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Is Sugar the Enemy?

30 Nov 2022

Malaysia has one of the highest diabetes rates in the world. Is it just because Malaysians have a sweet tooth, or is there something more behind this public health epidemic? We learn more from Dr Lee Ching Li, Senior Lecturer on Nutrition and Dietetics at International Medical University (IMU).


Diabetes statistics are nothing new and most people know the basics – namely, cutting down on sugar and carbohydrates – but with sweet drinks, rice and noodles as the mainstay of local foods, it can be a lot more difficult than it sounds.

Diabetes Trends in Malaysia
Prevalence of diabetes is steadily increasing in the country, from 11.2% in 2011 to 18.3% in 2019. It is projected to reach 31.3% in 2025.
Nationwide, 3.6 million Malaysians 18 and above have diabetes, and an estimated 3.7 million cases are undiagnosed. By 2025, the number is expected to increase to 7 million.
The cost of treating diabetes is significant, costing around USD600 million or RM3 billion per year.

For those with diabetes, managing this condition is a lifelong effort. For some, it can be frustrating when medication and lifestyle adjustments don’t seem to be effective. This may be partly caused by the assumptions we have about the food we eat. It may come as a surprise, but these mistaken assumptions may be to blame for poor control.


Let’s take another look at some common ideas about our food and our eating habits to see if we are making the right choices.

#1. I already cut out sugar from my diet.

“Contrary to what many people think, sugar is not the enemy – nor does it cause diabetes. Diabetes is caused by insulin resistance, where the body is unable to use insulin effectively to process the sugar we consume. The main reason for insulin resistance is obesity, especially abdominal obesity or fat that accumulates around your belly due to poor dietary habits, lack of exercise, insufficient sleep and other factors; this accumulated fat interferes with the body’s ability to use insulin affectively,” explained Dr Lee Ching Li, Senior Lecturer on Nutrition and Dietetics at International Medical University (IMU).

#2. I prefer savoury foods so I don’t need to worry about sugar

You may not think you have a sweet tooth, but most foods contain a mixture of sweet and salty flavours, with one or the other being dominant. This makes it easy to think that salty-tasting foods such as oyster sauce and curries don’t contain sugar, when in fact they do.


Taking less sauces and gravies can help – try taking your favourite curry or sauce in a separate dish so you can control how much you eat.

#3. Sugar-free options still taste sweet, so I think it’s just a scam

Some foods labelled as sugar-free do taste sweet as manufacturers may add sugar substitutes instead, to make them taste better. Some of these substitutes are plant-based or made from amino acids that mimic the flavour of sweetness without adding calories hence they are free from sugar and not a scam.

#4. I just choose low-GI foods to be safe

GI stands for Glycaemic Index, which is a measurement for how quickly blood sugar levels rise after eating a certain food. This is known as the GI response.


Normally, insulin works to reduce the effect of sudden spikes in blood sugar after eating but for people with diabetes, insulin resistance keeps blood sugar levels high. If their condition is not managed well and blood sugar levels remain persistently high, this can lead to complications such as heart and kidney disease, loss of vision and nerve damage in the legs and feet, among others.


However, it is not as simple as just choosing low GI foods that are low in carbs and simple sugars as GI is very specific not only to the type of food, but also how it is prepared, and what you eat it with.


Dr Lee explains with this example: short-grained rice has higher GI than long-grained rice like basmati. But when long-grained is cooked into porridge, it is quickly digested hence it will have a high GI response. However, when long-grained rice is made into nasi kandar and eaten with meat and vegetables, the GI is lower because the fat and fibre from the meat and vegetables help to lower the GI response. However, while fat helps to moderate the GI response, too much foods that are high in fat – such as nasi kandar and nasi lemak – can contribute to obesity and make it harder to manage diabetes.


However, it’s not all bad – you can still enjoy your favourite dish on occasion, and make sure to load up on vegetables. Aim to cover half your plate with vegetables, advises Dr Lee.

#5. Nutrition tables and ingredient lists are just too confusing and difficult to read, so I don’t bother

Instead of squinting at the small print, you can snap a picture on your handphone and zoom in to see it clearly.


Here’s another handy tip from Dr Lee for reading food labels – ingredients are universally listed according to its weight. This means that it contains more of the ingredients that are listed first, so if you see sugars listed among the first few ingredients, that means it contains high levels of sugar.


While it is easy to spot common names like ‘cane sugar’, you also need to look for any words that end in ‘ose’, which means it contains a form of sugar. This includes fructose and sucrose. Bear in mind that nutrition tables must show energy, protein and carbohydrates; sometimes, sugars are not listed and may be concealed under ‘carbohydrates’.

So how can we make better choices?

“Diabetes is known as a predictor of natural death so it’s worthwhile to be proactive in keeping it at bay, to reduce the medical and financial burden of treatment and prevent future complications,” explained Dr Lee.

Here is some practical advice to help:
Get tested One in five Malaysians have elevated blood sugar levels. To put this in perspective, that means one family member out of five, one person in a group of five friends catching up over a meal, or one person in a working team of five. In short, many people you know are likely to have diabetes, or it could even be you.


Getting tested and being aware means that you can take action early, when lifestyle adjustments and treatment are more likely to be effective and before possible organ damage occurs.

There is no ‘good’ or ‘bad’ food “Thinking of foods as good or bad is very common – this keeps things easier for us, but it’s often not that simple. Dividing foods that way often leads to people going to extremes, such as eating too much of one type because they think it is good for them. But this can cause them to neglect other types of food that are also beneficial! We all need a variety of nutrients from different sources so I want to stress that all foods are good, especially whole foods or foods that are minimally processed.  All you need to do is control your portion and how frequently you eat it,” she said.
Be persistent Simple steps to take charge of what you eat, done consistently, can have significant impact. Dr Lee recommends following the Healthy Plate Model, which means half your plate should consist of vegetables and fruits, one quarter grains or whole grains such as brown rice, and the final quarter protein such as fish, poultry, meat or egg.


A significant amount of sugar is consumed in sweetened drinks such as teh tarik, soft drinks and fruit-flavoured beverages. In addition to cutting back on these drinks, you can also ask for less sugar or no sugar at all – while it may taste as if something is lacking at first, it is possible to train your tastebuds to get used to it over time, says Dr Lee.


Whatever steps you take to prevent or manage diabetes, be firm in your conviction, she adds. “I’ve had patients who said they were ashamed to ask for less sugar or smaller portions because people would tease them for it. Others feel discouraged at the thought of all the things they have to give up, or feel deprived when they see other people enjoying their favourite foods.”


“Instead of feeling this way, be empowered – you are making these choices to be a healthier person. Rather than focusing on what you are giving up, remind yourself of what you gain by changing the way you eat and your approach to food,” she said.

Be SMART The best intentions can fail, so you need to set SMART goals that are Specific, Measurable, Assignable, Realistic and Time-related. For example, instead of just saying ‘I want to eat less fast food’, try ‘Instead of having fast food every week, I will only have it once a month’.


You can also practice Implementation Intention – this means having a planned strategy for dealing with challenges. For instance, your plans to go jogging every evening can be derailed by bad weather, social engagements and other disruptions. To improve your chances of sticking to your exercise regime, plan for how you will deal with each of these scenarios.


Lastly, “Don’t run away from diabetes; do something about it,” says Dr Lee, who is also the Programme Director for the Postgraduate Diploma in Diabetes Management and Education.


“When it comes to managing your blood sugar, especially for people with diabetes, think of it as driving a ‘diet car’ – sometimes you might take a detour or lose your way, but you can always get back to the main road. So, if you happen to give in and indulge, don’t give up! Just find your way to the ‘road’ and get back on track.”

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