Definition of Diabetes Mellitus

Diabetes Mellitus is increasing every year and has become a global health threat. Type 2 Diabetes Mellitus accounts for 90% of all diabetes cases and is one of the most prevalent diseases worldwide. According to the International Diabetes Federation (IDF) (2019), approximately half a billion people suffer from diabetes. Based on World Health Organization (WHO) data, it is estimated that there are 2.2 million deaths due to diabetes mellitus.

Diabetes Mellitus has a very dangerous impact as it can lead to complications. To achieve optimal management of Diabetes Mellitus, regularity is necessary. One of the most important things for diabetes mellitus patients is controlling blood sugar levels, so it is essential to understand the factors that affect blood sugar control. Blood sugar control in these patients is related to diet or meal planning because nutrition is connected to the disease (Perkeni, 2015).

Diabetes Mellitus cannot be cured, but with control through Diabetes Mellitus dietary management, complications can be prevented. Dietary compliance is one of the key factors in the management of Diabetes Mellitus. This is because meal planning is one of the four main pillars in the management of Diabetes Mellitus (Perkeni, 2015). The main challenge in managing the diet for Diabetes Mellitus patients is patient compliance (Fauzia, et al., 2017).

The key to the Diabetes Mellitus diet is the "3J," which stands for the amount of calories, the type of food, and the meal schedule. In the dietary management of Diabetes Mellitus patients, meal timing should take into account the patient's preferences for specific foods, their lifestyle, meal times they usually follow, and their ethnic and cultural background (Smeltzer, 2012). Zanti (2017) explained that the majority (53.1%) of Diabetes Mellitus patients do not comply with the Diabetes Mellitus diet standards based on the 3J (amount, type, and schedule). Non-compliance of Diabetes Mellitus patients with the diet can have negative health consequences if the food consumed by the patient is not controlled (Fauzia, et al., 2017).

Diabetes Mellitus is a syndrome caused by a disruption of insulin in the body, leading to hyperglycemia accompanied by abnormalities in carbohydrate, fat, and protein metabolism (Donelly, 2015). Diabetes Mellitus is a heterogeneous group of disorders characterized by an increase in blood glucose levels or hyperglycemia (Smeltzer, 2013). Diabetes Mellitus is a health disorder characterized by a collection of symptoms resulting from an increase in blood glucose (glucose) levels due to insulin deficiency or resistance (Bustan, 2015).

The absence of glucose entering cells results in cells having insufficient energy for cellular metabolism. This is then interpreted by the body's cells as a glucose deficiency condition, so the body responds with various mechanisms aimed at raising blood glucose levels. The first response is that patients often feel hungry in response to the low intake of glucose by the cells. Another response is an increase in the body's glucose production through the mechanisms of lipolysis and gluconeogenesis. Fats and proteins in tissues will be broken down into glucose. If this happens for an extended period, the body will experience a decrease in protein levels in tissues. Additionally, the breakdown of lipids will produce by-products in the form of ketones, which are acidic. This condition can lead to ketosis and ketoacidosis, which can be life-threatening. The decreased production of insulin in Diabetes Mellitus patients can result in metabolic disturbances, including reduced glucose transport into cells, increased muscle protein catabolism, and lipolysis (Sudoyo, 2009).

Genetics play a role in Type 2 Diabetes. However, there is a significant amount of evidence to show that dietary and lifestyle changes can reduce the risk of developing diabetes even if both parents have diabetes. A person is considered to have diabetes when laboratory blood chemistry tests show a fasting glucose concentration (FPG) in the morning of >126 mg/dL or a random blood glucose concentration (RBG) of >200 mg/dL.

Optimal Diet

Dietary management means designing food in such a way that the quantity matches the need, ensuring that the available insulin is sufficient. In addition, the nutritional composition should be healthy and balanced (Kariadi, 2009). The general goals of dietary management for Diabetes Mellitus patients include achieving and maintaining blood glucose and lipid levels close to normal, achieving and maintaining body weight within normal limits ± 10% of the desired weight, preventing acute or chronic complications, and improving quality of life (Suyono, 2009). The principles of the Diabetes diet are as follows:

1. Balanced menu (various types)

A balanced menu is diverse and the same for everyone.

Types of food: low glycemic index foods, substitutes for food

2. Meal division (schedule)

Meal division: breakfast, lunch, afternoon/evening

Snacks are provided between meal times

3. Quantity (calories)

The calorie value or the amount of food to be consumed is adjusted to individual needs. It is calculated based on interview data such as body weight, height, eating habits, daily activities, and gender.

Recommended types of foods for Diabetes Mellitus patients, Food Sources: Complex Carbohydrates such as rice, bread, noodles, potatoes, cassava, and sago. Low-fat protein sources such as fish, skinless chicken, skim milk, tofu, tempeh, and legumes. Fats (in limited quantities) should be processed by baking, steaming, boiling, and grilling (Almatsier, 2013).

Prevention of Diabetes Mellitus

a. Regular exercise

Physical exercise is one of the pillars in the management of T2DM if there is no nephropathy. Daily physical activity and exercise are carried out regularly, 3-5 times a week for about 30-45 minutes, with a total of 150 minutes per week. The interval between exercises should not be more than 2 consecutive days. It is recommended to check blood glucose levels before physical exercise. If blood glucose levels are 250 mg/dL, it is advisable to postpone physical exercise.

b. Maintaining ideal body weight

One of the factors contributing to the occurrence of diabetes mellitus is overweight. This means that the risk of diabetes mellitus can be reduced by maintaining a normal weight range.

c. Adopting a healthy eating pattern

The National Weight Control Registry (NWCR) explains that a beneficial eating pattern for weight loss involves eating frequently in small portions (five meals a day). Additionally, individuals need to prepare their own meals (cook and prepare food themselves), reduce fat intake to an average of 24% of total food intake, consume 55% of calories in the form of carbohydrates, and consume less than 1500 calories per day.

d. Regular blood glucose monitoring

e. Managing stress

f. Drinking water regularly according to the recommended amount

Fasting in Ramadan for Diabetes Mellitus Patients

For diabetes mellitus patients, fasting during Ramadan can affect blood glucose control due to changes in meal patterns, meal schedules, and physical activity. Diabetes patients often want to fast, even though it may not be medically advisable. Once again, the role of the doctor is not to issue a fatwa (religious ruling) on whether a patient can fast or not. The doctor's role is to provide insights and guidance on the

 impact of fasting on the patient's medical condition and how to reduce the risk of complications (Firmansyah, 2016).

Medical considerations related to the risks and comprehensive management of DM should be communicated by the doctor to DM patients and/or their families through educational activities. Fasting for an extended period increases the risk of acute complications such as hypoglycemia, hyperglycemia, diabetic ketoacidosis, and dehydration or thrombosis. These risks are particularly present in diabetes mellitus patients with moderate to very high risk (PERKENI, 2015).

In such situations during Ramadan fasting, diabetes patients can still fast without any changes to their diabetes condition, except for shifting meal schedules. From morning, noon, afternoon/evening to the time of breaking the fast and pre-dawn meal (sahur). Caloric values are still adjusted to individual needs, divided into a 3-meal, 3-snack pattern. Meal times are adjusted according to the schedule of oral medication or insulin injections. Here is an example of a meal pattern before and during fasting:

Before Fasting:

1. Breakfast

2. Morning Snack

3. Lunch

4. Afternoon Snack

5. Dinner

6. Evening Snack

During Fasting:

1. Pre-Dawn Meal (Sahur)

At 3:00 AM: Drink water, eat fruits

At 3:45 AM: Main meal

At 4:15 AM: Morning snack

2. Breaking the Fast (Iftar)

At 6:00 PM: Drink water + 5 to 7 dates/1 to 2 cookies + water

At 6:15 PM: After the Maghrib prayer, have the main meal + fruits + water

At 8:30 PM: After the Isha/Taraweeh prayer, have diabetes milk + 100 grams of fruit + drink water

For someone with a history of diabetes, fasting can be a significant challenge because they are typically advised to eat regularly. However, if done correctly, fasting can provide benefits to people with diabetes. Diabetes, also known as "sugar disease," is a chronic illness characterized by an increase in blood sugar levels within the body, disrupting the metabolic system. People with diabetes can fast as long as they consult with a doctor beforehand.

Author: Hera Ganefi TD, DCN, MARS
References:

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