Diabetes and

FastingDr. P.Naina Mohamed

Pharmacologist

Introduction Ramadan is the ninth lunar month of islamic

calendar year and Fasting during Ramadan is a duty for all healthy adult Muslims.

Children, elderly people, travelers, pregnant or nursing women and unhealthy individuals are exempt from fasting.

Muslims abstain from eating, drinking, use of oral medications, and smoking during fasting period which falls between sunrise and sunset.

The healthcare professionals should be aware of potential risks associated with fasting and appropriate measures to mitigate those risks.

Risks Associated with Fasting in Diabetics

Risks Associated with Fasting in Diabetics

Hypoglycemia

Hyperglycemia

Diabetic Ketoacidosis

Dehydration

Thrombosis

Hypoglycemia Fasting during Ramadan, the risk of severe

hypoglycemia is increased 4.7-fold in Type 1 diabetics and 7.5-fold risk in Type 2 diabetics, according to a largest study called EPIDIAR.

Decreased food intake is a well-known risk factor for the development of hypoglycemia.

Severe hypoglycemia was more frequent in patients who underwent dosage changes of oral hypoglycemic agents or insulin and in those who changed their lifestyle significantly.

Hyperglycemia Hyperglycemia may occur due to excessive

reduction of dosages of medications assuming to prevent hypoglycemia.

The higher intake of food and/or sugar may also increase the risk of severe hyperglycemia.

The extensive EPIDIAR study showed a fivefold increase in the incidence of severe hyperglycemia in type 2 diabetics and threefold increase in type 1 diabetics.

Diabetic ketoacidosis

Poorly controlled type 1diabetics are at increased risk for development of diabetic ketoacidosis.

The risk for diabetic ketoacidosis may also be increased by excessive reduction of insulin dosages assuming to avoid hypoglycemia.

Dehydration Dehydration can be caused by prolonged

limitation of fluid intake during the ramadan fast.

The dehydration may become severe due to excessive perspiration in hot and humid climates and among individuals who perform hard physical labor.

Osmotic diuresis caused by hyperglycemia, further contributing to volume and electrolyte depletion.

Preexisting autonomic neuropathy in diabetics may induce Orthostatic hypotension.

Hypovolemia and the associated hypotension may lead to syncope, falls, injuries, and bone fractures.

Thrombosis

Diabetes induces the contraction of the intravascular space which exacerbate the hypercoagulable state.

Excessive blood viscosity associated to dehydration may enhance the risk of thrombosis and stroke.

A report from Saudi Arabia suggested an increased incidence of retinal vein occlusion in patients who fasted during Ramadan.

However, hospitalizations due to coronary events or stroke were not increased during Ramadan.

Assessment before Ramadan

Medical assessment and structured education program should be done for all diabetics who wish to fast during Ramadan.

This assessment should take place 1–2 months before Ramadan.

To control the diabetics’ blood sugar, blood pressure, and lipids, appropriate blood studies should be ordered and evaluated.

Specific medical advice on the risks of fasting, should be provided to the diabetics who decide to fast.

During this assessment, necessary changes in diet or medication regimen should be made.

Categories of risks of DiabeticsVery high risk

• Severe hypoglycemia within the 3 months prior to Ramadan

• A history of recurrent hypoglycemia

• Hypoglycemia unawareness• Sustained poor glycemic

control• Ketoacidosis within the 3

months prior to Ramadan• Type 1 diabetes• Acute illness• Hyperosmolar hyperglycemic

coma within the previous 3 months

• Performing intense physical labor

• Pregnancy• Chronic dialysis

High risk• Moderate hyperglycemia

(average blood glucose 150–300 mg/dl or A1C 7.5–9.0%)

• Renal insufficiency• Advanced macrovascular

complications• Living alone and treated

with insulin or sulfonylureas

• Patients with comorbid conditions that present additional risk factors

• Old age with ill health• Treatment with drugs

that may affect mentation

Moderate risk

• Well-controlled diabetes treated with short-acting insulin secretagogues

Low risk• Well-

controlled diabetes treated with lifestyle therapy, metformin, acarbose, thiazolidinediones, and/or incretin-based therapies in otherwise healthy patients

Ramadan-focused Structured Diabetes Education

Many health care professionals are unable to give the appropriate medical advice due to lack of knowledge about the optimum management of diabetes while fasting.

Ramadan-focused diabetes educational program should ideally include three components: An awareness campaign aimed at people with diabetes, health

care professionals, the religious and community leaders as well as the general public.

Ramadan-focused structured education for health care professionals.

Ramadan-focused structured education for people with diabetes.

Education for Health care professionals

Health care professionals should be trained to deliver a structured patient education program that includes a better understanding of fasting and diabetes, individual risk quantification, and options to achieve safer fasting.

This includes the importance of glucose monitoring during fasting and nonfasting hours, when to stop the fast, meal planning to avoid hypoglycemia and dehydration during prolonged fasting hours, and the appropriate meal choices to avoid postprandial hyperglycemia.

The educational program should include advice on the timing and intensity of physical activity during fasting.

It is important that use of diabetes-related medications and their potential risk during fasting are also discussed.

A well-trained health care professional should be able to deliver all these components to people with diabetes either individually or in a group session at diabetes centers, primary health care centers, local mosques, and/or community centers.

Meal planning and Dietary advice The diet during Ramadan should be a healthy balanced diet. Slow energy release foods (wheat, semolina, beans, rice) and

high fibre foods (wholegrain cereals, granary bread, brown rice; beans and pulses) should be taken before and after fasting.

Foods high in saturated fat (such as ghee, samosas, and pakoras) should be minimised.

Limit the amount of sweet foods taken at Iftar (after sunset). Include fruits, vegetables, dhal (lentil) and yoghurt in Iftar

and Sehri (early morning) meals. Try to have the meal at Sehri at the proper time just before

sunrise, not at midnight. This will spread out energy intake more evenly and result in more balanced blood glucose when fasting.

Choose sugar-free drinks or water to quench your thirst. Avoid adding sugar to drinks.

Exercise

Type 2 diabetes patients should adopt regular light and moderate exercise.

The patients taking sulphonylureas or insulin should avoid rigorous exercise as the risk of hypoglycaemia may be increased.

Encourage patients to continue their usual physical activity, especially during non-fasting periods

Tarawaih prayers (a series of prayers after the sunset meal) should be considered as part of the daily exercise regimen as they involve standing, bowing, prostrating, and sitting.

Management of type 1 Diabetics Fasting at Ramadan carries a very high risk for people with type 1 diabetes. This risk is particularly exacerbated in poorly controlled patients and those with

limited access to medical care, hypoglycemic unawareness, unstable glycemic control, or recurrent hospitalizations.

The risk is also very high in patients who are unwilling or unable to monitor their blood glucose levels several times daily.

The Epidemiology for Diabetes Interventions and Complications (EDIC) study, demonstrated that intensive glycemia management is protective against microvascular and perhaps macrovascular complications and that the benefits are long lasting.

Very few studies have documented the safety and/or efficacy of different insulin regimens in type 1 diabetic patients who fast during the month of Ramadan.

A frequently used option is once- or twice-daily injections of intermediate or long-acting insulin along with premeal rapid-acting insulin.

A recent small study with insulin glargine suggests the relative safety and efficacy of this agent in 15 relatively well-controlled patients with type 1 diabetes who fasted for 18 h and experienced a minimal decline in mean plasma glucose from 125 to 93 mg/dl with only two episodes of mild hypoglycemia.

Another study in patients with type 1 diabetes using insulin glulisine, lispro, or aspart instead of regular insulin in combination with intermediate-acting insulin injected twice a day led to improvement in postprandial glycemia and was associated with fewer hypoglycemic events.

Continuous subcutaneous insulin infusion (pump) management is an appealing alternative strategy, but at a substantially greater expense.

The experts suggest that type 1 diabetics who are on a basal bolus regimen four times daily should be discouraged from fasting.

Management of type 2 Diabetics

Metformin: The possibility of severe hypoglycemia is minimal in patients treated with metformin alone and they may fast safely. 2/3 of the total daily dose of metformin should be administered with the sunset meal and the other third (1/3) before the predawn meal.

Glitazones: As glitazones require 2–4 weeks to exert substantial antihyperglycemic effects, they cannot be quickly substituted for agents associated with hypoglycemia during periods of fasting.

Sulfonylureas: Due to the risk of hypoglycemia, sulfonylureas use during fasting is unsuitable. With caution these agents may be used in Ramadan due to their worldwide use and relatively low cost.

Short-acting insulin secretagogues: One study in patients with type 2 diabetes who fasted showed that use of Repaglinide was associated with less hypoglycemia compared with glibenclamide. Nateglinide has the shortest duration of action and therefore the lowest risk of severe fasting hypoglycemia among the secretagogues.

Management of type 2 Diabetics

GLP – 1 agonists (Exenatide and Liraglutide ): Exenatide can be dosed before meals to minimize appetite and promote weight loss. It has short half-life of 2 h and it is not associated with a substantial effect on fasting glucose. Liraglutide can be dosed once a day, independent of meals, and is more effective in controlling fasting glycemia.

DPP 4 Inhibitors (saxagliptin, sitagliptin, and vildagliptin): DPP-4 inhibitors are among the best tolerated drugs for the treatment of diabetes. There are no specific studies of these agents during periods of fasting.

α-Glucosidase inhibitors (Acarbose, miglitol, and voglibose ): α-Glucosidase inhibitors may be useful during Ramadan as they are not associated with the risk of hypoglycemia, particularly in the fasting state.

Insulin: Use intermediate- or long-acting insulin preparations and a rapid-acting insulin analog or short-acting insulin to be administered before meals.

Management of Hypertension and Dyslipidemia

Fasting during Ramadan for prolonged hours with excessive perspiration, may cause Dehydration, volume depletion, and a tendency toward hypotension.

Hence, the dosage and/or the type of antihypertensive medications may need to be adjusted to prevent hypotension.

Diuretics may not be appropriate during Ramadan for some patients.

Appropriate counseling should be given to avoid foods rich in carbohydrates and saturated fats.

The agents previously prescribed for the management of elevated cholesterol and triglycerides should be continued.

Tips for Healthcare providers The healthcare providers can improve the diabetes care in Muslims

who are decided to fast during Ramadan, in following ways… Adjust diabetic medication if needed, since the Ramadan fasting

improves diabetes by lowering the blood glucose and HbA1c. As the Meditation and prayers tend to lower blood pressure,

adjust the dosage of antihypertensive drugs. Non-porcine synthetic (human) insulin should be given in place of

Pork insulins, pork-based synthetic insulins, and beef (non-halal) insulins which are unacceptable to devoted Muslims.

In Ramadan, a person with type 2 diabetes can take a sulphonylurea at the end of the fast, with the evening meal started within 30 minutes. Advise not to miss the sehri (before sunrise) meal so as to avoid hypoglycaemia later in the day.

Repaglinide (NovoNorm) can be taken when a meal is eaten, therefore no change in drug therapy will be required in Ramadan. A meal must be eaten within 15 minutes.

Adjust medication or advise the patients who take alternative medicine concurrently to treat diabetes.

Dietary tips about Glycaemic foods like khir (rice pudding) and vermicelli Hypoglycemic foods such as karela (a vegetable), onion and garlic should be provided to the patients.

Counsel the patient by saying ‘to see the doctor and comply with treatment is Prophet Mohammad's sunnat (precedent)’. To refuse would be a sin.

Tips to the Diabetics Type 1 Diabetic patients and type 2 diabetics who require

insulin should monitor their blood glucose levels multiple times daily.

Inappropriate diet, over-eating and insufficient sleep are the causes of most health problems occurring in Ramadan.

During iftar (sunset meal), large amounts of foods rich in carbohydrates and fats, should be avoided.

The foods containing “complex” carbohydrates (slow digesting foods) may be advisable at the predawn meal.

During nonfasting hours, fluid intake should be increased. To avoid the risk of hypoglycemia, excessive physical activity

should be avoided. All patients should understand that they must end their fast

immediately, if hypoglycemia (blood glucose of <60 mg/dl [3.3 mmol/l]) occurs.

Patients should avoid fasting on “sick days.”

Points to Remember

Diabetics should discuss with Healthcare

Professionals

Diabetics should undergo Pre

Ramadan Assessment

Ramadan-focused Structured Diabetes Education

• Risks involved in fasting

• Ways to mitigate the risks

• Assessment should be done 1-2 months before Ramadan

• Patients’ blood sugar, lipids and blood pressure should be assessed.

•Awareness campaign for all.•Ramadan-focused structured education for health care professionals as well as diabetics regarding physical activity, meal planning, glucose monitoring, and dosage and timing of medications.

CONCLUSIONS Type 1 Diabetics willing to Fast during Ramadan, are at very high risk

of life-threatening complications such as severe hypoglycemia, hyperglycemia and diabetic ketoacidosis.

Type 2 diabetics carry less risk of Hypoglycemia and Hyperglycemia in compared to Type 1 diabetics.

Current evidence has proved that Type 1 and Type 2 adult diabetics can fast during Ramadan safely after discussing with a health care provider concerning the risks involved.

The diabetics who insist on fasting should undergo pre-Ramadan assessment and receive appropriate education and instructions related to physical activity, meal planning, glucose monitoring, and dosage and timing of medications.

The management of children with diabetes who choose to fast during Ramadan is a challenge for pediatrician as the majority of guidelines and data on safety and metabolic impact of fasting are based on practice and studies on adult population.

If the child and family received proper education and intensive follow up clinic during Ramadan, it is feasible for children older than 8 years with long-standing Type 1DM to safely fast during Ramadan.

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