Correlation between pre-ramadan glycemic control and subsequent glucose fluctuation during fasting in adolescents with Type 1 diabetes

Personalized risk reduction strategies utilizing the diabetes and ramadan risk calculator: a narrative review

The Diabetes and Ramadan Risk Calculator, developed in 2021, is a pivotal tool for assessing fasting-related risks among patients with diabetes. This ground-breaking innovation offers a quantitative assessment of risk scores during fasting, revolutionizing the landscape of diabetes management during Ramadan. Many components assessed by the calculator are amenable to modification, presenting an opportunity for year-round intervention to mitigate risk scores and subsequent fasting risks. By targeting modifiable risk factors and adapting strategies over time, individuals with diabetes can proactively diminish their fasting-related risks, safeguarding their physical well-being and spiritual engagement and potentially improving their overall diabetes control. This review aims to elucidate the evolution of the strategies for addressing modifiable risk factors, reducing risk scores and levels, and ensuring safe fasting practices.

Ramadan fasting among adolescents with type 1 diabetes: a systematic review and meta-analysis

OBJECTIVE

This systematic review and meta-analysis assess the effects of Ramadan fasting in adolescents with type 1 diabetes mellitus (T1DM), on blood sugar factors such as hemoglobin A1C and problems caused by its lack of control such as hypoglycemia and DKA, and metabolic outcomes.

METHODS

Electronic databases including MEDLINE, Embase, and SINOMED were searched up to February 13, 2024, without language, region, or publication time restrictions. The outcomes were Acute complications, changes in Hemoglobin A1c (HbA1c) and weight changes. Meta-analyses used random-effects models to compute weighted Relative risk (RR) and standard mean differences (SMD). And to check the risk of bias of included studies, the Newcastle-Ottawa scale was used.

RESULTS

Nine studies were included, comprising 458 participants, with studies varying in quality from high to low. Meta-analysis showed no significant reduction in HbA1c levels post-Ramadan (SMD: -0.12; 95% CI: -0.38 to 0.14), indicating minimal impact on long-term glycemic control. The incidence of hypoglycemia was notably high (50.79 events per 100 observations), with hyperglycemia and diabetic ketoacidosis (DKA) also reported but less frequently. The variability in complication rates among studies was significant, reflecting the high heterogeneity across the data. Weight changes during Ramadan were minimal and not statistically significant, suggesting fasting's negligible effect on body weight among participants.

CONCLUSIONS

Ramadan fasting among adolescents with T1DM does not significantly alter HbA1c levels, suggesting potential feasibility under careful monitoring and management. However, the high incidence of hypoglycemia underscores the need for vigilant glucose monitoring and tailored adjustments to diabetes management plans during fasting periods.

Improvement of Glycemia Risk Index and Continuous Glucose Monitoring Metrics During Ramadan Fasting in Type 1 Diabetes: A Real-World Observational Study

BACKGROUND

Managing glycemia during Ramadan is challenging for individuals with type 1 diabetes (T1D) due to prolonged fasting and altered eating patterns. While many are exempt from fasting, some choose to fast, necessitating careful monitoring. The glycemia risk index (GRI) is valuable for assessing glycemic quality and interpreting continuous glucose monitoring (CGM) data to identify individuals needing closer clinical attention. This study investigates the effects of Ramadan fasting on glycemic control in T1D, focusing on GRI and its components for hypoglycemia (CHypo) and hyperglycemia (CHyper).

METHOD

An ambispective study involved 186 individuals with T1D using intermittent scanning CGM (isCGM). Data were retrospectively collected for one month before Ramadan and prospectively during and one month after Ramadan. Clinical, metabolic, and glycemic data were collected, with GRI calculated alongside its components.

RESULTS

During Ramadan, GRI improved by 54.6% (from 56.4 to 25.6), CHypo decreased by 60% (from 6 to 2.4), and CHyper dropped by 40.5% (from 21 to 12.5). However, these benefits were temporary, as glycemic measures increased after Ramadan, reflecting a return to pre-Ramadan patterns once normal routines resumed. No participants were admitted for diabetes emergencies during Ramadan. Adolescents and patients on insulin pumps had more favorable outcomes. GRI and its components significantly correlated with other CGM metrics, with these relationships maintained during and after Ramadan.

CONCLUSIONS

Ramadan fasting significantly improved GRI and its components in individuals with T1D. Incorporating GRI as a novel metric alongside classical CGM metrics could enhance glycemic control, highlighting the need for personalized diabetes management strategies.

Twenty-Four Hour Glucose Profiles and Glycemic Variability during Intermittent Religious Dry Fasting and Time-Restricted Eating in Subjects without Diabetes: A Preliminary Study

Intermittent religious fasting increases the risk of hypo- and hyperglycemia in individuals with diabetes, but its impact on those without diabetes has been poorly investigated. The aim of this preliminary study was to examine the effects of religious Bahá'í fasting (BF) on glycemic control and variability and compare these effects with time-restricted eating (TRE). In a three-arm randomized controlled trial, 16 subjects without diabetes were assigned to a BF, TRE, or control group. Continuous glucose monitoring and food intake documentation were conducted before and during the 19 days of the intervention, and the 24 h mean glucose and glycemic variability indices were assessed. The BF and TRE groups, but not the control group, markedly reduced the daily eating window while maintaining macronutrient composition. Only the BF group decreased caloric intake (-677.8 ± 357.6 kcal, p = 0.013), body weight (-1.92 ± 0.95 kg, p = 0.011), and BMI (-0.65 ± 0.28 kg, p = 0.006). Higher maximum glucose values were observed during BF in the within-group (+1.41 ± 1.04, p = 0.039) and between-group comparisons (BF vs. control: p = 0.010; TRE vs. BF: p = 0.022). However, there were no alterations of the 24 h mean glucose, intra- and inter-day glycemic variability indices in any group. The proportions of time above and below the range (70-180 mg/dL) remained unchanged. BF and TRE do not exhibit negative effects on glycemic control and variability in subjects without diabetes.

Glycemic Management Among Adults With Type 1 Diabetes During Passover: A Pre-Post Single-center Study

OBJECTIVES

No data are available regarding glycemic management of individuals with type 1 diabetes (T1D) during Passover. Our aim in this study was to assess the effect of Passover on diabetes management and glycemic management in adults with T1D with nutritional changes during Passover (observant) compared with those who did not change their dietary habits during Passover (nonobservant).

METHODS

We conducted an observational pre-post study of adults with T1D, followed in a diabetes clinic in Israel. Data were downloaded from insulin pumps and continuous glucose monitoring for 37 days: 2 weeks before Passover, 9 days of Passover, and 2 weeks thereafter. Differences in percentage of time spent above target (>10.0 to >13.9 mmol/L), at target (3.9 to 10.0 mmol/L), and below target (<3.9 to <3.0 mmol/L) were compared using paired t tests or paired signed rank tests.

RESULTS

The study cohort included 43 individuals with T1D (23 observant, 20 nonobservant). The average blood glucose was significantly higher during Passover compared with the period before Passover---in nonobservant patients 8.2±1.5 mmol/L and 7.9±1.3 mmol/L (p=0.043), respectively, and in observant patients 8.7±1.6 mmol/L and 8.4±1.6 mmol/L (p=0.048), respectively. Time above range 10 to 13.9 mmol/L was increased in observant individuals during Passover, as compared with the period before Passover, at 24.9±16.2% and 20.6±12.4% (p=0.04), respectively. The dose of bolus insulin had increased significantly in observant individuals: 27.4±13.9 units during Passover, as compared with 24.2±11.2 units before Passover (p=0.02).

CONCLUSIONS

Passover alters glycemic management and insulin needs in Jewish adults with T1D. It is advisable to make specific adjustments to maintain the recommended glycemic management.

Efficacy of Fasting in Type 1 and Type 2 Diabetes Mellitus: A Narrative Review

Over the last decade, studies suggested that dietary behavior modification, including fasting, can improve metabolic and cardiovascular markers as well as body composition. Given the increasing prevalence of people with type 1 (T1DM) and type 2 diabetes mellitus (T2DM) and the increasing obesity (also in combination with diabetes), nutritional therapies are gaining importance, besides pharmaceutical interventions. Fasting has demonstrated beneficial effects for both healthy individuals and those with metabolic diseases, leading to increased research interest in its impact on glycemia and associated short- and long-term complications. Therefore, this review aimed to investigate whether fasting can be used safely and effectively in addition to medications to support the therapy in T1DM and T2DM. A literature search on fasting and its interaction with diabetes was conducted via PubMed in September 2022. Fasting has the potential to minimize the risk of hypoglycemia in T1DM, lower glycaemic variability, and improve fat metabolism in T1DM and T2DM. It also increases insulin sensitivity, reduces endogenous glucose production in diabetes, lowers body weight, and improves body composition. To conclude, fasting is efficient for therapy management for both people with T1DM and T2DM and can be safely performed, when necessary, with the support of health care professionals.

Transient increase in glucose variability during Ramadan fasting in patients with insulin-treated type 2 diabetes: A preliminary study

AIM

We aimed to examine the effect of Ramadan fasting on interstitial glucose control and variability before, during, and after Ramadan in type 2 diabetes patients receiving insulin therapy.

METHODS

Participants received a flash glucose monitoring (FGM) system one week before Ramadan that was removed on the sixth or seventh day (pre- and early Ramadan periods) of Ramadan and a second FGM system one week before the end of Ramadan that was removed one week after the end of Ramadan (late and post-Ramadan periods). Fasting blood samples were collected during the pre-, early, and late Ramadan study visits and tested for HbA1c, serum creatinine, and plasma glucose levels.

RESULTS

Thirty-four patients were prospectively included. The standard deviation and coefficient of variation of glucose concentrations were higher in the early Ramadan period than in the pre-Ramadan period, but did not differ in the late or post-Ramadan periods. Changes in the early Ramadan period were restricted to males and patients aged <55 years. No significant changes were observed in the average glucose level, glucose management indicator, time in range, time in hyperglycemia, or time in hypoglycemia at any time point.

CONCLUSIONS

Ramadan fasting in patients with insulin-treated type 2 diabetes is associated with an initial increase in glucose variability that quickly returned to pre-Ramadan levels. Ramadan fasting was not associated with any significant changes in glycemic control measures.

Effects of Alternate Insulin Pump Settings in Patients With Type 1 Diabetes During Ramadan: A Randomized Pilot Study

BACKGROUND

Various studies have evaluated the safety and efficacy of using insulin pumps during Ramadan; some of them demonstrated favorable outcomes in reducing hypoglycemia and hyperglycemia. However, there is no consensus on the recommendations for basal insulin adjustments and the utilization of technical features of insulin pumps to improve glycemic control.

OBJECTIVES

We aimed to investigate the effects of different insulin pump settings on time in range in patients with type 1 diabetes during Ramadan.

METHODS

In this randomized pilot study, 30 patients classified to have low to moderate risk for fasting were assigned to either a control group to receive basal insulin adjustments only or an intervention group to use the temporary basal rate and extended bolus features in addition to the basal insulin modifications. The percentage of time spent at different glucose ranges was measured by continuous glucose monitoring.

RESULTS

The percentage of time spent within target (70-180 mg/dL) increased significantly in the intervention group from 63.0 ± 10.7 to 76 ± 16.2% (mean difference, 27% points; P < .001). The percentage of time spent in hyperglycemia level 1 (>180 mg/dL) and level 2 (>250 mg/dL) met the criterion of significance, indicating that the intervention group spent less time in hyperglycemia. However, there was no significant difference in the percentage of time spent in hypoglycemia ranges.

CONCLUSIONS

Incorporating technological approaches of pump therapy with clinical practice guidelines could improve glycemic control during Ramadan.

Glycemic control during Ramadan fasting in adolescents and young adults with type 1 diabetes on MiniMed™ 780G advanced hybrid closed‑loop system: A randomized controlled trial

BACKGROUND

MiniMed^TM 780G is the most advanced insulin pump system approved for the treatment of type 1 diabetes mellitus (T1DM). Hypoglycemic events are a serious complication associated with T1DM management during Ramadan fasting.

AIM

This prospective study assessed the safety, effectiveness and optimization of advanced hybrid closed loop (AHCL) system on glycemic metrics and the level of hypoglycemia in T1DM patients who wished to fast Ramadan.

METHODS

Forty-two T1DM patients (mean age 15.2 ± 3.4 years) using AHCL system were divided into two groups (each n = 21): intervention group who adjusted AHCL settings and control group who kept the same settings as before Ramadan.

RESULTS

The most aggressive system settings among control group consisting of a 100 mg/dL glucose target, active insulin time of 2 h and bolus increment,maintained exceptional glycemia withtime in range reaching82.0 ± 10.2%, time above range >180 mg/dL of 12.1 ± 3.5% without an increase in hypoglycemia (time below range 3.0 ± 0.3%). All of which were non-significant in comparison to the intervention group. Overall time spent in closed loop (SmartGuard) by users averaged 98.7 ± 2.1% in Auto Mode and involved only 1.0 ± 0.7 exits per week indicating confidence in the system's performance. There were no severe hypoglycemic or diabetic ketoacidosis events during the study.

CONCLUSIONS

MiniMed™ 780G AHCL system assist in safe fasting with minimal user input and allows for achievement of recommended glycemic targets in people with T1DM during Ramadan fasting. The system demonstrated reduction in hypoglycemia exposure without compromising safety.

Fructosamine as an Index of Short-Term Glycemic Control in Pregnant Women with Diabetes: Before, During and After Ramadan

Purpose

Impact of ramadan fasting on healthy and women with diabetes is already known. However, there is a scarcity of data on impact of fasting on pregnant women with diabetes. Moreover, religious and medical recommendations advise pregnant women against fasting as it is unsafe. Despite being exempted, many pregnant Muslim women with diabetes still choose to fast during ramadan. This study investigated different glycemic marker as an indicator for diabetes control in fasting pregnant women.

Patients and Methods

This is a prospective observational study. A total of 89 pregnant diabetes women were recruited. Blood glucose was self-monitored in all the pregnant women using glucose monitoring device at home. We measure the fructosamine, HbA1c levels before, during and after ramadan.

Results

Pregnant women with type 1 diabetes were 14 (25%), type 2 diabetes were 21 (37.5%), and gestational diabetes were 21 (37.5%). The mean fructosamine level decreased during and after ramadan in gestation diabetes pregnant women compared to type 2 diabetes and type 1 diabetes pregnant women subjects (p = 0.009).

Conclusion

The present study indicates that pregnant women with diabetes were able to fast during ramadan and there fructosamine level reduced during fasting. Utilization of fructosamine for short-term monitoring of glycemic control in addition to home glucose monitoring in pregnant women with diabetes will provide a good index of glycemic control.

Recommendation

Religious and medical recommendations advise pregnant women against fasting as it is unsafe, and they are under high risk. However, if they insist to do fast, they must do under strict medical supervision and fructosamine can be used as a glycemic control marker.

Ramadan Fasting and Maternal and Fetal Outcomes in Pregnant Women with Diabetes Mellitus: Literature Review

There is an emerging Muslim and diabetic population in the United States and other Western countries and majority of pregnant women and patients with diabetes mellitus choose to fast during Ramadan. Fasting during Ramadan in pregnant women with diabetes may represent a 'perfect storm' of metabolic disturbances including hyperglycemia, hypoglycemia and ketosis. Recent continuous and flash glucose monitoring data suggests increased glycemic variability (fasting hypo- and post-Iftar hyperglycemia) in non-pregnant patients with diabetes during Ramadan. Only five small-scale studies, predominantly focused on women with gestational diabetes mellitus in Muslim-majority nations have explored maternal glycemic outcomes during Ramadan which is associated with lower mean blood glucose levels and higher frequency of fasting hypoglycemia. Data is limited however on important clinical outcomes such as symptomatic and serious hypoglycemia requiring hospitalization. Results have been conflicting regarding maternal Ramadan fasting and association with fetal outcomes in women without diabetes. Only one recently published study reported on perinatal outcomes in pregnant women with gestational diabetes which found no effect of Ramadan exposure on mean birthweight or macrosomia frequency but lower neonatal hypoglycemia prevalence, however a significant limitation was lack of documentation of maternal fasting status. At this stage, due to paucity of data, the current medical recommendation is against Ramadan fasting for pregnant Muslim women with diabetes. Large-scale population-based studies are warranted regarding maternal and fetal outcomes in pregnant fasting women with diabetes and such studies should characterize maternal fasting status and have meaningful and consistent clinical outcomes. High-quality data derived from these studies can assist clinicians in providing more evidence-based advice to safely navigate both mother and fetus through a potentially challenging pregnancy.

Technological Ecological Momentary Assessment Tools to Study Type 1 Diabetes in Youth: Viewpoint of Methodologies

Type 1 diabetes (T1D) is one of the most common chronic childhood diseases, and its prevalence is rapidly increasing. The management of glucose in T1D is challenging, as youth must consider a myriad of factors when making diabetes care decisions. This task often leads to significant hyperglycemia, hypoglycemia, and glucose variability throughout the day, which have been associated with short- and long-term medical complications. At present, most of what is known about each of these complications and the health behaviors that may lead to them have been uncovered in the clinical setting or in laboratory-based research. However, the tools often used in these settings are limited in their ability to capture the dynamic behaviors, feelings, and physiological changes associated with T1D that fluctuate from moment to moment throughout the day. A better understanding of T1D in daily life could potentially aid in the development of interventions to improve diabetes care and mitigate the negative medical consequences associated with it. Therefore, there is a need to measure repeated, real-time, and real-world features of this disease in youth. This approach is known as ecological momentary assessment (EMA), and it has considerable advantages to in-lab research. Thus, this viewpoint aims to describe EMA tools that have been used to collect data in the daily lives of youth with T1D and discuss studies that explored the nuances of T1D in daily life using these methods. This viewpoint focuses on the following EMA methods: continuous glucose monitoring, actigraphy, ambulatory blood pressure monitoring, personal digital assistants, smartphones, and phone-based systems. The viewpoint also discusses the benefits of using EMA methods to collect important data that might not otherwise be collected in the laboratory and the limitations of each tool, future directions of the field, and possible clinical implications for their use.

Young people with type 1 diabetes on insulin pump therapy could fast safely during COVID-19 pandemic Ramadan: A telemonitoring experience in Bangladesh

Our aim was to report our telemedicine experience with type 1 diabetes patients using insulin pumps who fasted for Ramadan 2020 during the COVID-19 pandemic. The routine diabetes outpatient care in our Changing Diabetes in Children (CDiC) Pediatric Diabetes Center at the Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders hospital was closed, as there was a lockdown from 26 March in Bangladesh. The diabetes team in our center started telemedicine care for routine follow up of patients. Nine patients who wished to fast for Ramadan contacted our diabetes team over the phone. The mean age was 19.3 ± 5.0 years, and five (55.6%) were female. Most of the patients fasted >20 days. Hyperglycemia and mild hypoglycemia were common complications during fasting. There was no episode of severe hypoglycemia or diabetic ketoacidosis, and none of the patients required admission. During the COVID-19 crisis in Bangladesh, patients with type 1 diabetes using an insulin pump could fast safely for Ramadan with the support of the telemedicine service by the diabetes team.

Ramadan fasting and diabetes, latest evidence and technological advancements: 2021 update

Development of updated guidelines for management of diabetes in Ramadan Fasting is of paramount importance. Nonetheless, evidence-based guidelines in the field of Ramadan Fasting and Diabetes are scarce. Moreover, findings of some recent research such as effects of Ramadan fasting on microbiota, genetics and epigenetics, hormonal changes (such as adiponectin, leptin, testosterone…), and alternations in circadian rhythm should also be reviewed and included on a yearly basis. It is documented that self-monitoring of blood glucose (SMBG) is of vital importance for patients with type 1 diabetes who fast, and advantages of continuous glucose monitoring (CGM) or flash glucose monitoring (FGM) techniques should be highlighted. Moreover, the recent findings about applications of advanced insulin delivery technology in patients with diabetes who fast in Ramadan should also considered in the annual updates of the guidelines.

Ramadan fasting and diabetes, latest evidence and technological advancements: 2021 update

Development of updated guidelines for management of diabetes in Ramadan Fasting is of paramount importance. Nonetheless, evidence-based guidelines in the field of Ramadan Fasting and Diabetes are scarce. Moreover, findings of some recent research such as effects of Ramadan fasting on microbiota, genetics and epigenetics, hormonal changes (such as adiponectin, leptin, testosterone…), and alternations in circadian rhythm should also be reviewed and included on a yearly basis. It is documented that self-monitoring of blood glucose (SMBG) is of vital importance for patients with type 1 diabetes who fast, and advantages of continuous glucose monitoring (CGM) or flash glucose monitoring (FGM) techniques should be highlighted. Moreover, the recent findings about applications of advanced insulin delivery technology in patients with diabetes who fast in Ramadan should also considered in the annual updates of the guidelines.

Biometric and metabolic changes in patients with diabetes prior, during and after the holy month of Ramadan (ABCD Study)

Physiological impact of the intermittent or prolonged fasting is known from various studies on healthy subjects. However, data on impact of fasting on biochemical and biometric parameters in people with diabetes is building up. Safety of Ramadan fasting has always been assessed after Ramadan. This study looked into the immediate effect of fasting during the fasting days compared to time before and after the fasting month.

METHODS

This is an observational study. We looked into people with biometric and biochemical records before Ramadan, and we followed them up during and after Ramadan prospectively. We were aiming for assessing the biochemical and biometric changes for people with diabetes during Ramadan in comparison to pre-and post Ramadan. As well as the differences between these measures according to type and treatment of diabetes in those who fasted as well as in those who did not fast during Ramadan.

RESULTS

Total of 342 patients were recruited to the study. All were patients with diabetes at a mild to moderate risk of complications if fasted. Majority were males 52.3% (n = 180), while females were 47.7% (n = 162). Most of the results showed a U shape between Pre-Ramadan, During Ramadan and Post-Ramadan periods. there was a modest but significant reduction in weight but regained after Ramadan.

CONCLUSIONS

Our study suggests that for many people with diabetes fasting is not associated with an increased risk to their glycemic control, their weight and/or their blood pressure. Indeed, what is seen is marginal benefit or no change in all parameters. This stratifies the ongoing recommendation that allows patients with categorized as low risk to fast Ramadan or non-Ramadan days whenever desired.

Mitigation of hypoglycemia during Ramadan using the flash glucose monitoring system following dose adjustment of insulin and sulphonylurea in patients taking multiple glucose-lowering therapies (The PROFAST-IT Study)

BACKGROUND AND HYPOTHESIS

Patients with type-2 diabetes mellitus (T2DM) on multiple glucose-lowering therapies who fast during Ramadan are at increased risk of hypoglycemia. We have assessed the utility of the flash glucose monitoring system after adjusting the dose of insulin and sulphonylureas to mitigate the risk of hypoglycemia in patients with T2DM who fast during Ramadan.

PATIENTS AND METHODS

Patients with T2DM on either basal insulin or a sulphonylurea and at least 2 other glucose-lowering agents received structured education and adjustment of insulin or sulphonylurea dose according to the PROFAST Ramadan protocol. Glucose variability and episodes of hypoglycemia were assessed using the flash glucose monitoring system (Free Style Libre) before and during Ramadan.

RESULTS

A total of 33 patients with T2DM (on sulphonylurea (SU+) (n = 21), on basal insulin (BI+) (n = 12) aged 50.8 ± 1.6 years with a diabetes duration of 13.1 ± 6.5 years were studied. The average sensor glucose was 154 ± 34 mg/dl (8.5 ± 1.88 mmol/l) with 65.2% in the target range before Ramadan and the average sensor glucose was 156 ± 36 mg/dl (8.6 ± 2.0 mmol/l) with 67.1% in the target range during Ramadan. The incidence of hypoglycemia in the whole group (2.9 v 2.9) and in the SU+ (3.7 vs 3.0) and BI+ (1.7 vs 2.9) groups and eHbA1c (P = 0.56, P = 0.93), average glucose (P = 0.56, P = 0.92) and time within range (P = 0.63, P = 0.73) did not change in the SU+ and BI+ groups, respectively, before and during Ramadan.

CONCLUSION

Structured education with adjustment of the dose of glucose lowering medication alongside use of the FGMS can effectively mitigate the increased risk of hypoglycemia in patients with T2DM on multiple glucose-lowering therapies who fast during Ramadan.

Type 1 diabetes mellitus in children: experience in Indonesia

The prevalence of type 1 diabetes mellitus (T1DM) in children in Indonesia is increasing although the real number is unknown due to high rate of misdiagnosis. Public and healthcare awareness on T1DM in children is still low, reflected by the high number of children diagnosed with diabetic ketoacidosis (DKA). The Indonesian Pediatric Society (IPS) had published a guideline on T1DM management, which consists of insulin injection, daily monitoring of blood glucose, nutrition, physical activity, and education. Aside from low awareness, current challenges on T1DM management in Indonesia are funding by the national health insurance, fasting during Ramadan, and inequities on DM care. The involvement of society, healthcare workers, stakeholders, and the government is of importance to ensure optimal management for children with diabetes.

Impact of provision of optimum diabetes care on the safety of fasting in Ramadan in adult and adolescent patients with type 1 diabetes mellitus

BACKGROUND

All diabetes and Ramadan guidelines advice against fasting for people with type 1 diabetes, however, many insist on fasting. Consequently, this causes a challenge due to the risk of hypoglycaemia, hyperglycemia ± diabetic ketoacidosis.

AIM

To assess the impact of optimum care, which includes Ramadan-focused education, flash glucose monitoring, dietary advice and treatment adjustment on the safety of Ramadan fasting in people with type 1 diabetes.

METHODS

Thirty persons with type 1 diabetes who insisted to fast during Ramadan were recruited to the study. At pre-Ramadan visit, all patients received Ramadan focused education and Freestyle Libre (FSL) sensor insertion and training. Patients used the sensor for 6 weeks (pre-Ramadan and during Ramadan). The physical and biological parameters were collected 2-4 weeks before and after Ramadan.

RESULTS

22 patients on basal bolus insulin and 2 on an insulin pump had FSL data. Average number of days fasted were 24. Learning benefits was reported by 95% of patients following pre-Ramadan educational session. There was no clinically significant change in physical and/or biological data between pre and post-Ramadan. 63% reported making insulin dose adjustments in Ramadan. Flash glucose monitoring data showed 46.7% of patients had more than 10 hypoglycemic episodes in the 2 weeks prior to Ramadan compared to 29.2% during Ramadan. However, none of the data were statistically significant apart from HbA1c which reduced from prior to RamadanHbA1c of 8.2% to 7.9% post Ramadan (P 0.010). There was one DKA on 2nd day of Ramadan, reported due to missing insulin dose to avoid hypoglycemia.

CONCLUSION

Optimal care of selective patients with type 1 diabetes with a low complication rate may allow Ramadan fasting with improvement in glycemic control and without an increase in hypoglycemia, biometric or metabolic parameters. Larger, randomized controlled trials are required to be able to generalize this as a recommendation.

Initial increase in glucose variability during Ramadan fasting in non-insulin-treated patients with diabetes type 2 using continuous glucose monitoring

There are no studies evaluating the glucose variability in different periods of Ramadan fasting in patients with type 2 diabetes using continuous glucose monitoring (CGM). This study examined the effect of Ramadan fasting on interstitial glucose (IG) variability in early,- late-, and post-Ramadan compared to pre-Ramadan days in non-insulin-treated type 2 diabetes patients. Participants had a CGM system connected 2 or 3 days before Ramadan start, which was removed on the third or fourth day of Ramadan. CGM performance continued for a total of 6 days. A second CGM performance started on the 27th or 28th day of Ramadan and ended on the 4th or 5th post-Ramadan day. First, CGM recordings were divided into pre-Ramadan and early-Ramadan CGM, and second recordings into late-Ramadan and post-Ramadan. At each visit, blood pressure, body weight, and waist circumference were measured, and fasting blood samples were collected for HbA1c and plasma glucose. All patients received recommended Ramadan education before Ramadan. Thirty-three patients (mean age 55.0 ± 9.8 years, 73% males) were prospectively included. IG variability, estimated as mean amplitude of glycaemic excursions (MAGE), increased significantly in early-Ramadan compared to pre-Ramadan (P = 0.006) but not in late-Ramadan and post-Ramadan recording days. Only patients on >2 anti-diabetic drugs (n = 16, P = 0.019) and those on sulphonylureas (n = 14, P = 0.003) showed significant increase in MAGE in early-Ramadan. No significant changes were seen in coefficient of variation, time in range, time in hyperglycaemia, or time in hypoglycaemia. Except for an initial increase in glucose variability, fasting Ramadan for patients with non-insulin-treated type 2 diabetes did not cause any significant changes in glucose variability or time in hypoglycaemia during CGM recording days compared to non-fasting pre-Ramadan period.

Fasting during the holy month of Ramadan among older children and adolescents with type 1 diabetes in Kuwait

Background To evaluate the safety of fasting during the holy month of Ramadan among children and adolescent with type 1 diabetes (T1D). Methods A retrospective cohort study of 50 children and adolescents with T1D whose mean age was 12.7 ± 2.1 years was conducted. Twenty-seven patients (54%) were on multiple daily injections (MDI) insulin regimen and 23 (46%) were on insulin pump therapy. Before fasting for Ramadan, children and their families were evaluated and educated about diabetes management during Ramadan. Hemoglobin A1c (HbA1c), weight, number of days fasted, hypoglycemia and hyperglycemia episodes, and emergency hospital visits were collected and analyzed after completing the month. Participants were compared according to the insulin treatment regimen and their glycemic control level before Ramadan. Results The children were able to fast 20 ± 9.9 days of Ramadan, and the most common cause for breaking the fast was mild hypoglycemia (7.8% among all cases). There was no significant difference between the two insulin regimen groups in breaking fast days, frequency of hypo- or hyperglycemia, weight and HbA1c changes post Ramadan. Patients with HbA1c ≤ 8.5% were able to fast more days during Ramadan with significantly less-frequent hypoglycemic attacks as compared to patients with HbA1c > 8.5 (1.2 ± 1.5 vs. 3.3 ± 2.9 days of hypoglycemia, p = 0.01, respectively). Conclusions Fasting for children with T1D above the age of 10 years is feasible and safe in both pump and non-pump users, and well-controlled patients are less likely to develop complications. Education of the families and their children before Ramadan, along with intensive monitoring of fasting children during the month are crucial.

Diabetes and Ramadan: Utility of flash-glucose monitoring derived markers of glycaemic control and comparison with glycosylated haemoglobin

AIMS

Flash glucose monitoring (FGM)-derived markers of glucose control and variability and laboratory measured HbA1c among patients with diabetes on insulin in context of Ramadan fasting (RF) were examined and compared.

METHODS

FGM data on insulin-treated patients (n = 20, age 42.3 ± 11.4 years; 18 male, 2 female; 13 with type 1 and 7 with type 2 diabetes) who fasted during Ramadan were used to calculate Q-score as an indicator of glycaemia before, during and after RF. Post-hoc analysis in a group of patients (n = 12) who had HbA1c available and appropriate for these periods was performed. Other relevant data were extracted from patient records.

RESULTS

Mean glucose (9.6 ± 1.32 v 10.78 ± 1.64 mmol/l; P < 0.0001) and Q-score increased significantly with Ramadan fasting and reduced after Ramadan. Post-hoc subgroup analysis showed a significant rise in eA1c (7.2 ± 0.4%; 55.0 ± 4.4 mmol/mol v 7.7 ± 0.5%; 61.0 ± 5.5 mmol/mol) but not in laboratory HbA1c with Ramadan fasting; eA1c reduced after Ramadan (P = 0.018).

CONCLUSIONS

Ramadan fasting was associated with a deterioration in overall glucose control and time in hyperglycaemia in insulin-treated patients. FGM-derived markers are useful and a preferable alternative to HbA1c in Ramadan studies.

The role of optimum diabetes care in form of Ramadan focused diabetes education, flash glucose monitoring system and pre-Ramadan dose adjustments in the safety of Ramadan fasting in high risk patients with diabetes

BACKGROUND

Physiology of intermittent and prolonged fasting is known from healthy subjects. Evidence on high and very high-risk groups is lacking. The anticipated risks include hypoglycemia, hyperglycemia, dehydration and thrombosis. Education, pre-Ramadan doses adjustment, and glucose monitoring devices (Optimum diabetes care in Ramadan) is expected to lower this risk.

AIMS

We aimed to assess the value of optimum care in diabetes management during Ramadan on the metabolic parameters of high risk patients with diabetes. Moreover, we wanted to assess and understand the safety of fasting in this group.

METHODS

This is a prospective interventional study. Patient with high-risk diabetes who insisted on fasting. High risk patients defined as any one with type 1 or type 2 diabetes on insulin, Gestational diabetes, stage 3 kidney disease, and having history of ischemic heart disease. All patients received a Freestyle Libre continuous glucose monitoring device, and was offered to attend the clinic at any time during the study, this collectively defined as optimum diabetes care during Ramadan. Biometric (Weight, height, Blood pressure) and biochemical (Glycosylated hemoglobin A, Lipids profile, creatinine, and estimated glomerular filtration rate) were reported within 4-6 weeks before and after Ramadan.

RESULTS

Total of 169 patients were. Majority were females 54.4% (n = 92). There was a remarkable improvement in glycemic control from 7.6 + 1.2 to 7.3 + 1.2 percent (p = 0.00). Serum creatinine showed a negligible change at the end of the study from 0.81 + 0.3 to 0.82 + 0.2 mg/dl). Only total cholesterol worsened significantly (p = 0.02).

Intermittent Fasting Could Be Safely Achieved in People With Type 1 Diabetes Undergoing Structured Education and Advanced Glucose Monitoring

Background: Fasting during Ramadan is a form of intermittent fasting in which a person abstains from oral intake between the hours of sunrise and sunset. The fasting month of Ramadan is observed by Muslims worldwide. People with type 1 diabetes (T1DM) who choose to fast during Ramadan are at a particularly high risk of acute diabetes complications including hypoglycemia and significant hyperglycemia. We hypothesized that people with uncomplicated T1DM would be able to fast safely during Ramadan following structured education and with daily advanced glucose monitoring. Methods: People with stable and uncomplicated T1DM treated with multiple daily injections (MDIs) or continuous subcutaneous insulin infusion (CSII) who chose to fast during Ramadan were recruited for the study. Participants attended Dose Adjustment for Normal Eating (DAFNE) structured education training, and basal insulin was reduced in a controlled fashion. Participants were assigned a sensor-augmented insulin pump or FreeStyle Libre for advanced glucose monitoring. The primary endpoint was the rate of hypoglycemia during Ramadan compared to before Ramadan. Secondary endpoints were percentage time spent <4 mmol/L, >10 mmol/L (range, 4-10 mmol/L), episodes of diabetic ketoacidosis (DKA), and acute kidney injury or hospitalization for any cause. Results: Rates of hypoglycemia were significantly reduced during Ramadan compared with rates before Ramadan (0.53 ± 0. 49 vs. 0.81 ± 0.69 episodes/day, p = 0.0015). No episodes of severe hypoglycemia, DKA, acute kidney injury, or hospitalization occurred during Ramadan period. Percentage time spent >10 mmol/L (46.7 ± 17.7% vs. 42.5 ± 16.4%, p = 0.03) was significantly increased, and percentage time [range, 4-10 mmol/L (48.8 ± 15.9% vs. 50.9 ± 15.9%, p = 0.13)] and percentage time spent <4 mmol/L (4.7 ± 5.4.7% vs. 5.7 ± 6.3%, p = 0.09) were reduced, but these differences were not significant. Conclusions: People with uncomplicated T1DM could safely participate in intermittent fasting similar to Ramadan fasting if equipped with structured education and advanced glucose monitoring systems.

Comparison of continuous glucose monitoring in adolescents with type 1 diabetes: Ramadan versus non-Ramadan

AIM

To assess the impact of fasting on interstitial glucose (IG) in adolescents with type 1 DM (T1DM) by using continuous glucose monitoring (CGM).

METHOD

A minimum of 2.5 days CGM was done on adolescents with T1DM during fasting in Ramadan and in the month before or after Ramadan to compare the differences in mean IG, and in the durations of hypoglycemia (<70 mg/dL), hyperglycemia (200-299 mg/dL), and severe hyperglycemia (≥300 mg/dL).

RESULTS

Fourteen adolescents were studied, age 15 ± 4 years, duration of diabetes 6 ± 4 years, and HbA1C 8.6 ± 1.1% (70.3 mmol/mol). There was no difference in the mean IG (190 ± 39 and 180 ± 37, p= 0.4), or in the durations of hypoglycemia (5.14 ± 5% and 7.03 ± 4.9%, p=0.3), hyperglycemia (25.35 ± 11.3% and 24.24 ± 10.1% (P=0.7)), and severe hyperglycemia (13.21 ± 13.4% and 10.96 ± 10.6%, P=0.6), between Ramadan and, non-Ramadan, respectively.

CONCLUSION

Adolescents with T1DM have the same wide fluctuation in IG during fasting in Ramadan as they do outside Ramadan. Insulin regimen adjustment should be targeting both extremes of glucose abnormality.