Norlaila Mustafa, MD Pakar Perunding Endokrinologi. Hospital Serdang, 10 hb Mei 2016

Size: px

Start display at page:

Download "Norlaila Mustafa, MD Pakar Perunding Endokrinologi. Hospital Serdang, 10 hb Mei 2016"

Brian Ford
6 years ago
Views:

1 Norlaila Mustafa, MD Pakar Perunding Endokrinologi Hospital Serdang, 10 hb Mei 2016

2 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

3 Diabetes di Malaysia 5 th National Health and Morbidity Survey (NHMS) in % penduduk Malaysia beruusia 30 tahun ke atas menghidap diabetes % % % % Setiap seorang dari 5 orang di Malaysia menghidap diabetes!!!

4 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. 4

5 Bagaimana diabetes berlaku? Kerintangan Insulin di dalam badan Kekurangan insulin yang dihasilkan oleh pankreas Faktor faktor lain: - berat badan berlebihan - sejarah keluarga/genetik - umur

6 Diabetes Jenis 2

7 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

8 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

9 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: mmol/l -Sebelum masa makan: 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,

10 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

11 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 -lelaki : kkal/hari : kkal/hari Berat badan berlebihan & menopos : kkal/hari

12 Pemakanan untuk pesakit diabetes Masa makan yang tetap dan mengikut masa digalakkan i.e. sarapan, makan tengahari dan makan malam Snek i.e am dan 4.00 pm Total/jumlah kalori yang diambil perlu berpatutan dan sesuai dengan aktiviti yang dilakukan sehari hari

13 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

14 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

15 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)

16 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

17 Berpuasa Wahai orang-orang yang beriman, diwajibkan atas kamu berpuasa sebagaimana diwajibkan atas orangorang 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 harihari yang lain. Allah menghendaki kemudahan bagimu dan tidak menghendaki kesukaran bagimu. Al Baqarah Ayat 185

Berpuasa Ramadan di kalangan pesakit diabetes tertentu Strongly advised against fasting during Ramadan 1 Fasting pregnant patients should be managed in high-risk clinics staffed by an obstetrician,

Children and adolescents with good glycaemic control who do regular self-monitoring can fast safely during Ramadan 2 Kanak2 dan Remaja This is provided that a well structured program of education for

18 Berpuasa Ramadan di kalangan pesakit diabetes tertentu Strongly advised against fasting during Ramadan 1 Fasting pregnant patients should be managed in high-risk clinics staffed by an obstetrician, diabetologist, a nutritionist, and diabetes nurse educators 1 Wanita Mengandung The management of pregnant patients during Ramadan is based on an appropriate diet and intensive insulin therapy 1 Children and adolescents with good glycaemic control who do regular self-monitoring can fast safely during Ramadan 2 Kanak2 dan Remaja This is provided that a well structured program of education for both children and their families is completed prior to Ramadan, and that they receive close follow up during the month of Ramadan 2 References: 1. Al-Arouj M, Assaad-Khalil S, Buse J, et al. Recommendations for management of diabetes during Ramadan: update Diabetes Care. 2010; 33(8): Azad K, Mohsin F, Zargar AH, et al. Fasting guidelines for diabetic children and adolescents. Indian J Endocrinol Metab. 2012; 16(4):

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

are maintained 1,2 Elderly patients are exempted from fasting.

19 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 restrictions 1,2 Pesakit Dialisis These patients should be followed-up closely to detect any complications and to ensure that adequate fluid and electrolyte balance are maintained 1,2 Elderly patients are exempted from fasting. Many may wish to observe the fast 3 Pesakit Warga Emas Those with diabetes having any degree of cognitive dysfunction, dehydration, or an increased risk of thrombosis are advised against fasting 3 References: 1. Al-Arouj M, Assaad-Khalil S, Buse J, et al. Recommendations for management of diabetes during Ramadan: update Diabetes Care. 2010; 33(8): Azad K, Mohsin F, Zargar AH, et al. Fasting guidelines for diabetic children and adolescents. Indian J Endocrinol Metab. 2012; 16(4): 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):

20 Diabetes dan Ramadan EPIDIAR (Epidemiology of Diabetes and Ramadan): melibatkan 13 negara, 12,243 pesakit Muslim Puasa Ramadan Menilai dan meneliti masalah-masalah semasa berpuasa dan risikonya Risiko: hipoglisemia hiperglisemia kekurangan air (dehidrasi)

21 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

22 Risiko dehidrasi Dehidrasi berlaku akibat: - kurang pengambilan air - cuaca panas - disebabkan hiperglisemia Tanda-tanda dehidrasi: - sakit kepala - letih - koma

23 Tanda-tanda hipoglisemia Perasaan tidak selesa Keletihan yang teruk Kelaparan Berpeluh-peluh Pucat Berdebar-debar Menggigil Koma

24 Tanda- tanda hiperglisemia Kerap kencing Dahaga berlebihan Keletihan

25 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 *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. *Refer to Section 7: Self-monitoring of blood glucose during Ramadan: Ministry of Health (MOH) Malaysia. Practical Guide to Diabetes Management in Ramadan Reference: 1. Ministry of Health (MOH) Malaysia. Practical Guide to Diabetes Management in Ramadan 2015.

26 Perkara yang boleh dan yang tidak sepatutnya dilakukan semasa berpuasa Perlu mengambil/makan sahur Berbuka seberapa segera apabila azan maghrib Mengambil ubat/insulin seperti yang diarahkan oleh doktor Jangan makan berlebihan ketika berbuka (iftar) Kenalpasti tanda- tanda hipoglisemia, hiperglisemia dan dehidrasi - berbuka puasa dengan segera jika perlu

27 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

28 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

29 Nasihat pemakanan Good buka puasa meal Food that should be limited during buka puasa A B Reference: 1. Ministry of Health (MOH) Malaysia. Practical Guide to Diabetes Management in Ramadan 2015.

30 Menyesuaikan diet yang sihat ketika berpuasa 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 Reference: 1. Persatuan Dietitian Malaysia. Medical Nutrition Therapy Guidelines for Type 2 Diabetes Mellitus Second Edition.

Merancang pemakanan/diet Appropriate meal planning is important to avoid postprandial hyperglycaemia 1 The diet during Ramadan should not differ from a healthy balanced diet 1 Distribute calories

Recommendations for management of diabetes during Ramadan: update 2010. Diabetes Care. 2010; 33(8): 1895-902. 2. Persatuan Dietitian Malaysia.

31 Merancang pemakanan/diet Appropriate meal planning is important to avoid postprandial hyperglycaemia 1 The diet during Ramadan should not differ from a healthy balanced diet 1 Distribute calories over two to three smaller meals during the non-fasting interval 2 Consume slow-energy food 3 (i.e. wheat, beans and rice) References: 1. Al-Arouj M, Assaad-Khalil S, Buse J, et al. Recommendations for management of diabetes during Ramadan: update Diabetes Care. 2010; 33(8): Persatuan Dietitian Malaysia. Medical Nutrition Therapy Guidelines for Type 2 Diabetes Mellitus 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):

Aktiviti Fizikal/Senaman Berkala Light and moderate intensity exercise on a regular

preferably 1-2 hours after the break of fast 1,2 Performance of Tarawih night

Ramadan Education and Awareness in Diabetes (READ) programme for Muslims with Type

Review of diabetes management and guidelines during Ramadan. J R Soc Med.

32 Aktiviti Fizikal/Senaman Berkala Light and moderate intensity exercise on a regular basis 1,2 Avoid rigorous exercise during fasting time 1,2 The timing of exercise is preferably 1-2 hours after the break of fast 1,2 Performance of Tarawih night prayers 3 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): Karamat MA, Syed A, Hanif W. Review of diabetes management and guidelines during Ramadan. J R Soc Med. 2010; 103(4): Ibrahim MA. Managing diabetes during Ramadan. Diabetes voice. 2007; 52(2):

33 Perubahan ubat diabetes semasa Ramadan Regimen Sunset meal (iftar) Pre-dawn meal (sahur) α-glucosidase inhibitors (Acarbose) No changes No changes Biguanides (Metformin) Immediate-release Twice daily Thrice daily No changes Two third of dose No changes One third of dose Extended-release Full dose None Dipeptidyl peptidase-4 inhibitors (Januvia/ Galvus/Kombiglyze/Trajenta) Meglitinides (Novonorm) No changes No changes No changes No changes Sulphonylurea Glibenclamide, Gliclazide Gliclazide modified-release, Glimepiride No changes Reduce / Omit Sunset meal dosing Sodium glucose co-transporter 2 inhibitors* No changes Sunset meal dosing Thiazolidinediones No changes None * Based on expert opinion Reference: 1. Almaatouq MA. Pharmacological approaches to the management of Type 2 diabetes in fasting adults during Ramadan. Diabetes Metab Syndr Obes. 2012; 5:

34 Masa pemeriksaan darah bergantung kepada jenis ubat/insulin yang diambil Therapy Timing and frequency SMBG Oral anti-diabetic (OAD) Monitor when symptomatic 1 Insulin Diabetic patients who are in the moderate to high risk categories are advised to monitor their blood glucose 5 times per day 2 Pre-meal and 2-hour post pre-dawn meal (sahur) Mid-day Pre-meal and 2-hour post sunset meal (iftar) Bedtime References: 1. Ministry of Health (MOH) Malaysia. Practical Guide to Diabetes Management in Ramadan Hui E, Bravis V, Hassanein M, et al. Management of people with diabetes wanting to fast during Ramadan. BMJ. 2010; 340:c3053.

35 Pemantauan paras gula darah semasa berpuasa Digalakkan memantau paras gula lebih kerap berbanding hari biasa; - semasa sahur am pm pm pm

36 Bila perlu berbuka semasa berpuasa Ramadan Conditions to stop fasting: Blood glucose <3.3 mmol/l at anytime during the fast 1 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/l 1 Experience symptoms of hypoglycaemia (patients without SMBG) 4 Symptoms suggestive of severe dehydration such as syncope and confusion 4 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): 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): Ibrahim MA. Managing diabetes during Ramadan. Diabetes voice. 2007; 52(2): Ministry of Health Malaysia. Practical guide to Insulin Therapy in Type 2 Diabetes Mellitus

37 Pemeriksaan darah dapat memastikan dos insulin yang sesuai Time of glucose monitoring Mid-day Pre-iftar 2-hour post-iftar or bedtime Pre-sahur Insulin timing Pre-sahur Pre-sahur Pre-iftar Pre-iftar / Pre-bed Insulin type Premixed / bolus / basal insulin Premixed / basal insulin Premixed / basal insulin Premixed / basal insulin 2-hour post-sahur Pre-sahur Premixed / bolus insulin 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):

38 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!

40 THANK YOU FOR YOUR ATTENTION

Stroke Prevention. Adding years of healthy life. A Public Education Guide to. National Healthcare Group Adding years of healthy life

Stroke Prevention. Adding years of healthy life. A Public Education Guide to. National Healthcare Group Adding years of healthy life An educational service brought to you by the NHG Stroke Workgroup A Public Education Guide to Stroke Prevention Adding years of healthy life National Healthcare Group Adding years of healthy life Stroke