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 Ramadan

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  • During Ramadan, eating habits change in many ways, not only do mealtimes change, but patterns of meals, the short of food eaten and caloric intake all change in a stereotyped way.
    There is an increase in post prandial physical activity during the nighttimes associated with observation of religious practices (Tarawih).
    Psychological changes due to the general spiritual atmosphere during Ramadan, which create a feeling of inner well-being, are also important.
  • Practical Management of Type 2 Diabetes during the Holy month of Ramadan

    1. 1. Practical Management of Type 2 DiabetesPractical Management of Type 2 Diabetes During the Holy Month of RamadanDuring the Holy Month of Ramadan Prof. Md. Farid Uddin Founder Chairman & Course-Coordinator Department of Endocrinology Bangabandhu Sheikh Mujib Medical University Dhaka, Bangladesh Email: dr.md.fariduddin@gmail.com Web: www.endobsmmu.com
    2. 2. 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
    3. 3. Frequently asked questions during RamadanFrequently asked questions during Ramadan  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?
    4. 4. Can a diabetic patient fastCan a diabetic patient fast during Ramadan?during Ramadan?
    5. 5. IslamiCity.com- Ramadan Fasting and DiabetesIslamiCity.com- Ramadan Fasting and Diabetes MellitusMellitus The bulk of literature indicates thatThe bulk of literature indicates that fasting in Ramadan is safe for thefasting in Ramadan is safe for the majority of diabetic patients, but…majority of diabetic patients, but…
    6. 6. Patient needs-Patient needs- 1.1. Pre-Ramadan assessmentPre-Ramadan assessment 2.2. Proper educationProper education 3.3. ManagementManagement
    7. 7. Physician’s Role?Physician’s Role?
    8. 8. Guidance and advice to allowGuidance and advice to allow diabetic patients to fast as safely asdiabetic patients to fast as safely as possiblepossible
    9. 9. Pre-Ramadan AssessmentPre-Ramadan Assessment 1.1. Assessment of glycemic statusAssessment of glycemic status 2.2. Assessment of complications &Assessment of complications & co-morbid conditionsco-morbid conditions 3.3. Assessment of patient’s abilityAssessment of patient’s ability
    10. 10. 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 following are 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
    11. 11. 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 following are advised not to fastare advised not to fast
    12. 12. Benefits associated with fastingBenefits associated with fasting
    13. 13. 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
    14. 14. General BenefitsGeneral Benefits
    15. 15. 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.
    16. 16. 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)”
    17. 17. What are the risksWhat are the risks associated with fasting?associated with fasting?
    18. 18. Major risks associated with fastingMajor risks associated with fasting in patients with diabetesin patients with diabetes  Hypoglycemia  Hyperglycemia  Dehydration  Weight changes DIABETES CARE, VOLUME 28, NUMBER 9 SEPTEMBER 2005
    19. 19. Special precautions are recommendedSpecial precautions are recommended to 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
    20. 20. Management of hyperglycemiaManagement of hyperglycemia in type 2 diabetes while fastingin type 2 diabetes while fasting
    21. 21. IndividualizationIndividualization • Care must be individualizedCare must be individualized • The management plan will differ for eachThe management plan will differ for each specific patientsspecific patients
    22. 22. 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 duringIncreased in post prandial physical activity during the nighttimes associated with Tarawih.the nighttimes associated with Tarawih. • Psychological changes due to the generalPsychological changes due to the general spiritual atmosphere during Ramadan, whichspiritual atmosphere during Ramadan, which create a feeling of inner well-beingcreate a feeling of inner well-being
    23. 23. General advice for those who fastGeneral advice for those who fast • Consult your doctor first for pre RamadanConsult 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 eitherWith the approval of physician switch to either long acting or twice daily medicationlong acting or twice daily medication • Elderly patients on NSAID should have frequentElderly patients on NSAID should have frequent monitoring of renal functionsmonitoring of renal functions • Anticoagulant and Antiplatilate medicationsAnticoagulant and Antiplatilate medications should be given at nightshould be given at night
    24. 24. Education & CounselingEducation & Counseling Educate the patients regarding – Acute complications & their management – Blood sugar monitoring – Meal planning – Physical activity – Drug adjustment
    25. 25. Benefits of Education & CounselingBenefits of Education & Counseling according to the READ studyaccording to the READ study
    26. 26. READ
    27. 27. What about diet & exercise?What about diet & exercise?
    28. 28. 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
    29. 29. 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
    30. 30. Adjustment of DrugsAdjustment of Drugs
    31. 31. Before Ramadan During Ramadan Patients on “diet and exercise” - No change is needed - Modify time & intensity of exercise - Ensure adequate fluid intake Treatment RecommendationsTreatment Recommendations
    32. 32. Before Ramadan During Ramadan Sulfonylurea Once Daily: Morning dose. e.g., Gliclazide MR/60 Glimepiride Iftar: Full Morning Dose Sulfonylurea Twice Daily: Morning & Evening dose. e.g., Gliclazide Glibenclamide Iftar: Full Morning Dose Suhur: ½ Evening Dose Treatment RecommendationsTreatment Recommendations Majority of our type 2 diabetic patients are treatedMajority of our type 2 diabetic patients are treated with Sulfonylurea & Metforminwith Sulfonylurea & Metformin
    33. 33. Before Ramadan During Ramadan Metformin 500 mg thrice daily Iftar: 1,000 mg, Suhur: 500 mg Treatment RecommendationsTreatment Recommendations
    34. 34. Before Ramadan During Ramadan DPP4 inhibitor As usual at night Glitazone As usual at night Glinide As usual at night Treatment RecommendationsTreatment Recommendations
    35. 35. Before Ramadan During Ramadan Premixed 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+R N+0+N R+0+50%of R N+0+50%of N R+R+R 0+0+N R+R+50% of R 0+0+50% of N Treatment RecommendationsTreatment Recommendations
    36. 36. Can a patient monitorCan a patient monitor blood sugar while fasting?blood sugar while fasting?
    37. 37. Monitoring RecommendationsMonitoring Recommendations  Patients should monitor their blood glucose evenPatients should monitor their blood glucose even during the fast to recognize subclinical hypo andduring the fast to recognize subclinical hypo and hyperglycemiahyperglycemia  Islam allows diabetics to have regular blood testIslam allows diabetics to have regular blood test while fastingwhile fasting  If blood glucose is noted to be low (<60mg/dl), theIf blood glucose is noted to be low (<60mg/dl), the fast must be brokenfast 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 advicein urine should be checked & medical advice soughtsought
    38. 38. Ramadan AwarenessRamadan Awareness Activities in BangladeshActivities in Bangladesh
    39. 39. Awareness: SymposiumAwareness: Symposium DHAKA 2006DHAKA 2006 SYLHET 2007SYLHET 2007 KHULNA 2008KHULNA 2008 COMILLACOMILLA
    40. 40. Awareness: SymposiumAwareness: Symposium BARISAL 2010BARISAL 2010 TONGI & GAZIPUR 2011TONGI & GAZIPUR 2011 KUSHTIA 2012KUSHTIA 2012JESSORE 2012JESSORE 2012
    41. 41. Awareness: SymposiumAwareness: Symposium NARAYANGONJ 2013NARAYANGONJ 2013 SAVAR: Enam Medical 2013SAVAR: Enam Medical 2013 Hotel Ruposhi Bangla, DHAKAHotel Ruposhi Bangla, DHAKA
    42. 42. Awareness Poster: Expert opinion on BloodAwareness Poster: Expert opinion on Blood sugar monitoring while fasting in Ramadansugar monitoring while fasting in Ramadan
    43. 43. Awareness: Physician’s GuidelineAwareness: Physician’s Guideline
    44. 44. Awareness: Print MediaAwareness: Print Media
    45. 45. Awareness: Press ConferenceAwareness: Press Conference Inauguration of “Ramadan & Diabetes” bookInauguration of “Ramadan & Diabetes” book
    46. 46. Review ArticlesReview Articles
    47. 47. 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
    48. 48. Thank YouThank You

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