Norlaila Mustafa, MD

Pakar 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
•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

Wanita
Mengandung an appropriate diet and intensive insulin therapy1

• Children and adolescents with good glycaemic control who do regular

self-monitoring can fast safely during Ramadan2
• 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 Ramadan2
Kanak2 dan
Remaja

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.
 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
Pesakit Dialisis balance are maintained1,2

•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
Pesakit Warga
fasting3
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 semasa
berpuasa 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

*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
*Refer suggestive
to Section 7: Self-monitoring of blood glucoseof severe
during dehydration
Ramadan: Ministry such
of Health (MOH) Malaysia. asGuide
Practical syncope and in Ramadan 2015.
to Diabetes Management

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

 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
Food that should be limited
Good “buka puasa” meal
during “buka puasa”

A B

Reference:
1. Ministry of Health (MOH) Malaysia. Practical Guide to Diabetes Management in Ramadan 2015.
 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. 2013. Second Edition.
 Merancang pemakanan/diet
Appropriate meal planning is important to avoid postprandial
hyperglycaemia1

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

Distribute calories over two to Consume slow-energy food3

three smaller meals during
(i.e. wheat, beans and rice)
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
Regimen Sunset meal (iftar) Pre-dawn meal (sahur)

α-glucosidase inhibitors (Acarbose) No changes No changes

Immediate-release
Twice daily No changes No changes
Biguanides
Thrice daily Two third of dose One third of dose
(Metformin)

Extended-release Full dose None

Dipeptidyl peptidase-4 inhibitors (Januvia/

No changes No changes
Galvus/Kombiglyze/Trajenta)

Meglitinides (Novonorm) No changes No changes

Glibenclamide, Gliclazide Reduce / Omit

Sulphonylurea No changes
Gliclazide modified-release,
Sunset meal dosing
Glimepiride

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: 109-119.
 Masa pemeriksaan darah bergantung
kepada jenis ubat/insulin yang diambil
Therapy Timing and frequency SMBG

Oral anti-diabetic
Monitor when symptomatic1
(OAD)

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)
Insulin 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 2015.
2. Hui E, Bravis V, Hassanein M, et al. Management of people with diabetes wanting to fast during Ramadan. BMJ. 2010; 340:c3053.
 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

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

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.
 Pemeriksaan darah dapat
memastikan dos insulin yang sesuai
Time of glucose
Insulin timing Insulin type
monitoring
Premixed / bolus / basal
Mid-day Pre-sahur
insulin

Pre-iftar Pre-sahur Premixed / basal insulin

2-hour post-iftar or
Pre-iftar Premixed / basal insulin
bedtime

Pre-sahur Pre-iftar / Pre-bed 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): 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