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PPPP18363/05/2016(033935)

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The Diabetes Issue
The Official Publication of Prince Court Medical Centre

Malaysia Diabetes Profile 2016

ARTICLES

Diabetes in Pregnancy
By Dr Shilpa Nambiar
Tips for Diabetics During Ramadan
By Datin Farah DiBa Khan
Management of Diabetes in Ramadhan
By Dr Norshinah Kamarudin

RECIPES

Healthy Recipes for Diabetes

SCHOOL HOLIDAYS

Safety Tips for Long Distance Travel

Health Talk

28 May 2016
Free Glucose
Check

9 - 28 May 2016
Exhibition

23 - 28 May 2016
Special Health
Packages
for the month of May

Malaysia Diabetes Profile 2016

Mortality

Prevalence of diabetes and related risk factors

Number of deaths attributable
to high blood glucose

Number of diabetes deaths

Age 30-69

1170

1210

Age 30-69

3970

2520

Age 70+

1070

1260

Age 70+

3580

3080

Proportional mortality (% of total deaths, all ages)*

Injuries

11%

Communicable,
maternal, perinatal
and nutritional
conditions

Diabetes

10.2%

Overweight

36.2%

Obesity

Physical
Inactivity

10.3%

45.6%

Availability of medicines, basic technologies and

procedures in the public health sector
Medicines in primary care facilities
Insulin....................................................................................................................
Metformin...........................................................................................................
Sulphonylurea.................................................................................................

9.5%

38.3%

15.3%

57.2%

Procedures
Retinal photocoagulation......................................................................
Renal replacement therapy by dialysis.......................................

Cardiovascular
diseases

36%

16%

Renal replacement therapy by transplantation...................

9.8%

37.3%

12.9%

51.6%

Basic technologies in primary care facilities

Blood glucose measurement.............................................................

Other NCDs

3%

Cancers

Diabetes

3%

15%

Respiratory
diseases

* The mortality
estimates for this
country have a high
degree of uncertainty
because they are not
based on any national
NCD mortality data

National response to diabetes

HbA1c test..........................................................................................................

Policies, guidelines and monitoring

Operational policy/strategy/action plan for
diabetes

No

Operational policy/strategy/action plan to

reduce overweight and obesity

Yes

Operational policy/strategy/action plan to

reduce physical inactivity

No

Evidence-based national diabetes guidelines/

protocols/standards

Available and fully

implemented

5%

Standard criteria for referral of patients from

primary care to higher level of care

Available and fully

implemented

0%

Diabetes registry

Yes

Recent national risk factor survey in which

blood glucose was measured

Yes

7%

Trends in age-standardized prevalence of diabetes

15%

% of population

Oral glucose tolerance test...................................................................

10%

14
20
12
20
10
20
08
20
06
20
04
20
02
20
00
20
98

96

19

94

19

92

19

90

19

88

19

86

19

84

19

82

19

80

19

19

Male

Female

Dilated fundus examination................................................................

Foot vibration perception by tuning fork..................................
Foot vascular status by Doppler.........................................................
Urine strips for glucose and ketone measurement...........
= not generally available

= not generally available

SOURCE: World Health Organization

Diabetes country profiles, 2016.

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Articles

Diabetes in
Pregnancy
Gestational Diabetes Mellitus (GDM)

What causes GDM?

If a woman is unable to make more insulin,
gestational diabetes occurs.
Insulin is a hormone that regulates blood
sugar and helps the body use the sugar for
important functions. During pregnancy, the
placenta makes certain hormones that are
anti-insulin. This makes insulin less effective.
The body then needs to produce more
insulin to do the same work.
How common is it in Malaysia?

Dr Shilpa Nambiar
Consultant O&G
Prince Court Medical Centre, Kuala Lumpur

t is a type of diabetes which

affects women who are pregnant
where there is too much sugar
(glucose) in the blood. The body
uses glucose for energy, and levels in
the blood are normally regulated by a
hormone called insulin.
GDM is usually diagnosed at
around 28 weeks of pregnancy and
disappears by the time of delivery.
However, some women will continue
to have diabetes after delivery and up
to 50 percent of women may develop
diabetes later in life if they have had
gestational diabetes mellitus.
If a woman is diagnosed with
gestational diabetes early in
pregnancy, it may mean that she
may have had diabetes before
becoming pregnant and this is more
dangerous as it may affect the babys
development and cause certain birth
defects. Women who have Type 1 or
Type 2 diabetes should consult their
doctors and get good control before
embarking on a pregnancy.

DID YOU
KNOW?

Nearly 15%
of Malaysian
women have
been reported
to be at risk of
diabetes

South Asian women have a genetic

predisposition to developing diabetes and
depending on the population studied,
it varies between 3-10%. Incidence in
Malaysian women have been reported to
be as high as 15% in certain areas. And the
newest recommendation since December
2015 is that all pregnant women are
screened because of how common it is.
How are women screened for GDM?
1. Women are given an oral glucose
tolerance test (OGTT) at 24-28 weeks of
pregnancy. This involves giving a blood
sample after an overnight fast.
2. She is then given a drink which contains
75g sugar and another blood sample is
taken two hours later to see if her body
is able to handle that glucose load by
producing enough insulin.
3. If she does not, the glucose levels remain
high and she will need monitoring
throughout the pregnancy.
How will GDM affect the baby?
1. When mothers have high glucose levels,
babies have high glucose levels and have
to produce more insulin to control it. One
of the side effects is fat storage causing
this baby to be big (macrosomic).
2. The baby has a higher risk of having
hypoglycaemia ( low sugar levels) after

delivery, breathing problems and

jaundice needing phototherapy. The
baby may also develop diabetes later in
life.
How does GDM affect the mother?
1. Put mothers at a higher risk of
developing other problems in pregnancy
such as high blood pressure and preeclampsia.
2. Higher risk of having a delivery by
Caesarean section or injuries during a
normal delivery.
3. Higher risk of developing postnatal
depression and diabetes in the future.
How is GDM managed?
1. Women who have GDM will be managed
by a team which includes a dietician and
specialist nurses.
2. The first step is to try diet modification
therapy and daily monitoring of blood
sugar. Healthy eating and regular
exercise can be very effective in
controlling blood sugar.
3. If this is unable to achieve good control,
there are options which include taking
tablets or injecting insulin. Mothers will
have to monitor sugar levels when fasting
and after meals every day and have more
ultrasound scans to assess how the baby
is growing.
Can GDM be prevented?
Unfortunately, if a woman has a genetic
predisposition to developing GDM, it cannot
be prevented. However, if she is overweight,
losing weight before pregnancy and doing
regular exercise may reduce its risk or make
it more manageable. A diet with reduced
carbohydrates and more proteins and
fibre can make the glucose levels more
stable as can taking small frequent meals
throughout the day.

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Articles

Tips for Diabetics

During Ramadan
Datin Farah DiBa Khan
Dietician
Prince Court Medical Centre, Kuala Lumpur

Could I fast during

Ramadan if I am a Diabetic?
Yes, you could but you must know the risk of
having high glucose levels following consuming
larger meals eaten before sahur and after
breaking fast (iftar). The risk of hyperglycemia
(high blood sugar levels) and dehydration (lack
of water) are high. Distribute energy intake from
food over two to three smaller meals during the
non-fasting interval. This may help you avoid the
spike in blood sugar.

Do I need to go on a special
diet during Ramadan?
If you are following a balanced diet as
recommended by your Dietitian, then there
is a big chance you do not need to change
the selection of foods of your diet. Eat as you
normally would do, with the only difference
being the time you eat your meals. Eat slowly
when breaking your fast. This will help you to
avoid indigestion, as well as regulating the
blood sugar. The diet should be kept simple
and include foods from all the food groups.

It is important to ensure that when breaking

fast, it remains a simple meal and not a feast!
Be cautious of consuming too much of sweet
desserts and cakes. Aim to drink plenty of water
rather than sweetened drinks or caffeinated
drinks during the non-fasting hours to keep
hydrated.
At sahur, you should eat complex starchy
carbohydrates that releases energy slowly, such
as multigrain bread, oat-base cereals, brown
rice or basmati rice or noodles or chapatti
together with lean meat, fish, chicken or lentils
or pulses, vegetables and some fruits.

Do I need to wake up for

Sahur?
Long hours without eating increases the risk of
hypoglycemia, especially if you have taken your
medication / insulin. By having a meal during
Sahur, it will help keep your glucose levels more
balanced throughout the fast. Plus you should
hydrate with water.

This health awareness message is brought to you by our dieticians. For further information, visit Lifestyle Modification
Centre at Level 2 or call 603-2160 0240 for an appointment.

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Articles

Management
of Diabetes in
Ramadhan
Dr Norshinah Kamarudin
Consultant Endocrinologist
Prince Court Medical Centre, Kuala Lumpur

For DM patients, they should

discuss with their doctor about
their level of risk of fasting.

iven the 15% prevalence of

type 2 diabetes mellitus
(T2DM) in Malaysia, all
healthcare providers
should have some basic knowledge
on how to advise patients with
diabetes mellitus (DM) at their level
of care, be it a doctor, nurse, nurse
aide, caregiver at home, or simply,
yet importantly, the patients family
members.
We are fortunate to have a simple
and user-friendly Guide book issued
jointly by Ministry of Health Malaysia
and Malaysian Endocrine & Metabolic
Society (MEMS), entitled Practical
Guide to Diabetes Management in
Ramadan. It contains many useful
tips on how to manage diabetes in
the fasting month.

Who are at risk?

For DM patients, they should discuss
with their doctor about their level of risk
of fasting.
Patients who are low-risk are well
controlled and otherwise healthy.
Patients at very high risk, are advised
to abstain from fasting. They are those:
with a history of severe diabetes
complications within three months prior
to fasting, acute illness, sustained poor
glycaemic control (HBA1c >9), pregnancy,
chronic dialysis and hypoglycaemic
unawareness.
Elderly patients living alone, and being
on insulin or sulfonylureas should also
be cautioned from fasting.

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Articles

Patients at very high risk, are

advised to abstain from fasting.
Preparation before Ramadan
Assessment should be made one to
two months before Ramadan. This
includes overall wellbeing, glucose
control, blood pressure control, lipid
control, and complications of diabetes.
Types and dose of anti-diabetes
medications, both oral agents and
insulin, may need to be adjusted.
Dose and timing of anti-hypertensives
may need to be adjusted to prevent
hypotension.

DID YOU
KNOW?
Finger pricking does not
constitute the breaking of
fast; hence self-monitoring
of blood glucose should
be continued during
Ramadan.

Patients and caregivers/family should

receive education concerning self-care;
this includes features of hypoglycaemia,
hyperglycaemia, dehydration, home
blood glucose monitoring, meal plans
and food choices, medications doses
and when to stop the fast.
Self-monitoring of blood glucose
during Ramadan

if blood glucose (BG) <3.3 mmol/L

at anytime during the fast, or <3.9
in the first few hours of fasting;
if BG >16.7 mmol/L; experience
symptoms of hypoglycaemia, or
symptoms suggestive of dehydration (marked fatigue, dizziness,
confusion).
Meal Plans
The diet during Ramadan should not
differ from a healthy balanced diet.
Never skip sahur (dawn meal). Do not
delay berbuka (the breaking of fast)
or iftar, one to two dates (kurma) at
start of iftar is acceptable. Fried or
fatty foods should be limited. High
fibre carbohydrates are encouraged
at all meals.

The diet during Ramadan should not

differ from a healthy balanced diet.

Medications
Anti-hypertensive pills need not
be adjusted. However, certain
oral hypoglycaemic agents
need to be adjusted in terms of
timing. Diamicron (gliclazide)
should be adjusted from prebreakfast to iftar.
Doses of certain agents such as
DPP4-inhibitors, SGLT-2 agonist,
and biguanides, example
metformin, need not be adjusted
and rarely cause hypoglycaemia.
Insulin doses may need to
be adjusted, and reduced, in
particular the sahur doses, and
the dose regime may need to be
reversed. It is best to advise the
patient to discuss the changes
with the physician.
With reinforced education,
regular diabetes counselling,
combined with patient
empowerment, diabetes care
can lead to good long term
outcome for these individuals.

Finger pricking does not constitute the

breaking of fast; hence self-monitoring
of blood glucose should be continued
during Ramadan. Patients must
immediately break fast:

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School Holidays

Follow these tips for a

pleasant and safe journey.
Happy travelling!

Safety Tips For

Long Distance Travel

Rest Up Before
You Leave

Bring Plenty of
Food and Water

Conserve
Gas

Stop
Regularly

Keep Yourself
Entertained

a. Eat breakfast before

your road trip

a. Peanut butter & jam

sandwiches

Do not rush and

speed

Listen to radio, play

games, be alert

b. Bring snacks

b. Fresh seasonal fruits

c. Eat smaller portions &

have protein snacks

c. Nuts & seeds, popcorn,

cold unsweetened drink

Every 2-3 hours

of driving, stop to
stretch out and
walk for 5 minutes

d. Avoid caffeinated
drinks

d Ice packs, hand sanitizer,

zip lock bags

e. Hydrate with lots of

water

e. Ice box cooler

Clean Your
Windshield
Often
Service your car before
a long distance drive

Remember
Your GPS
Know where you are
going, if need be bring
a map

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Recipes

Pollo ala Cacciatore

Fruits Punch
Jelly

SERVING FOR 4

Ingredients:
500gm boneless chicken leg

10gm paprika powder

10gm fine salt
Season chicken pieces with
paprika and salt. Arrange on
baking tray and bake for 10
minutes. Arrange on casserole
pan and keep aside.

2nos ripe tomato, coarsely

diced

60gm tomato paste

Serving for 4

4nos cloves garlic,

crushed

Ingredients
180gm mango puree

1 sprig fresh rosemary

1 nos white onion, coarsely

chopped

120gm pineapple juice

1 sprig fresh thyme

90gm orange juice

40gm button mushroom,

cut into cubes

30gm black olive

30gm lemon juice

30ml cooking oil

30gm strawberry puree

Salt and pepper to taste

300ml water

1 stick fresh celery, peeled

and coarsely diced

40gm carrots, coarsely

diced

3gm agar-agar strip

9gm gelatin powder

Methods:
1. Heat up a small braising pan.
2. Saut vegetable for a while and then add in tomato paste and continue cooking for 5 minutes.
3. Add in tomatoes and fresh herbs.
4. Let it simmer for 10 minutes and season with salt and pepper.
5. Pour gravy over the chicken in the casserole pan, place lid and continue baking for 20 minutes.

Methods
1. Stir and combine all the juices in one
bowl.
2. Soak gelatine with 30gm of water and
set aside.
3. Bring to boil the agar-agar and
remaining water until completely
dissolved.
4. Add in juice mixture.
5. Add in soaked gelatine and stir
gradually.
6. Remove from the heat and strain.
7. Pour the mixture into individual bowl.
8. Chill in fridge until set.
9. Ready to serve.

Indian Lentil Salad

Serving for 4
Ingredients:
200gm cooked yellow lentil

10gm spring onion, coarsely sliced

40gm red onion, coarsely diced
40gm plum tomato, coarsely diced
40gm red pepper, coarsely diced
40gm green pepper, coarsely diced
8gm mint leaf, coarsely chopped
10gm garam masala
Juice from 1 lemon

40ml olive oil

Salt and pepper to taste
Methods:
1. Mix lentil, red onions, bell pepper, tomatoes, and spring
onion together in a large bowl
2. Add lemon juice, garam masala, olive oil, salt and
pepper to taste; stir.
3. Cover bowl with plastic wrap and refrigerate for 1 hour.

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