practical management of type 2 diabetes during the holy month of ramadan
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Practical Management of Type 2 Diabetes during the Holy month of RamadanTRANSCRIPT
Practical Management of Type 2 DiabetesPractical Management of Type 2 DiabetesDuring the Holy Month of RamadanDuring the Holy Month of Ramadan
Prof. Md. Farid UddinChairman & Coordinator
Department of Endocrinology Bangabandhu Sheikh Mujib Medical University
Dhaka, BangladeshEmail: [email protected]
Diabetes & RamadanDiabetes & Ramadan
Diabetes Mellitus is a chronic disease
Fasting is one of the five pillars of Islam
About 50 million people with Diabetes fast during Ramadan
Recent Advancements give us the opportunity to offer the patients have a normal or near normal life
Frequently asked questions during Frequently asked questions during RamadanRamadan
Can a diabetic patient fast?
What are the risks & benefits associated with fasting?
What about diet and exercise?
How to adjust drugs?
Can a patient monitor blood sugar while fasting?
Can a diabetic patient fastCan a diabetic patient fastduring Ramadan? during Ramadan?
IslamiCity.com- Ramadan Fasting and Diabetes IslamiCity.com- Ramadan Fasting and Diabetes Mellitus Mellitus
The bulk of literature indicates that The bulk of literature indicates that fasting in Ramadan is safe for the fasting in Ramadan is safe for the majority of diabetic patients, but…majority of diabetic patients, but…
Patient needs-Patient needs-
1.1. Pre-Ramadan assessmentPre-Ramadan assessment2.2. Proper educationProper education3.3. ManagementManagement
Physician’s Role?Physician’s Role?
Guidance and advice to allow Guidance and advice to allow diabetic patients to fast as safely diabetic patients to fast as safely
as possibleas possible
Pre-Ramadan AssessmentPre-Ramadan Assessment
1.1. Assessment of glycemic Assessment of glycemic statusstatus
2.2. Assessment of complications Assessment of complications & co-morbid conditions& co-morbid conditions
3.3. Assessment of patient’s Assessment of patient’s abilityability
Conditions related to diabetes:Conditions related to diabetes:- Advanced nephropathy- Advanced nephropathy- Severe retinopathy- Severe retinopathy- Autonomic neuropathy- Autonomic neuropathy- Hypoglycemic unawareness- Hypoglycemic unawareness- Major macrovascular diseases- Major macrovascular diseases- Recent hyper-osmolar state or DKA- Recent hyper-osmolar state or DKA- Poorly controlled diabetes (Mean RBG> 300)- Poorly controlled diabetes (Mean RBG> 300)- Multiple insulin injections per day- Multiple insulin injections per day
Patients with one or more of the followingPatients with one or more of the followingare advised not to fastare advised not to fast
Physiological conditions:Physiological conditions:- Pregnancy- Pregnancy- Lactation- Lactation
Clinical Diabetes ( Middle East Edition)- Volume 3, Number 3, 2004
Co-existing major medical conditions such as:Co-existing major medical conditions such as:- Acute peptic ulcer- Acute peptic ulcer- Severe Pulmonary Tuberculosis- Severe Pulmonary Tuberculosis- Severe infection- Severe infection- Severe bronchial asthma- Severe bronchial asthma- Recurrent stones formation- Recurrent stones formation- Cancer with poor general condition- Cancer with poor general condition- Overt cardiovascular diseases (Recent MI)- Overt cardiovascular diseases (Recent MI)- Severe psychiatric conditions- Severe psychiatric conditions- Hepatic dysfunction (liver enzymes > 2 × ULN)- Hepatic dysfunction (liver enzymes > 2 × ULN)
Clinical Diabetes ( Middle East Edition)- Volume 3, Number 3, 2004
Patients with one or more of the followingPatients with one or more of the followingare advised not to fastare advised not to fast
Benefits associated with Benefits associated with fastingfasting
The Health Benefits of fastingThe Health Benefits of fasting
• Fasting improves metabolic function• Helps to loose excess weight & water• Better control of Hypertension• Flush out toxins• Strengthen immune system
Prescription for nutritional healing by James and Phyllis Blach, pp 548-550
General BenefitsGeneral Benefits
Patients should be advised to make use of this opportunity to combine
the spiritual benefit with improvement in the metabolic control of the diabetes mainly
through weight reduction.
Spiritual BenefitsSpiritual Benefits
Quran 2:183Quran 2:183
“ O you who believe! Fasting has been prescribed to you as it was
prescribed to those before you so that you attain Taqwa (self restraint , God Awareness)”
What are the risksWhat are the risksassociated with fasting?associated with fasting?
Major risks associated with fastingMajor risks associated with fastingin patients with diabetesin patients with diabetes
Hypoglycemia
Hyperglycemia
Dehydration
Weight changes
DIABETES CARE, VOLUME 28, NUMBER 9 SEPTEMBER 2005
Special precautions are recommendedSpecial precautions are recommendedto avoid hypoglycemic eventsto avoid hypoglycemic events
To take Suhur close to Suhur time To change in the schedule, amount and composition of meals To reduce physical activity during the day time. However physical exercise can be performed about one hour after Iftar To keep the same calorie during Ramadan as before
Management of hyperglycemiaManagement of hyperglycemiain type 2 diabetes while in type 2 diabetes while
fastingfasting
Individualization Individualization
• Care must be individualizedCare must be individualized• The management plan will differ for The management plan will differ for
each specific patientseach specific patients
Things Happened During RamadanThings Happened During Ramadan
• Eating habits change in many waysEating habits change in many ways– Meal time changeMeal time change– Pattern of mealPattern of meal– Calorie intakeCalorie intake
• Increased in post prandial physical activity Increased in post prandial physical activity during the nighttimes associated with Tarawih.during the nighttimes associated with Tarawih.
• Psychological changes due to the general Psychological changes due to the general spiritual atmosphere during Ramadan, which spiritual atmosphere during Ramadan, which create a feeling of inner well-beingcreate a feeling of inner well-being
General advice for those who fastGeneral advice for those who fast
• Consult your doctor first for pre Ramadan Consult your doctor first for pre Ramadan medical assessment & educationmedical assessment & education
• Practice fasting in Shaban firstPractice fasting in Shaban first• With the approval of physician switch to With the approval of physician switch to
either long acting or twice daily medicationeither long acting or twice daily medication• Elderly patients on NSAID should have Elderly patients on NSAID should have
frequent monitoring of renal functionsfrequent monitoring of renal functions• Anticoagulant and Antiplatilate medications Anticoagulant and Antiplatilate medications
should be given at night should be given at night
Education & Counseling Education & Counseling
Educate the patients regarding– Acute complications & their
management– Blood sugar monitoring– Meal planning– Physical activity– Drug adjustment
Benefits of Education & CounselingBenefits of Education & Counselingaccording to the READ study according to the READ study
READ
What about diet & exercise?What about diet & exercise?
Diet in RamadanDiet in Ramadan
Total calorie should not be changed Divide food in to 2-3 meal: Iftar, Dinner & Suhur Limit the amount of sweet food taken at Iftar Limit the fried food Choose sugar free type drinks Drink plenty of water Use sugar free sweetener where needed Fill up on starchy food during dinner and Suhur- rice, chapati, nan, vegetables, dal, fish, meat, egg, milk, yoghurt and fruits
Exercise in RamadanExercise in Ramadan
Physical activity should be reduced during day time Exercise can be performed for an hour after Iftar or after Tarawih prayer Increased prayer during Ramadan should be taken into account
Adjustment of DrugsAdjustment of Drugs
Before Ramadan During RamadanPatients on “diet and exercise”
- No change is needed - Modify time & intensity of exercise- Ensure adequate fluid intake
Treatment RecommendationsTreatment Recommendations
Before Ramadan During RamadanSulfonylurea Once Daily: Morning dose.e.g., Gliclazide MR Glimepiride
Iftar: Full Morning Dose
Sulfonylurea Twice Daily: Morning & Evening dose.e.g., Gliclazide Glibenclamide
Iftar: Full Morning DoseSuhur: ½ Evening Dose
Treatment RecommendationsTreatment Recommendations
Majority of our type 2 diabetic patients are treatedMajority of our type 2 diabetic patients are treatedwith Sulfonylurea & Metforminwith Sulfonylurea & Metformin
Before Ramadan During RamadanMetformin 500 mg thrice daily
Iftar: 1,000 mg,Suhur: 500 mg
Treatment RecommendationsTreatment Recommendations
Before Ramadan During RamadanDPP4 inhibitor As usual at night
Glitazone As usual at night
Glinide As usual at night
Treatment RecommendationsTreatment Recommendations
Before Ramadan During RamadanPremixed insulin 30 Morning: (30 U)Dinner: (20 U)
Iftar: Full Morning Dose (30 U)Suhur: ½ Dinner Dose (10 U)
Basal Analogue At the same time 20-30% dose reduction
Split Mixed (R+N)R+0+RN+0+N
R+0+50%of RN+0+50%of N
R+R+R0+0+N
R+R+50% of R0+0+50% of N
Treatment RecommendationsTreatment Recommendations
Can a patient monitor Can a patient monitor blood sugar while fasting?blood sugar while fasting?
Monitoring Recommendations Monitoring Recommendations
Patients should monitor their blood glucose Patients should monitor their blood glucose eveneven during the fast to recognize subclinical hypo during the fast to recognize subclinical hypo andand hyperglycemia hyperglycemia
Islam allows diabetics to have regular blood Islam allows diabetics to have regular blood testtest while fasting while fasting
If blood glucose is noted to be low (<60mg/dl), If blood glucose is noted to be low (<60mg/dl), thethe fast must be broken fast must be broken
If blood glucose is noted to be (>300mg/dl), If blood glucose is noted to be (>300mg/dl), ketonesketones in urine should be checked & medical advice in urine should be checked & medical advice soughtsought
Ramadan AwarenessRamadan AwarenessActivities in BangladeshActivities in Bangladesh
Awareness: SymposiumAwareness: Symposium
DHAKA 2006DHAKA 2006 SYLHET SYLHET 20072007
KHULNA KHULNA 20082008
COMILLA 2009COMILLA 2009
Awareness: SymposiumAwareness: Symposium
BARISAL BARISAL 20102010
TONGI & GAZIPUR 2011TONGI & GAZIPUR 2011
Kushtia 2012Kushtia 2012Jessore Jessore 20122012
Awareness: SymposiumAwareness: Symposium
Narayangonj Narayangonj 20132013
Savar: Enam Medical Savar: Enam Medical 20132013
Hotel Ruposhi Bangla, Dhaka 2013Hotel Ruposhi Bangla, Dhaka 2013
Awareness Poster: Expert opinion on Blood Awareness Poster: Expert opinion on Blood sugar monitoring while fasting in Ramadansugar monitoring while fasting in Ramadan
Awareness: Physician’s GuidelineAwareness: Physician’s Guideline
Awareness: Print MediaAwareness: Print Media
Awareness: Press ConferenceAwareness: Press Conference
Inauguration of “Ramadan & Diabetes” Inauguration of “Ramadan & Diabetes” bookbook
Review ArticlesReview Articles
ConclusionConclusion
Majority of uncomplicated type 2 diabetic patients can fast during Ramadan safely
Pre-Ramadan medical assessment, education and motivation are very important to prevent diabetic related complications
Islam allows diabetics to have regular blood test while fasting
Fasting along with regular prayer have been proved to aid in better control of diabetes
Individualization and frequent monitoring of glycemia can significantly reduced the major risks associated with fasting
Thank YouThank You