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Diabetics getting younger

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A nurse attending to a diabetic patient at the Sungai Buloh Hospital.

 

PETALING JAYA: The number of diabetics is continuing to rise and the more worrying statistic is that the disease is claiming more younger Malaysians as among its victims.

The most recent National Health and Morbidity Survey (NHMS) shows that almost double those in the 30 to 39 age group were afflicted with the disease compared to five years earlier in 2006.

With one-in-five adult Malaysians over 30 already a diabetic, Health Minister Datuk Seri Dr S. Subra­maniam said this situation could impact the economy and lower quality of life, particularly when complications of the disease set in.

“The fact that it is affecting younger people, which in turn has an effect on productivity as well as the economy, is very worrying. It also leads to a lower quality of life,” he said.

Some 2.6 million adult Malaysians aged 18 and above are diabetics and this figure is projected to hit 4.5 million by 2020, according to the 2011 NHMS.

The survey also shows an increasing number of diabetic patients across all age groups – almost doubling from 4.9% (in the 2006 survey) to 9.4% for those aged between 30 and 34 years, and from 6.4% to 10.9% for those between 35 and 39.

For those in the 40 to 44 age group, the increase is from 10.3% to 17.6%; and those between 45 and 49 – from 15% to 20.6%.

“Besides genetic predisposition, diabetes is a lifestyle disease brought on by unhealthy eating habits. We have also had a change in the nature of our jobs from one that was labour-intensive to a sedentary one where there is little physical activity,” said Dr Subramaniam.

He also said there were an estimated 53% of Malaysians who were still undiagnosed.

“What this means is that patients are likely to seek treatment late and it will be costly to treat diabetes-related complications when they seek treatment,” he said.

Dr Subramaniam said the rising number of diabetics and late diagnosis continued to strain the public healthcare system.

He cited a 2010 study which estimated the cost of treatment for diabetes to account for 16% of the national healthcare budget or RM2.4bil.

“This is a substantial amount,” he said.

He said the impact was already being seen with an increasing number of diabetic patients at public health clinics and rising number of hospital admissions due to diabetic complications.

“This has cost implications to the Malaysian Government in continuing to provide quality care to its population. It will also affect productivity and ultimately negatively impact our economic development,” he said.

 

via Diabetics getting younger – Nation | The Star Online.

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8 in 10 overweight diabetics say condition under control despite high blood sugar levels

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File photo: A nurse checks readings on a glucometer after taking a blood sample. AFP/Noah Seelam

 

A new survey on some 400 overweight diabetics in Singapore shows that more than eight in 10 say their condition is under control, but many had blood sugar readings that were above the optimal range.

SINGAPORE: A new survey on some 400 overweight diabetics in Singapore shows that more than eight in 10 say their condition is under control, but many had blood sugar readings that were above the optimal range.

The survey was conducted by healthcare company Abbott.

And it also found that nearly one in five did not know their blood sugar level taken at their last medical check-up.

Poor management of diabetes can lead to complications such as kidney failure, coronary heart disease and stroke.

The survey aims to help doctors better identify the problems faced by overweight diabetic patients.

Dr Kevin Tan, vice-president of Diabetic Society of Singapore, said: “Those who are overweight, face — in the management of their condition — meal planning, food choices, diet control and weight management. So it helps us to understand our patients better.”

– CNA/nd

via 8 in 10 overweight diabetics say condition under control despite high blood sugar levels – Channel NewsAsia.

Diabetics’ access to blood glucose test strips ‘restricted’

Blood glucose testing strips are vital for diabetics

 

Access to blood glucose test strips vital to help diabetics manage their condition is being restricted against government guidance, a charity says.

Of about 2,200 people who answered a question about the strips as part of a survey forDiabetes UK, 39% had had prescriptions refused or restricted.

It says restrictions are being imposed by local health managers to save money.

But a spokesman representing Clinical Commissioning Groups said the strips had been over-prescribed in the past.

It comes after Health Minister Anna Soubry told MPs the restriction of access to the testing strips was “unacceptable”.

Following this, the Department of Health wrote to all GPs in England telling them that prescriptions for the testing strips should be on the basis of clinical need and not restricted.

However, Diabetes UK says its survey found a quarter of those whose prescriptions had been restricted had been told by their GP that this was because of restrictions put in place by their local Clinical Commissioning Group (CCG).

It says there is widespread variation in different parts of the country of guidance on prescribing test strips, with some patients allowed only two testing strips per week.

Long-term complications

This is despite the fact people with type-1 diabetes need to test their blood every time they eat, plus more often if they exercise and every time they drive – typically at least four times a day, the charity says.

A box of 50 test strips retails at about £25, but the cost to the NHS is lower, depending on the deal agreed by each area’s CCG – who manage healthcare services and commission care locally – with the manufacturers.

Diabetes UK is calling on health leaders to remove restrictions, so prescriptions can be made according to patients’ clinical needs.

It says rationing them could be putting people’s lives at risk, as well as storing up long-term costs for the NHS because of the “extremely expensive” cost of treating diabetics who develop complications.

The charity says all people with type-1 diabetes and those with type-2 diabetes who are on glucose-lowering medication, including insulin, need to monitor their blood glucose levels so they can adjust their treatment accordingly.

Failure to do so can lead to short-term complications such as diabetic ketoacidosis, which is caused by untreated consistent high blood glucose levels and is potentially fatal, and hypoglycaemia, which is the result of low blood glucose levels.

‘Basic tools’

In the long term, high blood glucose levels can lead to serious complications such as blindness, strokes and the need for amputations.

Diabetes UK chief executive Barbara Young said: “Test strips are the most basic of tools for managing type-1 diabetes and insulin-treated type-2 diabetes so it is very worrying that so many people are telling us they are having their test strips rationed because of cost-saving measures.

“When people with type-1 or insulin-treated type-2 diabetes have their test strips restricted or denied it has a huge impact on their life.

“Our survey showed a lack of test strips was stopping them driving, exercising or knowing how much insulin to take when they are eating or whether they are experiencing a ‘hypo’ [hypoglycaemic episode], which needs to be treated immediately.”

She added: “Rationing test strips to save money does not make any sense, because it is putting people at increased risk of complications that are hugely expensive to treat.

“Diabetes costs the NHS around £10bn annually and 80% of this spend goes on treating complications.”

Of those who told the charity they had had their prescription restricted, 58% had type-1 diabetes and 42% had type-2 diabetes.

Dr Steve Kell, co-chair of NHS Clinical Commissioners Leadership Group, which represents CCGs, said: “Prescribing decisions should be made on the basis of clinical need and cost-effectiveness, not cost alone.

“Patients with diabetes should receive a review at least annually to ensure that they are receiving the appropriate treatment and that all prescriptions are suitable.”

He added: “There has been significant over-testing and over-prescribing of strips in the past for some patients and this is not beneficial for the patient or the NHS.”

Dr Ken Aswani, a GP in Waltham Forest, north-east London. and spokesman for the NHS Alliance, which represents primary care providers, said: “Although some people may feel their strips are being restricted, ultimately, GPs will provide blood glucose testing strips based on need, and where it is appropriate to provide them for the patient.

“So, someone with type-2 diabetes most likely won’t require frequent tests as their condition will be controlled in other ways such as through diet, whereas those with type-1 will need the strips much more often, therefore these patients’ access to strips will most likely not be restricted.”

There are about 3.8 million diabetics in the UK. Diabetes UK says about three million have been diagnosed with either type-1 or type-2, with a further 850,000 thought to have undiagnosed type-2 diabetes.

 

TYPES OF DIABETES

  • People with type-1 diabetes cannot produce insulin. No-one knows exactly what causes it, but it is not to do with being overweight and it is not currently preventable. It usually affects children or young adults, starting suddenly and getting worse quickly. Type-1 diabetes is treated by daily insulin doses, a healthy diet and regular physical activity.
  • People with type-2 diabetes do not produce enough insulin or the insulin they produce does not work properly (known as insulin resistance). They might get diabetes because of their family history, age and ethnic background. They are also more likely to get type-2 diabetes if they are overweight. Type-2 diabetes is treated with a healthy diet and increased physical activity.

via BBC News – Diabetics’ access to blood glucose test strips ‘restricted’.

Life in the fasting lane

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Beware of overeating while breaking your fast, especially after a trip to the Ramadan bazaar. Overeating can lead to a spike in blood sugar, which can lead to hyperglycaemia. – GARY CHEN / The Star

Many Muslims with medical conditions such as diabetes observe a fasting period during Ramadan despite being religiously exempted from doing so. We break down the health risks, as well as preventive measures, to ensure a safe and healthy fasting season.

MILLIONS of Muslims in Malaysia are now celebrating the holy month of Ramadan, including those with medical conditions like diabetes.

In Islam, Ramadan is considered to be the most blessed and spiritually-beneficial month of the year.

For this reason, many observe a fast from dawn to dusk throughout the month, during which they must abstain from eating, drinking and smoking, amongst other practices.

There are however, no restrictions on the amount of food or drink they can consume at night.

According to religious tenets, fasting is intended to teach a person patience, humility and self-control.

This practice is also thought to be good for health, and provides a yearly routine of spiritual cleansing for Muslims.

Many Muslims with legitimate health concerns also fast despite being religiously exempted from doing so – some even going against their doctor’s advice.

Hence, it is imperative for medical professionals, and even more so for those who are fasting, to be aware of the potential risks associated with fasting, and take steps to fast in a safe and healthy manner.

Rising numbers

Diabetes is a condition that causes a person’s blood sugar level to rise too high.

It occurs when the body does not produce enough insulin to function properly, or when the body’s cells do not react to insulin. This is known as insulin resistance.

Type 2 diabetes is the most common type of diabetes and affects up to 90% of diabetic patients around the world.

It usually affects those over the age of 40, although increasingly younger people are also being affected.

Its growing prevalence is associated with rapid cultural and social changes, and is often attributed to unhealthy lifestyle and behavioural patterns such as a poor diet coupled with physical inactivity.

 

Professor Dr Nor Azmi Kamaruddin explains that factors such as taking too much insulin or other diabetes medications, skipping a meal, or strenuous exercise can cause a dive in blood sugar in diabetic patients.

Prof Nor Azmi explains that factors such as taking too much insulin or other diabetes medications, skipping a meal, or strenuous exercise, can cause a dive in blood sugar in diabetic patients. –Filepic

In 2010, the National Health and Morbidity Survey revealed that an estimated 3.4 million Malaysians suffer from diabetes.

The survey showed an increase in diabetic cases among Malaysians aged 30 and above, from 8.3% in 1996, to 14.9% in 2006. This marks an 80% increase over a period of just 10 years.

The same survey revealed an even more dramatic increase in diabetic cases among the nation’s youth. Between 1996 and 2006, the number of diabetic cases in Malaysians aged 18 years and above rose from 4.4% to 14%, a 200% increase in just a decade.

More alarmingly, it is believed that an estimated one-third (or 36%) of the diabetic population remains undiagnosed.

Fasting is not meant to create excessive hardship on the individual, but Muslims who are diabetic may face significant challenges in managing their condition, as fasting requires abstinence from all foods, fluids, oral medications, as well as IV fluids, which may be required to keep their blood sugar level in check.

Among the problems to look out for include:

Hypoglycaemia (low blood sugar)

Low blood sugar is a well-known risk associated with daytime fasting, especially for diabetic patients. It occurs when there is too much insulin and not enough sugar (glucose) in your blood.

If left untreated, low blood sugar can lead to serious medical problems, including loss of consciousness, and convulsions or seizures that require emergency treatment.

Professor Dr Nor Azmi Kamaruddin, head of the diabetes and endocrine unit at Universiti Kebangsaan Malaysia (UKM), explains that factors such as taking too much insulin or other diabetes medications, skipping a meal, or exercising harder than usual can cause low blood sugar in diabetics.

Not eating enough during sahur, the meal consumed before dawn, can increase the risk of hypoglycaemia, he explains.

The logic behind this is simple. Most diabetic patients are required to take insulin or other diabetic medications to decrease their blood sugar levels. However, consuming less calories than what your body needs naturally will lower your sugar levels. This, compounded with the use of insulin or diabetic medications, could cause blood sugar to plummet to dangerous levels.

“Most people do not eat enough during sahur, because they are not used to eating at that hour. Hence, appetite tends to be poor,” says Prof Azmi.

“Diabetics, in particular, need to consume the same amount of food they usually consume, to maintain a healthy blood sugar level.”

He stresses that reduction of insulin or medication is not recommended because if you do not have enough insulin to cover the extra sugar in your blood, ketoacidosis can occur.

Ketoacidosis itself is a severe, life-threatening condition that requires immediate treatment. Symptoms include nausea, vomiting, abdominal pain, rapid breathing, and in some cases, unconsciousness.

Hyperglycaemia (high blood sugar)

Conversely, high blood sugar also affects people with diabetes. Contributing factors include excessive food intake, illness, and not taking enough glucose-lowering medication.

High blood sugar can become severe and result in serious complications such as diabetic coma, which requires emergency care. In the long term, persistent hyperglycaemia, even if not severe, can lead to complications affecting the eyes, kidneys, nerves and heart.

During Ramadan, most people usually consume two meals per day – one before sunrise and one after sunset.

“However, some people have the tendency to binge-eat when they break fast. That’s when the problem arises,” says Prof Azmi.

“When you starve yourself for some 14 hours, and then consume a significant amount of food, your blood sugar levels will shoot up if you’re diabetic.”

“This occurs especially when people go to bazaars hungry. They tend to overbuy, and subsequently overeat.”

Dehydration

When you have diabetes, excess glucose builds up in your blood. As a result, your kidneys have to work harder to filter and absorb the excess sugar.

If your kidneys can’t keep up, the excess sugar is excreted through your urine, along with fluids drawn from your tissues. This causes frequent urination, which may leave a diabetic dehydrated and constantly thirsty. As they drink more fluids to quench their thirst, they will urinate even more.

This is where the problem arises. Says Prof Azmi: “During Ramadan, diabetic patients tend to suffer from dehydration because they don’t drink enough water to replenish the fluids that have been lost.

“To make things worse, Malaysia is situated in the tropics. On average, we lose up to half a litre of sweat everyday due to the heat.

“Those who work outdoors could lose over a litre every day.”

 

Mobile applications such as Ramadan, Diabetes and Me (as shown in the picture) allow diabetic patients to keep track of their blood sugar levels throughout the day. .

Mobile applications such as Ramadan, Diabetes and Me (as shown in the picture) allow diabetic patients to keep track of their blood sugar levels throughout the day.

Fasting tips for diabetics

During Ramadan, your regular day-to-day dietary habits get thrown out the window. Health problems can arise from an insufficient diet or as a consequence of overeating.

To avoid this, it is essential for diabetic patients to maintain a healthy and balanced diet throughout the holy month. The aim should be to maintain a consistent body mass.

Nutrition

At the predawn meal, consuming foods rich in “complex” carbohydrates (slow-digesting foods) is advisable because of the delay in digestion and absorption, which keeps you feeling fuller for longer.

In addition, increase your fluid intake during non-fasting hours to avoid dehydration.

When breaking fast, Prof Azmi advises diabetic Muslims to start off with a glass of water, before moving on to dishes, starting from vegetables, protein, and finally to carbohydrates, to avoid overeating.

Ingesting large amounts of foods rich in carbohydrates and fats should be avoided, he says. “About 70-80% of the Asian diet consists of rice. However, the high glycaemic index (GI) in rice could cause blood sugars to spike.

“Also, try to avoid sweetened or carbonated drinks. You might also want to go for whole fruit options instead of fruit juices.

“Ingestion of fruit juices leads to a rapid absorption of glucose in the bloodstream, resulting in a sudden spike in blood sugar.

“In comparison, eating whole fruits involves processes such as chewing and digestion. This will result in a more gradual and stable increase in blood sugar.”

Frequent monitoring of sugar levels and medication

It is important for diabetic patients to monitor their blood sugar levels multiple times a day.

This is especially critical for type 2 diabetes patients who require insulin.

Mobile applications such as Ramadan, Diabetes and Me allow diabetic patients to keep track of their blood sugar levels throughout the day.

Developed by MSD, the app (which is currently only available on IOS devices) feature a blood sugar tracker that offers an easy and convenient way to monitor your daily blood sugar levels.

Meanwhile, those who are on oral medication may have to adjust the dosage or switch to short-acting medication, which can be taken along with their main meal of the day.

Similarly, patients who are on insulin will need to switch to a twice-a-day regime of short-acting insulin, with the larger dose timed before the main evening meal.

Exercise

Normal levels of physical activity may be maintained. However, Prof Azmi advises against strenuous exercise, as it may lead to a higher risk of hypoglycaemia.

“If a diabetic patient has already been exercising regularly, he should continue, but stick to mild or moderate-intensity exercises,” he says.

“I would suggest exercising just before the break of fast, rather than in the morning, so they will be able to recover from their workouts by replenishing their bodies with food.”

He also points out that diabetic patients should try to avoid sun exposure to avoid further fluid loss.

Pre-Ramadan medical assessment

Ideally, all diabetic patients who wish to fast during Ramadan should undergo a medical assessment and engage in an education programme to undertake the obligation as safely as possible.

The American Diabetes Association recommends that people with type 2 diabetes undergo a medical assessment at least two months prior to fasting.

South-east Asian guidelines for management of endocrine disorders during Ramadan advise planning for the period at least three months in advance.

During this assessment, individual patients need to understand the potential risks they may face if they decide to fast.

Specific changes in diet or medication regimens should be tailored to a patient’s needs, so they can fast on a stable and effective programme.

Such assessments should also extend to those who do not wish to fast due to the heightened risk of hypo- and hyperglycaemia.

via Life in the fasting lane – Health | The Star Online.

Diabetics, watch your eyes

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An eye check is vital. Diabetes patients experiencing vision problem should immediately contact their ophthalmologist.


Without proper management, diabetes can lead to diabetic retinopathy, a leading cause of blindness among adults, writes Dr Asokumaran Thanaraj

A TWENTY-EIGHT-YEAR-OLD woman walks into my clinic, complaining of poor vision in both eyes which she claims happened over the past few weeks. After a thorough eye examination, she was diagnosed with having advanced diabetic eye disease with a loss of vision in both eyes, almost 90 per cent.

She works as a cook at the hawker stall owned by her fiance. She has to be accompanied by him every time she comes to the clinic as she has lost her navigating vision. In medical terms, she is legally blind.

After a long explanation regarding the prognosis and risks involved, she undergoes vitrectomy surgery and endolaser in one eye to repair the damage done by the disease. Post-operation, she gains slight vision which will enable her to navigate, with the other eye remaining at high risk even for surgery.

During follow-up she has one question which I can never answer: “Doctor, when can I see again?”

WHERE DID WE GO WRONG?

Diabetic retinopathy is the leading cause of blindness and visual disability in adults.

The World Health Organisation has estimated the global prevalence of diabetes to rise from 2.8 to 4.4 per cent from the year 2000 to 2030. It is a costly disease both for the affected individuals and health sector. Diabetic retinopathy leads the complication list of diabetes with a worldwide prevalence estimated at 6.8 to 44.4 per cent.

In Malaysia, the prevalence of diabetes among those aged 30 years and above has increased from 6.3 per cent (1986) to 14.9 per cent (2006).

It is recommended that all patients with Type I diabetes be screened for diabetic retinopathy from three to five years after initial diagnosis and for Type II diabetes, the recommendation for screening is immediately at the time of diagnosis.

We can go on giving these figures for public consumption. One can surf the net and find hundreds of pages of information available on this blinding disease.

But what difference does it make for the young woman who has already lost her vision? Is everyone still unaware of these facts and figures?

There are enough seminars, screenings and talks organised by the relevant authorities to tackle this problem.

The Health Ministry has even supplied Fundus cameras to selected primary care centres in this country to help screen patients and to be referred to tertiary centres for review and appropriate treatment.

THE SYMPTOMS

The fact that this patient has been totally unaware of her problem tells us how silent this blinding disease can be. Most of the time, the damage done is so severe that a person can enter the eye clinic for the first time being legally blind without any prior knowledge about his deteriorating condition.

So how does one know if the eyes are affected with diabetic retinopathy?

The answer lies in only getting their eyes screened either by a trained primary care physician, family physician or by an ophthalmologist. Other clues are blurred vision or slow vision loss over time, floaters, shadows or missing areas of vision and trouble seeing at night.

Often, many patients with early diabetic retinopathy have no symptoms before major bleeding occurs in the eye and that is why a regular check-up is needed once they are confirmed having diabetes or still at early stages of diabetic retinopathy.

THE SIGNS AND TREATMENT

The ophthalmologist can diagnose diabetic retinopathy by dilating your eyes and carefully examining the retina. He is usually fully equipped with other assessment tools to help him come to a conclusion about the stages of diabetic retinopathy the patient is suffering from.

In early stages of diabetic retinopathy (non proliferative), no treatment may be needed but the patient will need regular assessment. In cases where the non-proliferative stage has progressed, laser treatment is usually required.
If the condition has progressed to proliferative or advanced diabetic retinopathy stage, surgical treatment is usually initiated. A surgical procedure called vitrectomy is done to clear the blood within the eye which has bled from the abnormal vessels and also to repair a detached retina.

In certain cases, injection of drugs directly into the eye is done. This is to prevent development of any new vessels which are responsible for the bleeding.

FURTHER COMPLICATIONS

At a time when the patient feels everything is solved, the doctors will have to keep their fingers crossed.

This is because diabetic eye disease does not only affects the retina, but it causes other complications like cataract and glaucoma.

Cataract probably is easily manageable but glaucoma or specifically known as neovascular glaucoma is one of the most dreaded complications of the disease.

A few months after the surgery, the patient came for follow up and I was happy to see her being able to navigate on her own without much help. She will need to undergo another surgery to remove the silicone oil placed inside the operated eye to stabilise the detached retina.

I was invited to go to their stall to taste their new cooking and probably a new recipe. It was amazing to see her standing and being able to cook while her fiance was busy serving the dish to the customers.

She is learning to use her sense of smell, touch and taste more to cook and never needed to ask me the same question — whether she will be able to see again.

The writer is consultant ophthalmologist at Columbia Asia Hospital-Puchong

Early diagnosis

IF you have diabetes and have not seen an ophthalmologist for the past one year, make an appointment now.
If you have any of these symptoms, it is even more important to do so:
• You cannot see well in dim light
• You have dark spots in your field of vision
• You are unable to focus and the vision is blurred and hazy
• You have double vision
• You see some spots floating in your field of vision
• You have pain in any one of the eyes which can be associated with headache

Read more: Diabetics, watch your eyes – Health – New Straits Times http://www.nst.com.my/life-times/health/diabetics-watch-your-eyes-1.173641#ixzz2Cm9zNIAA

1m diabetics by 2050 as Singaporeans get older, fatter

A diabetic man undergoing dialysis treatment. Ageing and obesity are the two main factors that will drive Singapore’s number of diabetics up in the next 40 years, according to new research by the National University of Singapore’s Saw Swee Hock School of Public Health. — ST FILE PHOTO: DESMOND WEE
By Salma Khalik Health Correspondent

By 2050, Singapore may have as many as one million diabetics. Every one in two people, by age 70, will be diabetic – up from one in three today. Of the adult population, 15 per cent will suffer from the disease, compared with 11.3 per cent now.

And because people here are not just getting older, but also fatter, obesity is likely to push up the risks of diabetes, which in turn raises the risk of stroke, heart and kidney failure, and blindness.

Ageing and obesity are the two main factors that will drive Singapore’s number of diabetics up in the next 40 years, according to new research by the National University of Singapore’s Saw Swee Hock School of Public Health.

Sounding the warning on Monday at the Grand Copthorne Waterfront Hotel, its dean Chia Kee Seng said such academic knowledge has to be translated into action. “We can now project the impact of proposed obesity reduction programmes on the prevalence of diabetes in Singapore in 2050,” he told more than 400 international participants at the opening of the inaugural Singapore International Public Health Conference.

ST

App on fasting for diabetics

PHARMACEUTICAL firm MSD has launched a mobile app called Ramadhan, Diabetes And Me to help diabetics manage their blood sugar levels while fasting.

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Ewe (left) with diabetic patient Mohd Kamal Muda and Dr Nor Azmi showing the app and booklets

Its managing director, Ewe Kheng Huat, says the app is part of its Ramadan Hypoglycaemia campaign 2012. The company has also launched a booklet, Fact About Fasting, to create greater awareness about possible complications while fasting for diabetics.

The app offers tips and information about fasting and helps diabetics track their sugar level. The data stored is only available to the user who can later share it with doctors during consultations or save the information as a PDF file to be emailed.

The app also provides a Qiblat compass and times for prayers and breaking fast.

Both the app and booklet are available for free on AppStore and at Persatuan Diabetes Malaysia, clinics and hospitals.

For the video on a special interview with UKM Medical Centre head of endocrinology department Professor Dr Nor Azmi Kamaruddin on diabetes and how to use the Ramadhan, Diabetes And Me app, click on NST e-paper.

Read more: NST

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