Norlaila Mustafa, MD Pakar Perunding Endokrinologi · dan stroke Komplikasi hanya ... sebanyak hari yang ditinggalkannya itu, pada hari-hari yang lain.

Norlaila Mustafa, MDPakar Perunding Endokrinologi

Hospital Serdang, 10hb Mei 2016

KANDUNGAN

Mengapa seseorang mendapat diabetes?

Apakah paras gula yang sesuai untuk pesakit diabetes?

Apakah pemakanan seimbang untuk diabetes?

Perkara yang boleh dan yang tidak sepatutnya dilakukan semasa berpuasa

Perubahan ubat-ubatan diabetes semasa berpuasa

Diabetes di Malaysia

5th National Health and Morbidity Survey (NHMS) in 2015 – 17.5% penduduk Malaysia beruusia 30 tahun ke atas menghidap diabetes

1960 – 1.2%

1985 - 6.3%

1996 - 8.3 %

2011 – 14.9%

Setiap seorang dari 5 orang di Malaysia menghidap diabetes!!!

Diabetes is defined by high levels of blood glucose

The World Health Organization and the International Diabetes Federation define diabetes as:

“a condition primarily defined by the level of

hyperglycaemia

giving rise to risk of microvascular damage…”

Adopted from International Diabetes Federation. Diabetes Atlas, Fifth Edition. www.diabetesatlas.org.4

Bagaimana diabetes berlaku? Kerintangan Insulin di dalam badan

Kekurangan insulin yang dihasilkan oleh pankreas

Faktor faktor lain:

- berat badan berlebihan

- sejarah keluarga/genetik

- umur

Diabetes Jenis 2

Bagaimana diabetes dikesan?

Ujian Darah: sebelum sarapan (berpuasa) dan random

Simptom diabetes:

- senang penat dan letih, haus,

kerap kencing,

kehilangan berat badan, ulcser

yang kronik

Diabetes dan komplikasi Jika diabetes tidak dikawal, kemungkinan besar

tekanan darah dan paras kolesterol juga akan tinggi

Meningkatkan serangan jantung dan stroke

Komplikasi hanya berlaku apabila

paras gula dalam darah sentiasa

tinggi

Paras gula yang berpatutan untuk pesakit diabetes

Biasanya, paras gula di dalam darah ditentukan oleh

pemakanan pesakit dan aktiviti insulin di dalam

badan;

-Sebelum sarapan: 4.0 - 6.0 mmol/L

-Sebelum masa makan: 5.0 – 7.0 mmol/L

-2 jam selepas makan: < 10.0 mmol/L

Paras gula normal

Penting untuk memastikan paras gula normal bagi

mengelakkan komplikasi diabetes

Komplikasi diabetes: serangan jantung, angin ahmar,

amputasi kaki, buta, kerosakan saraf (neuropathy)

Pemakanan sihat dan seimbang, senaman berkala,

pengambilan ubat diabetes penting untuk

mengelakkan komplikasi

Pemakanan untuk pesakit diabetes Seharusnya mengandungi nutrisi dan kalori yang cukup

bersesuaian dengan aktiviti harian

Wanita biasanya memerlukan kalori yang lebih rendah berbanding lelaki

-wanita : 1400-1600 kkal/hari

-lelaki : 1600-1800 kkal/hari

Berat badan berlebihan & menopos : 1200-1400 kkal/hari

Pemakanan untuk pesakit diabetes

Masa makan yang tetap dan mengikut masa digalakkan i.e. sarapan, makan tengahari dan makan malam

Snek i.e 10.00 am dan 4.00 pm

Total/jumlah kalori yang diambil perlu berpatutan dan sesuai dengan aktiviti yang dilakukan sehari hari

Rawatan untuk pesakit diabetes

Pemakanan sihat dan senaman berkala dapat menurunkan paras gula dalam darah

Ubat ubatan perlu sentiasa diambil, dan meminta nasihat doktor jika perlu

Rawatan untuk pesakit diabetes

Insulin – jika paras gula dalam darah terlalu tinggi dan tidak terkawal

Keperluan dan dos insulin berbeza beza di kalangan pesakit diabetes : JANGAN BUAT PERBANDINGAN

- sekali/hari

- dua hingga lima kali/hari

Islam dan Ramadan

1.57 billion populasi dunia (23%)

Peningkatan sebanyak ~3% setiap tahun

Satu kewajipan pada semua Muslim yang sihat dan berkemampuan untuk berpuasa

Menahan lapar dan dahaga, tidak boleh mengambil ubat-ubatan dan merokok

Bermula sesudah suboh sehingga maghrib (matahari jatuh)

Bolehkah pesakit diabetes berpuasa ketika Ramadan?

Berpuasa di bulan Ramadan adalah selamat dan tidak memudaratkan bagi kebanyakan pesakit

Bermula dengan nasihat dan rawatan diabates yang betul

Berpuasa Wahai orang-orang yang beriman, diwajibkan atas

kamu berpuasa sebagaimana diwajibkan atas orang-orang sebelum kamu agar kamu bertaqwa “

Al Baqarah Ayat 183

“…Dan barangsiapa sakit atau dalam perjalanan (lalu ia berbuka) maka (wajiblah baginya berpuasa) sebanyak hari yang ditinggalkannya itu, pada hari-hari yang lain.

Allah menghendaki kemudahan bagimu dan tidak menghendaki kesukaran bagimu. ”

Al Baqarah Ayat 185

Berpuasa Ramadan di kalangan pesakit diabetes tertentu

References:1. Al-Arouj M, Assaad-Khalil S, Buse J, et al. Recommendations for management of diabetes during Ramadan: update 2010. Diabetes Care. 2010; 33(8): 1895-902. 2. Azad K, Mohsin F, Zargar AH, et al. Fasting guidelines for diabetic children and adolescents. Indian J Endocrinol Metab. 2012; 16(4): 516-518.

•Strongly advised against fasting during Ramadan1

•Fasting pregnant patients should be managed in high-risk clinics

staffed by an obstetrician, diabetologist, a nutritionist, and diabetes

nurse educators1

•The management of pregnant patients during Ramadan is based on

an appropriate diet and intensive insulin therapy1Wanita Mengandung

• Children and adolescents with good glycaemic control who do regularself-monitoring can fast safely during Ramadan2

• This is provided that a well structured program of education for bothchildren and their families is completed prior to Ramadan, and thatthey receive close follow up during the month of Ramadan2

Kanak2 dan Remaja

Berpuasa Ramadan di kalangan pesakit diabetes tertentu

•Most stable patients on haemodialysis and peritoneal dialysis can

fast, provided that they strictly adhere to their medications and

dialysis therapy in addition to the dietary restrictions1,2

•These patients should be followed-up closely to detect any

complications and to ensure that adequate fluid and electrolyte

balance are maintained1,2Pesakit Dialisis

•Elderly patients are exempted from fasting. Many may wish to

observe the fast3

•Those with diabetes having any degree of cognitive dysfunction,

dehydration, or an increased risk of thrombosis are advised against

fasting3Pesakit Warga

Emas

References:1. Al-Arouj M, Assaad-Khalil S, Buse J, et al. Recommendations for management of diabetes during Ramadan: update 2010. Diabetes Care. 2010; 33(8): 1895-902. 2. Azad K, Mohsin F, Zargar AH, et al. Fasting guidelines for diabetic children and adolescents. Indian J Endocrinol Metab. 2012; 16(4): 516-518. 3. Al Wakeel J, Mitwalli AH, Alsuwaida A, et al. Recommendations for fasting in Ramadan for patients on peritoneal dialysis. Perit Dial Int. 2013; 33(1): 86-91.

Diabetes dan Ramadan EPIDIAR (Epidemiology of Diabetes and Ramadan):

melibatkan 13 negara, 12,243 pesakit Muslim

Puasa Ramadan

Menilai dan meneliti masalah-masalah semasaberpuasa dan risikonya

Risiko: hipoglisemia

hiperglisemia

kekurangan air (dehidrasi)

Risiko hipoglisemia:

- 7.5x lebih kerap dikalangan pesakit

diabetes jenis 2

- 4.7x lebih kerap dikalangan pesakit

diabetes jenis 1

Risiko hiperglisemia:

- risiko meningkat sebanyak 5x ganda

Risiko dehidrasi

Dehidrasi berlaku akibat:

- kurang pengambilan air

- cuaca panas

- disebabkan hiperglisemia

Tanda-tanda dehidrasi:

- sakit kepala

- letih

- koma

Tanda-tanda hipoglisemia

Perasaan tidak selesa

Keletihan yang teruk

Kelaparan

Berpeluh-peluh

Pucat

Berdebar-debar

Menggigil

Koma

Tanda- tanda hiperglisemia

Kerap kencing

Dahaga berlebihan

Keletihan

Merawat Hipoglisemia ketika berpuasa Ramadan

Patients need to end their fast if they experience symptoms of hypoglycaemia or have low blood

glucose values*

Take simple carbohydrates

Reference:1. Ministry of Health (MOH) Malaysia. Practical Guide to Diabetes Management in Ramadan 2015.

*Refer to Section 7: Self-monitoring of blood glucose during Ramadan: Ministry of Health (MOH) Malaysia. Practical Guide to Diabetes Management in Ramadan 2015.

*Blood glucose < 3.3 mmol/l at anytime during the fast.*Blood glucose < 3.9 mmol/l in the first few hours of fasting (especially if the patient is taking sulfonylureas, meglitinides, or insulin).

*Experience symptoms of hypoglycaemia (patients without SMBG).*Symptoms suggestive of severe dehydration such as syncope and confusion.

Perkara yang boleh dan yang tidaksepatutnya dilakukan semasa berpuasa

Perlu mengambil/makan sahur

Berbuka seberapa segera apabila azan maghrib

Mengambil ubat/insulin seperti yang diarahkan olehdoktor

Jangan makan berlebihan ketika berbuka (iftar)

Kenalpasti tanda- tanda hipoglisemia, hiperglisemiadan dehidrasi

- berbuka puasa dengan segera jika perlu

Pengambilan ubat ketika berpuasa

Mungkin perlu menukar dos ubat diabetes atau pun insulin semasa berpuasa

Tidak makan dan minum di siang hari, selama 14 jam

Pemakanan ketika berpuasa

Cara makan sihat (Healthy eating)

Makanan tinggi serat (kekacang, beras perang, sayur-sayuran)

Kurangkan makanan berlemak

Jangan makan berlebihan ketika berbuka (2 kurma)

Minum air dengan banyak

Nasihat pemakanan

Reference:1. Ministry of Health (MOH) Malaysia. Practical Guide to Diabetes Management in Ramadan 2015.

Good “buka puasa”mealFood that should be limited

during “buka puasa”

A B

Menyesuaikan diet yang sihat ketika berpuasa

Reference:1. Persatuan Dietitian Malaysia. Medical Nutrition Therapy Guidelines for Type 2 Diabetes Mellitus. 2013. Second Edition.

Never skip sahur (dawn meal)

Do not delay “berbuka”

Supper after Tarawih can be taken as replacement of pre-bed snack

Include fruits and vegetables at both sahur and iftar

Limit fried and fatty foods

Limit intake of highly salted foods to reduce risk of dehydration

Drink adequately at sahur, choose sugar-free drinks, aim for 8 glasses per day

Avoid excessive binging of carbohydrates during non–fasting period

Merancang pemakanan/diet

Appropriate meal planning is important to avoid postprandial hyperglycaemia1

The diet during Ramadan should not differ from a healthy balanced diet1

Consume slow-energy food3

(i.e. wheat, beans and rice)

Distribute calories over two to three smaller meals during

the non-fasting interval2

References:

1. Al-Arouj M, Assaad-Khalil S, Buse J, et al. Recommendations for management of diabetes during Ramadan: update 2010. Diabetes Care. 2010; 33(8): 1895-902. 2. Persatuan Dietitian Malaysia. Medical Nutrition Therapy Guidelines for Type 2 Diabetes Mellitus. 2013. Second Edition. 3. Bravis V, Hui E, Salih S, et al. Ramadan Education and Awareness in Diabetes (READ) programme for Muslims with Type 2 diabetes who fast during Ramadan. Diabet Med. 2010; 27(3): 327-331.

Aktiviti Fizikal/Senaman Berkala

Light and moderate intensity exercise on a regular basis1,2

Avoid rigorous exercise during fasting time1,2

The timing of exercise is preferably 1-2 hours after the break of fast1,2

Performance of Tarawih night prayers3

References:1. Bravis V, Hui E, Salih S, et al. Ramadan Education and Awareness in Diabetes (READ) programme for Muslims with Type 2 diabetes who fast during Ramadan. Diabet Med. 2010; 27(3): 327-331. 2. Karamat MA, Syed A, Hanif W. Review of diabetes management and guidelines during Ramadan. J R Soc Med. 2010; 103(4): 139-147. 3. Ibrahim MA. Managing diabetes during Ramadan. Diabetes voice. 2007; 52(2): 19-22.

Perubahan ubat diabetes semasa Ramadan

Reference:1. Almaatouq MA. Pharmacological approaches to the management of Type 2 diabetes in fasting adults during Ramadan. Diabetes Metab Syndr Obes. 2012; 5: 109-119.

Regimen Sunset meal (iftar) Pre-dawn meal (sahur)

α-glucosidase inhibitors (Acarbose)

Biguanides (Metformin)

Thiazolidinediones

Sodium glucose co-transporter 2 inhibitors*

Dipeptidyl peptidase-4 inhibitors (Januvia/ Galvus/Kombiglyze/Trajenta)

Meglitinides (Novonorm)

No changes No changes

No changes

Two third of dose

No changes

One third of dose

No changes No changes

No changes No changes

No changes Sunset meal dosing

No changes None

Sulphonylurea

Glibenclamide, Gliclazide

Gliclazide modified-release, Glimepiride

No changes

Reduce / Omit

Sunset meal dosing

Immediate-release

Twice daily

Thrice daily

Extended-release Full dose None

* Based on expert opinion

Masa pemeriksaan darah bergantung kepada jenis ubat/insulin yang diambil

Therapy Timing and frequency SMBG

Oral anti-diabetic (OAD)

Monitor when symptomatic1

Insulin

References:1. Ministry of Health (MOH) Malaysia. Practical Guide to Diabetes Management in Ramadan 2015.2. Hui E, Bravis V, Hassanein M, et al. Management of people with diabetes wanting to fast during Ramadan. BMJ. 2010; 340:c3053.

Diabetic patients who are in the moderate to high risk categories are advised to monitor their blood glucose 5 times per day2

Pre-meal and 2-hour post pre-dawn meal (sahur)Mid-dayPre-meal and 2-hour post sunset meal (iftar)Bedtime

Pemantauan paras gula darah semasa berpuasa

Digalakkan memantau paras gula lebih kerap berbanding hari biasa;

- semasa ‘sahur’

- 10.00 am

- 1.00 pm

- 5.00 pm

- 10.00 pm

Bila perlu berbuka semasa berpuasa Ramadan

References:1. Pathan MF, Sahay RK, Zargar AH, South Asian Consensus Guideline: Use of insulin in diabetes during Ramadan. Indian J Endocrinol Metab. 2012; 16(4): 499-502. 2. Bravis V, Hui E, Salih S, et al. Ramadan Education and Awareness in Diabetes (READ) programme for Muslims with Type 2 diabetes who fast during Ramadan. Diabet Med. 2010; 27(3): 327-331. 3. Ibrahim MA. Managing diabetes during Ramadan. Diabetes voice. 2007; 52(2): 19-22. 4. Ministry of Health Malaysia. Practical guide to Insulin Therapy in Type 2 Diabetes Mellitus. 2010.

Conditions to stop fasting:

• Blood glucose <3.3 mmol/l at anytime during the fast1

• Blood glucose <3.9 mmol/l in the first few hours of fasting (especially if the patient is taking sulfonylureas, meglitinides, or insulin)2,3

• Blood glucose >16.7 mmol/l1

• Experience symptoms of hypoglycaemia (patients without SMBG)4

• Symptoms suggestive of severe dehydration such as syncope and confusion4

Pemeriksaan darah dapat memastikan dos insulin yang sesuai

Insulin type

Premixed / bolus / basal insulin

Premixed / basal insulin

Premixed / basal insulin

Premixed / basal insulin

Premixed / bolus insulin

Insulin timing

Pre-sahur

Pre-sahur

Pre-iftar

Pre-iftar / Pre-bed

Pre-sahur

Time of glucose monitoring

Mid-day

Pre-iftar

2-hour post-iftar or bedtime

Pre-sahur

2-hour post-sahur

Reference:

1. Pathan MF, Sahay RK, Zargar AH, South Asian Consensus Guideline: Use of insulin in diabetes during Ramadan. Indian J Endocrinol Metab. 2012; 16(4): 499-502.

Ringkasan

Kajian menunjukkan pesakit diabetes boleh berpuasa. Berpuasa tidak memudaratkan jika telah di priksa dan mendapat nasihat yang betul dari doktor

Pesakit diabetes perlu mendapatkan nasihat yang sewajarnya mengenai ubat diabetes dan prubahan dos yang mungkin perlu dilakukan ketika berpuasa

Adalah penting untuk makan secara seimbang dan sihat terutamanya ketika ‘berbuka’, jangan lupa bersahur, minum air sebanyak mungkin dan jangan lupa makan ubat diabetes!

THANK YOU FOR YOUR ATTENTION