Guidelines for managing diabetes in Ramadan

Diabetes, driving and fasting during Ramadan: the interplay between secular and religious law

A large proportion of the Muslim population fasts during Ramadan. The risk of hypoglycemia is increased with fasting during Ramadan in people with diabetes who are on insulin and insulin secretagogues. Therefore, the combination of fasting with diabetes and driving presents a challenging situation, with legal implications for such individuals and their healthcare professionals. This novel, narrative, non-systematic review discusses the importance of addressing hypoglycemia in fasting with reference to secular legal guidance on driving with diabetes. We discuss religious aspects relating to fasting and driving in Islam. While there is no clear guidance or legal position on diabetes and driving for individuals who are fasting, Islamic law provides a logical framework to address this. Healthcare professionals need to raise and facilitate discussions on this often-overlooked topic with people with diabetes who are planning on fasting to minimize the potential for public harm. For some individuals fasting perhaps should be avoided when driving and that this religiously compatible position would best be adopted when one is dependent on driving for livelihood. Ultimately further research on glycemic control and management when fasting and driving, as well as a formal legal guidance on this topic, is required to safeguard healthcare professionals and the public from the potential dangers of driving with diabetes and fasting.

Effectiveness of gliclazide MR 60 mg in the management of type 2 diabetes: analyses from the EASYDia trial

BACKGROUND

Although the number of antihyperglycemic agents has expanded significantly, sulfonylureas (in particular gliclazide) remain an important option because of a variety of patient and health system factors. The large, real world, observational, and international EASYDia trial evaluated the effectiveness of gliclazide modified release (MR) 60 mg in individuals with type 2 diabetes with a broad range of diabetes history, body mass index (BMI) and background antihyperglycemic treatment.

METHODS

A total of 7170 participants from eight countries, age ≥ 35 years with HbA1c ≥ 7.5% and not treated with insulin, were prescribed 30-120 mg of gliclazide MR 60 mg once daily. HbA1c goals were individualized and dosing uptitrated, as required, over the 6-month long study. In this post hoc subanalysis, efficacy endpoints were analyzed according to stratified baseline HbA1c levels, weight and glucose-lowering regimens. Episodes of hypoglycemia requiring assistance were documented.

RESULTS

At baseline, mean age was 58.9 years, HbA1c 8.8%, BMI 30.1 kg/m², and diabetes duration 5.1 years. At study end, clinically significant HbA1c improvements (mean change - 1.78%) were noted across all baseline HbA1c strata (> 7.0 to ≤ 8.0%, > 8.0 to ≤ 9.0%, > 9.0 to ≤ 10.0%, and > 10.0%), BMI classifications (18.5 to < 25.0, 25.0 to < 30.0, and ≥ 30.0 kg/m²), and regardless of the original diabetes treatment regimen (P < 0.001 in all cases). In contrast to the subgroups with BMI 25.0-30.0 and ≥ 30.0 kg/m² that registered weight losses of 0.9 and 2.2 kg, respectively (P < 0.001 vs. baseline weight); the BMI 18.5-24.9 kg/m² subgroup gained a mean 0.5 kg (P < 0.02 vs. baseline weight). Severe hypoglycemic events were rare (0.06%).

CONCLUSIONS

Progressive gliclazide MR 60 mg uptitration was well tolerated and lowered HbA1c across a broad range of HbA1c, BMI and background glucose-lowering therapy. Weight loss was noted when BMI was ≥ 25.0 kg/m². Individuals with the highest baseline HbA1c and BMI experienced the greatest HbA1c and weight improvements.Trial registration ISRCTN Registry ISRCTN00943368 on 1st July 2011.

A novel glucagon-like peptide-1/glucagon receptor dual agonist exhibits weight-lowering and diabetes-protective effects

Glucagon has plenty of effects via a specific glucagon receptor(GCGR) like elevating the blood glucose, improving fatty acids metabolism, energy expenditure and increasing lipolysis in adipose tissue. The most important role of glucagon is to regulate the blood glucose, but the emergent possibilities of hyperglycaemia is exist. Glucagon could also slightly activate glucagon-like peptide-1 receptor(GLP-1R), which lead to blood glucose lowering effect. This study aims to erase the likelihood of hyperglycaemia and to remain the inherent catabolic effects through improving GLP-1R activation and deteriorating GCGR activation so as to lower the bodyweight and show diabetes-protective effects. Firstly, twelve cysteine modified GLP-1/GCGR dual agonists were synthesized (1-12). Then, the GLP-1R/GCGR mediated activation and biological activity in normal ICR mice were comprehensively performed. Compounds substituted by cysteine at positions 22, 23 and 25 in glucagon were observed to be better regulators of the body weight and blood glucose. To prolong the half-lives of derivatives, various fatty side chain maleimides were modified to optimal glucagon analogues. Laurate maleimide conjugate 4d was the most potent. Administration of 1000 nmol/kg 4d once every two days for a month normalized adiposity and glucose tolerance in diet-induced obese (DIO) mice. Improvements in plasma metabolic parameters including insulin, leptin, and adiponectin were observed. These studies suggest that compound 4d behaves well in lowering body weight and maintaining energy expenditure without a chance of hyperglycaemia, 4d has strong clinical potential as an efficient GLP-1/GCGR agonist in the prevention and treatment of obesity and dyslipidemia.

Fasting, Diabetes, and Optimizing Health Outcomes for Ramadan Observers: A Literature Review

INTRODUCTION

Globally, and in Australia, diabetes has become a common chronic health condition. Diabetes is also quite prevalent in culturally and linguistically diverse pockets of the Australian population, including Muslims. There are over 90 million Muslims with diabetes worldwide. Diabetes management and medication use can be affected by religious practices such as fasting during Ramadan. During Ramadan, Muslims refrain from oral or intravenous substances from sunrise to sunset. This may lead to many potential health or medication-related risks for patients with diabetes who observe this religious practice. This literature review aimed to explore (1) health care-related interventions and (2) intentions, perspectives, or needs of health care professionals (HCPs) to provide clinical services to patients with diabetes while fasting during Ramadan with a view to improve health outcomes for those patients.

METHODS

Using a scoping review approach, a comprehensive search was conducted. Databases searched systematically included PubMed, Medline, Embase, and International Pharmaceutical Abstracts. Studies published in English that described interventions or intentions to provide interventions regarding diabetes and Ramadan fasting were included.

RESULTS

Fourteen published articles that met the inclusion criteria were retrieved and content analyzed. Of those, nine intervention studies regarded diabetes management education. Five studies described professional service intention, four of which were related to the role of pharmacists in diabetes management in Qatar, Australia, and Egypt, and one French study examined the general practitioners' (GPs) experiences in diabetes management for Ramadan observers. The intervention studies had promising outcomes for diabetes management during Ramadan. Effect sizes for improvement in HbA1c post intervention ranged widely from -1.14 to 1.7. Pharmacists appeared to be willing to participate in programs to help fasting patients with diabetes achieve a safe therapeutic outcome. Service intention studies highlighted pharmacists' and GPs' need for training prior to providing services from a clinical as well as cultural competence perspective.

CONCLUSION

Interventions research in this area requires robustly designed and structured interventions that can be tested in different contexts. This literature review revealed many gaps regarding diabetes management in Ramadan. Health professionals are willing to provide services for fasting diabetes patients, but need upskilling.

Type 2 diabetes patient's perspective on Ramadan fasting: a qualitative study

OBJECTIVE

We evaluated the beliefs, experience and diabetes management strategies of type 2 diabetes mellitus (T2DM) Muslim patients that chose to fast during Ramadan.

RESEARCH DESIGN AND METHODS

A semistructured focus group interview was conducted with 53 participants with T2DM. Participants were purposefully sampled and asked to share their perspective on Ramadan fasting. All interviews were audio recorded, transcribed verbatim and analyzed thematically.

RESULTS

Participants reported optimism towards fasting during Ramadan, as they believed that fasting was beneficial to their overall well-being, and a time for family bonding. Most participants made limited attempts to discuss with their doctors on the decision to fast and self-adjusted their medication based on experience and symptoms during this period. They also reported difficulty in managing their diet, due to fear of hypoglycemia and the collective social aspect of fasting.

CONCLUSION

Muslims are optimistic about their well-being when fasting during Ramadan. Many choose to fulfill their religious obligation despite being discouraged by their doctors. Collaboration with religious authorities should be explored to ensure patients receive adequate education before fasting during Ramadan.

TRIAL REGISTRATION NUMBER

NCT02189135; Results.

Effects of yoga in adults with type 2 diabetes mellitus: A meta-analysis

Aims/Introduction

A meta‐analysis was carried out to evaluate the efficacy of yoga in adults with type 2 diabetes mellitus.

Materials and Methods

The PubMed, EMBASE and Cochrane databases were searched to obtain eligible randomized controlled trials. The primary outcome was fasting blood glucose, and the secondary outcomes included glycosylated hemoglobin A1c, total cholesterol, high‐density lipoprotein cholesterol, low‐density lipoprotein cholesterol, triglyceride and postprandial blood glucose. Weighted mean differences and 95% confidence intervals (CIs) were calculated. The I² statistic represented heterogeneity.

Results

A total of 12 randomized controlled trials with a total of 864 patients met the inclusion criteria. The pooled weighted mean differences were −23.72 mg/dL (95% CI −37.78 to −9.65; P = 0.001; I² = 82%) for fasting blood glucose and −0.47% (95% CI −0.87 to −0.07; P = 0.02; I² = 82%) for hemoglobin A1c. The weighted mean differences were −17.38 mg/dL (95% CI −27.88 to −6.89; P = 0.001; I² = 0%) for postprandial blood glucose, −18.50 mg/dL (95% CI −29.88 to −7.11; P = 0.001; I² = 75%) for total cholesterol, 4.30 mg/dL (95% CI 3.25 to 5.36; P < 0.00001; I² = 10%) for high‐density lipoprotein cholesterol, −12.95 mg/dL (95% CI −18.84 to −7.06; P < 0.0001; I² = 37%) for low‐density lipoprotein cholesterol and −12.57 mg/dL (95% CI −29.91 to 4.76; P = 0.16; I² = 48%) for triglycerides.

Conclusions

The available evidence suggests that yoga benefits adult patients with type 2 diabetes mellitus. However, considering the limited methodology and the potential heterogeneity, further studies are necessary to support our findings and investigate the long‐term effects of yoga in type 2 diabetes mellitus patients.