meal replacement shakes.

“I told them not to consider this a failure,” she says. “It’s just that this doesn’t work for you.”

Another option for such patients is the community-based weight management programme LighterLife, which includes exercise and diet plans that are not as restrictive.

Does going on this intensive programme lead to lasting results?

A similar weight loss programme trialled in Britain in 2014 and was studied over five years. Less than half of the participants achieved remission and maintained it.

Those who maintained remission and weight loss received low-intensity dietary support over that period of time.

Even if the results overseas have been less encouraging, Dr Koh says the continuity of care in the polyclinics should help people in Singapore maintain their weight loss for longer than observed in other countries.

“The same care team is continuing to monitor patients and looking out for predictors of relapse,” he says. “We can see what we can do to prevent that relapse.” It might mean reintroducing more dietitian sessions, or encouraging patients to join LighterLife or other weight management programmes.

Other options

Over at Singapore General Hospital, very low calorie diets are just one of the weight management options for people with diabetes. Others include going on a prescribed course of GLP-1 agonists to reduce appetite, or opting for surgery.

Bariatric surgery reduces the size of the stomach and can be recommended for diabetics with a BMI greater than or equal to 32.5.

With bariatric surgery, people feel full after having eaten less, and this leads to weight loss.

Dr Lee Phong Ching, senior endocrinologist at the hospital, says that more than half of Type 2 diabetes patients who have undergone bariatric surgery at SGH achieved diabetes remission at the one-year mark.

He adds that every treatment option has its benefits and drawbacks. “What’s most important is addressing the underlying cause of the disease and tailoring the approach to each patient’s needs, goals and preferences,” he says.

Some patients want to avoid surgery, while some know they are unable to keep up with a restrictive calorie diet and want help through medication or surgery.

For those willing to try, he recommends the very low calorie diet option if a doctor suggests it.

“Diabetes remission through intensive lifestyle change or very low calorie diets is certainly possible, though the chances vary from person to person,” he says. “It’s always worth trying, and it’s wonderful when remission happens.”

“Good glucose control, even if full remission isn’t reached, has a strong ‘legacy effect’,” he adds. “Over time, maintaining healthier blood sugar levels can protect vital organs and reduce the risk of complications.”