PRACTICAL MANAGEMENT OFPRACTICAL MANAGEMENT OFDIABETES DURING HOLY HAJJDIABETES DURING HOLY HAJJ

Prof. M. FariduddinProf. M. FariduddinFounder Chairman & Course CoordinatorFounder Chairman & Course Coordinator

Department of Endocrinology Department of Endocrinology Bangabandhu Sheikh Mujib Medical UniversityBangabandhu Sheikh Mujib Medical University

Dhaka, BangladeshDhaka, BangladeshEmail: dr.md.fariduddin@gmail.comEmail: dr.md.fariduddin@gmail.com

Diabetes & HajjDiabetes & Hajj

Holy Hajj is one of the five pillars of IslamHoly Hajj is one of the five pillars of Islam Good physical and mental health is the most important Good physical and mental health is the most important prerequisiteprerequisite More than two million Muslims perform Hajj each year; among More than two million Muslims perform Hajj each year; among them 20-30% are diabeticthem 20-30% are diabetic Hajj is a real challenge for diabetic patients & their attendantsHajj is a real challenge for diabetic patients & their attendants However by good planning & pre travel education and However by good planning & pre travel education and consultation with medical teams & muallem Hajj can be performed consultation with medical teams & muallem Hajj can be performed safely without major health consequencessafely without major health consequences

Health hazards during HajjHealth hazards during Hajj

People with diabetes may face difficulties as they travel through People with diabetes may face difficulties as they travel through places where geography, weather, diet, habits & language are places where geography, weather, diet, habits & language are different.different. Specific risks during Hajj includes inter-current illnesses i.e upper Specific risks during Hajj includes inter-current illnesses i.e upper respiratory tract infections, urinary tract infections, dysentery & respiratory tract infections, urinary tract infections, dysentery & diarrhea, heat stroke, dehydration , generalized body ache & diarrhea, heat stroke, dehydration , generalized body ache & fluctuating blood sugar levels. fluctuating blood sugar levels. So not only acquiring conception about those common problems but So not only acquiring conception about those common problems but also having the preliminary knowledge of management by consulting also having the preliminary knowledge of management by consulting with concerned physician prior travel for holy Hajj is the basis to with concerned physician prior travel for holy Hajj is the basis to overcome such unpleasant circumstances.overcome such unpleasant circumstances.

Preparation Before TravelPreparation Before Travel

Better to start preparation for Hajj prior to Ramadan by consulting Better to start preparation for Hajj prior to Ramadan by consulting with concerned physician as well as caravan manager (Muallem)with concerned physician as well as caravan manager (Muallem) Practice walking for at least half an hour a day.Practice walking for at least half an hour a day. Complete your recommended vaccinations.Complete your recommended vaccinations. Try to have a good control of diabetes & high blood pressure.Try to have a good control of diabetes & high blood pressure. Seek for other medical management if needed.Seek for other medical management if needed. Do an X-ray Chest & ECG consulting your doctors.Do an X-ray Chest & ECG consulting your doctors. It is obligatory to learn practical management of diabetes including It is obligatory to learn practical management of diabetes including hypoglycemia , sick day management & blood pressure control in hypoglycemia , sick day management & blood pressure control in different adverse situations by consulting with physicians prior to different adverse situations by consulting with physicians prior to travel.travel.

Preparation Before Travel… cont.Preparation Before Travel… cont.

Pack your general & emergency medications, insulin, syringe, Pack your general & emergency medications, insulin, syringe, glucometer, cotton, dipstick etc. in separate plastic container or glucometer, cotton, dipstick etc. in separate plastic container or in your hand luggage. in your hand luggage. Carry on your physicians’ prescription always with you and a Carry on your physicians’ prescription always with you and a keep a duplicate copy in luggage. keep a duplicate copy in luggage. You can keep your insulin in water for better storage in hot You can keep your insulin in water for better storage in hot weather where facilities not available (i.e freezing) or can take weather where facilities not available (i.e freezing) or can take suggestions from provider company. suggestions from provider company. Monitor blood sugar regularly by glucometer. Monitor blood sugar regularly by glucometer.

Diabetes care during HajjDiabetes care during Hajj

Always carry some carbohydrates (i.e glucose, sugar, biscuit, dates Always carry some carbohydrates (i.e glucose, sugar, biscuit, dates etc.)etc.) As hypoglycemia is a medical emergency, it is obligatory to explain As hypoglycemia is a medical emergency, it is obligatory to explain its’ proper management to the caravan manager as well as to the its’ proper management to the caravan manager as well as to the teammates in the very beginningteammates in the very beginning Drink plenty of normal Jamjam water dailyDrink plenty of normal Jamjam water daily If use insulin, before Ehram one can check blood glucose by If use insulin, before Ehram one can check blood glucose by glucometer & urine ketone by dipstick.glucometer & urine ketone by dipstick. If needed, use a small dose of insulin to cover hyperglycemia and or If needed, use a small dose of insulin to cover hyperglycemia and or some bread for hypoglycemia by measuring sugar with dipstick.some bread for hypoglycemia by measuring sugar with dipstick. Insulin can be stored in special cool wallets. Kept away insulin & Insulin can be stored in special cool wallets. Kept away insulin & blood glucose test strips from direct sunlight.blood glucose test strips from direct sunlight.

Diabetes care during Hajj… cont.Diabetes care during Hajj… cont. Better to consume some extra carbohydrates before Tawaf Better to consume some extra carbohydrates before Tawaf (Circumambulation around Ka’abah), saaye (walking between Safa (Circumambulation around Ka’abah), saaye (walking between Safa and Marwah) and whenever long walking & more activities are and Marwah) and whenever long walking & more activities are needed.needed. It is recommended to decrease dose of insulin about 25% and same It is recommended to decrease dose of insulin about 25% and same can also be applied to sulfonylurea drugs before and during those can also be applied to sulfonylurea drugs before and during those days of long walking.days of long walking. Try to protect your feet from damage by ground tiles or other Try to protect your feet from damage by ground tiles or other pilgrims during walking or from being stamped on while circling the pilgrims during walking or from being stamped on while circling the Ka’abah barefoot.Ka’abah barefoot. Consult Hajj medical team promptly in case of fever, diarrhoea, Consult Hajj medical team promptly in case of fever, diarrhoea, vomiting or any acute medical conditions.vomiting or any acute medical conditions.

Sick day management of DMSick day management of DM

Insulin or diabetes medication should be continued.Insulin or diabetes medication should be continued. Blood glucose level should be monitored by glucometer Blood glucose level should be monitored by glucometer more frequently (both fasting & after meal) and medications more frequently (both fasting & after meal) and medications should be adjusted accordingly.should be adjusted accordingly. With type 1 diabetes if blood glucose level more than 15 With type 1 diabetes if blood glucose level more than 15 mmol/L blood or urine should be tested for ketones.mmol/L blood or urine should be tested for ketones. If being sick, take carbohydrate containing drinks such as If being sick, take carbohydrate containing drinks such as milk & other milky drinks, fruit juice or sugary drinks.milk & other milky drinks, fruit juice or sugary drinks.

Sick day management of DM… cont.Sick day management of DM… cont.

If able to eat but no appetite, eat little & often, taking If able to eat but no appetite, eat little & often, taking carbohydrate containing drinks, as above, and snacks such as carbohydrate containing drinks, as above, and snacks such as toast, biscuits & cerealtoast, biscuits & cereal Must contact with health care team if any of the followings Must contact with health care team if any of the followings

i. Blood glucose levels are continuously highi. Blood glucose levels are continuously high

ii. Ketones present in blood or urineii. Ketones present in blood or urine

iii. No improvement of vomiting or diarrhoeaiii. No improvement of vomiting or diarrhoea

iv. If unsure what to doiv. If unsure what to do

HypoglycemiaHypoglycemia

What is meant by hypoglycemiaWhat is meant by hypoglycemia::

When blood glucose level <3.5 mmol/L, it is termed as hypoglycemia. When blood glucose level <3.5 mmol/L, it is termed as hypoglycemia.

It is a medical emergency.It is a medical emergency.

Why diabetic people are more prone to hypoglycemia during HajjWhy diabetic people are more prone to hypoglycemia during Hajj::

Hajj is demanding in terms of physical activities & mental effort. Hajj is demanding in terms of physical activities & mental effort.

Insulin dose which shows effective & adequate during sedentary life at Insulin dose which shows effective & adequate during sedentary life at home proves excessive during Hajj due to imbalance of dietary home proves excessive during Hajj due to imbalance of dietary adjustment and strenuous exercise during the different formalities of Hajj. adjustment and strenuous exercise during the different formalities of Hajj.

Similarly performing prayers in the holy shrines, distance of residence Similarly performing prayers in the holy shrines, distance of residence etc. may delay meal times which may contribute to hypoglycemia etc. may delay meal times which may contribute to hypoglycemia particularly in patients who are on insulin or sulphonylurea like drugs.particularly in patients who are on insulin or sulphonylurea like drugs.

Hypoglycemia… cont.Hypoglycemia… cont.

How to recognize hypoglycemiaHow to recognize hypoglycemia: : Common manifestations of hypoglycemia are sweating, Common manifestations of hypoglycemia are sweating, hunger, confusion, drowsiness, inability to concentrate, hunger, confusion, drowsiness, inability to concentrate, irritability, nausea, headache, tiredness etc.irritability, nausea, headache, tiredness etc.How to prevent hypoglycemiaHow to prevent hypoglycemia: : All well controlled diabetic patients should reduce the oral All well controlled diabetic patients should reduce the oral dose of oral hypoglycemic agent or insulin as they are likely to dose of oral hypoglycemic agent or insulin as they are likely to be exercising the equivalent of two hours or more every day. be exercising the equivalent of two hours or more every day. Insistence on regular meals & taking mid morning snacks is Insistence on regular meals & taking mid morning snacks is also important. People on twice daily mixture insulin may need also important. People on twice daily mixture insulin may need to consider changing to basal bolus regime to allow flexibility.to consider changing to basal bolus regime to allow flexibility.

Hypoglycemia… cont.Hypoglycemia… cont.

How to manage hypoglycemiaHow to manage hypoglycemia:: All diabetic people along with their mates & Muallem should know All diabetic people along with their mates & Muallem should know how to manage hypoglycemia promptly as mentioned earlier it is a how to manage hypoglycemia promptly as mentioned earlier it is a medical emergency.medical emergency. In such case, if able to swallow, oral carbohydrate i.e glucose, In such case, if able to swallow, oral carbohydrate i.e glucose, biscuits, honey, Jamjam water etc. should be given on urgent basis.biscuits, honey, Jamjam water etc. should be given on urgent basis. If unable to swallow, patient should be taken to the nearest If unable to swallow, patient should be taken to the nearest health care team.health care team.

Thank You AllThank You All