The value of Continuous Glucose Monitoring and Self-Monitoring of Blood Glucose in patients with Gestational Diabetes Mellitus during Ramadan fasting

Reflection on Ramadan Fasting Research Related to Sustainable Development Goal 3 (Good Health and Well-Being): A Bibliometric Analysis

There is a large body of research on Ramadan intermittent fasting (RIF) and health in Muslim communities, that can offer insights to promote the achievement of Sustainable Development Goal 3 (SDG 3), which encompasses good health and well-being. Based on recent bibliometric evidence, we hypothesized that RIF research is highly relevant to SDG 3, particularly Targets 3.1, 3.2, 3.4, and 3.5. Therefore, this bibliometric study quantified RIF literature supporting SDG 3 and associated targets over the past seven decades and explored themes and trends. All types of research articles were extracted from the Scopus database from inception to March 2022. Microsoft Excel, Biblioshiny, and VOSviewer were used to qualitatively and quantitatively examine RIF research trends supporting SDG 3 and associated targets. We identified 1729 relevant articles. The number of publications notably increased since 1986, with a dramatic increase in 2019-2020. RIF research predominantly supported Target 3.4 (reducing risk for non-communicable diseases), with research hotspots being diabetes, diabetes medications, pregnancy, physiology, metabolic diseases, and obesity and metabolism. This target was also the most commonly supported by dedicated authors and institutions publishing on RIF, whereas other SDG 3 targets were negligibly addressed in comparison. Our comprehensive bibliometric analysis of RIF literature showed growing support for SDG 3 through positive contributions to half of the SDG 3 targets, although Target 3.4 received the most attention. We also identified knowledge gaps that may shape further research directions on RIF and promote the achievement of SDG 3 in Muslim communities.

Effect of Ramadan Fasting on Blood Glucose Level in Pregnant Women with Gestational and Type 2 Diabetes

Background

Pregnant women with diabetes are strongly advised against Ramadan fasting and have religious exemption, but a large proportion still choose to fast. Unfortunately, there is little information about glycemic control in these patients. This study aims to determine the fasting and postprandial blood glucose levels and to predict the risk factors for hypoglycemia in pregnant women with type 2 diabetes mellitus (DM) and gestational DM (GDM) who fast during Ramadan.

Methods

A prospective cohort research was conducted at a single tertiary hospital between 2021 and 2023 on 70 pregnant women with GDM (n = 53) and type 2 DM (n = 17) in their second and third trimester. Their fasting and postprandial blood glucose levels during Ramadan were compared to those of the previous month, and hypoglycemia was defined as blood glucose levels less than 60 mg/dl. Binary regression was used to predict the risk variables for hypoglycemia.

Results

The GDM and type 2 DM groups were similar in terms of age, parity, number of fasting days, and number of daily fasting hours. Only 26.9% of the women who were permitted to fast were given special instructions for Ramadan fasting. Dietary intervention was more common in the GDM group, whereas insulin and metformin treatment were more common in the type 2 DM group. The fasting glucose level decreased significantly after Ramadan fasting in both groups, from 92.5 (17.4) mg/dl to 90 (17.13) mg/dl (p = 0.033). However, there were a significantly higher number of hypoglycemia events in the type 2 DM group. Further, type 2 DM was identified as a risk factor for hypoglycemia (OR = 6.23; 95% CI = 1.04-37.54; P = 0.046.

Conclusion

The present findings indicate that Ramadan fasting may improve fasting glucose control. In addition, type 2 DM was identified as a risk factor for hypoglycemia.

Efficacy of Continuous Glucose Monitoring on Glycaemic Control in Pregnant Women with Gestational Diabetes Mellitus-A Systematic Review

Gestational diabetes mellitus (GDM) is one of the most common complications of pregnancy, affecting up to 14% of pregnant women. The population of patients with risk factors of GDM is increasing; thus, it is essential to improve management of this condition. One of the key factors affecting perinatal outcomes in GDM is glycaemic control. Until recently, glucose monitoring was only available with self-monitoring of blood glucose (SMBG). However, nowadays, there is a new method, continuous glucose monitoring (CGM), which has been shown to be safe in pregnancy. Since proper glycaemia assessment has been shown to affect perinatal outcomes, we decided to perform a systematic review to analyse the role of CGM in glycaemic control in GDM. We conducted a web search of the MEDLINE, EMBASE, Cochrane Library, Scopus, and Web of Science databases according to the PRISMA guidelines. The web search was performed by two independent researchers and resulted in 14 articles included in the systematic review. The study protocol was registered in the PROSPERO database with registration number CRD42021289883. The main outcome of the systematic review was determining that, when compared, CGM played an important role in better glycaemic control than SMBG. Furthermore, glycaemic control with CGM improved qualification for insulin therapy. However, most of the articles did not reveal CGM’s role in improving neonatal outcomes. Therefore, more studies are needed to analyse the role of CGM in affecting perinatal outcomes in GDM.

Diabetes and Ramadan: Practical guidelines 2021

Fasting during Ramadan is one of the five pillars of Islam and is obligatory for all healthy Muslims from the age of puberty. Though individuals with some illness and serious medical conditions, including some people with diabetes, can be exempted from fasting, many will fast anyway. It is of paramount importance that people with diabetes that fast are given the appropriate guidance and receive proper care. The International Diabetes Federation (IDF) and Diabetes and Ramadan (DaR) International Alliance have come together to provide a substantial update to the previous guidelines. This update includes key information on fasting during Ramadan with type 1 diabetes, the management of diabetes in people of elderly ages and pregnant women, the effects of Ramadan on one's mental wellbeing, changes to the risk of macrovascular and microvascular complications, and areas of future research. The IDF-DAR Diabetes and Ramadan Practical Guidelines 2021 seek to improve upon the awareness, knowledge and management of diabetes during Ramadan, and to provide real-world recommendations to health professionals and the people with diabetes who choose to fast.

Largest Amplitude of Glycemic Excursion Calculating from Self-Monitoring Blood Glucose Predicted the Episodes of Nocturnal Asymptomatic Hypoglycemia Detecting by Continuous Glucose Monitoring in Outpatients with Type 2 Diabetes

AIMS

Nocturnal asymptomatic hypoglycemia (NAH) is a serious complication of diabetes, but it is difficult to be detected clinically. This study was conducted to determine the largest amplitude of glycemic excursion (LAGE) to predict the episodes of NAH in outpatients with type 2 diabetes.

METHODS

Data were obtained from 313 outpatients with type 2 diabetes. All subjects received continuous glucose monitoring (CGM) for consecutive 72 hours. The episodes of NAH and glycemic variability indices (glucose standard deviation [SD], mean amplitude of plasma glucose excursion [MAGE], mean blood glucose [MBG]) were accessed via CGM. LAGE was calculated from self-monitoring blood glucose (SMBG).

RESULTS

A total of 76 people (24.3%) had NAH. Compared to patients without NAH, patients with NAH showed higher levels of glucose SD (2.4 ± 0.9 mmol/L vs 1.7 ± 0.9 mmol/L, p <0.001), MAGE (5.2 ± 2.1 mmol/L vs 3.7 ± 2.0, p<0.001) and LAGE (4.6 ± 2.3 mmol/L vs 3.8 ± 1.9 mmol/L, p=0.007), and lower level of MBG (7.5 ± 1.5 mmol/L vs 8.4 ± 2.2 mmol/L, p=0.002). LAGE was significantly associated with the incidence of NAH and time below rang (TBR) in model 1 [NAH: 1.189 (1.027-1.378), p=0.021; TBR: 0.008 (0.002-0.014), p=0.013] with adjustment for age, BMI, sex, work, hyperlipidemia, complication and medication, and in model 2 [NAH: 1.177 (1.013-1.367), p=0.033; TBR: 0.008 (0.002-0.014), p=0.012] after adjusting for diabetes duration based on model 1, as well as in model 3 [NAH: 1.244 (1.057-1.464), p=0.009; TBR: 0.009 (0.002-0.016), p=0.007] with further adjustment for HbA1c based on model 2. In addition, no significant interactions were found between LAGE and sex, age, HbA1c, duration of diabetes, BMI and insulin therapy on the risk of NAH. The receiver operator characteristic (ROC) curve shows the ideal cutoff value of LAGE for the prediction of NAH was 3.48 mmol/L with 66.7% sensitivity, 50% specificity and 0.587 (95% CI: 0.509-0.665) of area under the ROC curve.

CONCLUSIONS

High glycemic variability is strongly associated with the risk of NAH. The LAGE based on SMBG could be an independent predictor of NAH for outpatients with type 2 diabetes, and LAGE greater than 3.48 mmol/L could act as a warning alarm for high risk of NAH in daily life.

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.

Evaluation of optimum diabetes care on glycemic control of patients with gestational diabetes during Ramadan fasting

AIMS

There is limited evidence that evaluates the impact of fasting during Ramadan in pregnant women. We explored the safety of fasting in Gestational Diabetes Mellitus (GDM) in Ramadan, while understating the glycemic variability.

METHODS

25 patients with GDM who choose to fast, were enrolled and provided optimum care that included Ramadan focused education and FreeStyle LibreFlashContinuous Glucose Monitoring(FSL-CGM) was utilized for 2-4 weeks assessment period of non-Ramadan days plus 2-3 weeks during Ramadan and medication adjustment.

RESULTS

The average glucose improved significantly, while time in target and percent above target numerically improved during Ramadan compared to pre-Ramadan. There was significant increment on the number of hypoglycemic events in Ramadan. The average lowest blood glucose reading reduced significantly by 14 mg/dL with average duration of hypoglycemic events increased significantly by 38.5 min.

CONCLUSION

Our study reinforces the importance of structured education before Ramadan to deliver optimal care for the management of diabetes. Strikingly FSL-CGM demonstrated that hypoglycemia is significantly increased during Ramadan Fasting. There was effective reflection of hyperglycemic spikes, immediately post Iftar. The results corroborated with the earlier studies for higher frequency of hypoglycemia during Ramadan fasting, under similar standards of care in high-risk patients with diabetes.

Ramadan fasting and diabetes 2019: The year in review

INTRODUCTION

The literature on health aspects of Ramadan fasting is widely spread in many journals making it not readily available to those interested in the subject.

MATERIALS AND METHODS

A narrative, non-systematic review of the international literature from two major online databases (viz. Scopus, PubMed) in one year (2019). The search term "Ramadan fasting AND Diabetes" was used, and relevant literature was narrated in a concise thematic account.

RESULTS

Research design included qualitative, quantitative, and mixed methods. Articles included controlled trials, critical appraisals, literature narrations, and systematic reviews, and meta-analyses. The publications spanned a vast array of topics related to Ramadan fasting, including assessments of current safety and efficacy profiles of newer diabetes therapies, modes of insulin delivery, and utilization of advanced technology for the treatment and monitoring of blood glucose during Ramadan fasting. Increased interest was particularly evident in capturing the experience element manifested by perceptions, attitudes, and practices of both patients and healthcare professionals during Ramadan. The current literature consolidates previous data on the safety of fasting practices amongst the well-controlled. On the other hand, it emphasizes the need for more aggressive interventions for high-risk patients, promoting the usage of newer anti-diabetic agents and advanced glucose monitoring technology for safer fasting practices.

CONCLUSIONS

The volume of global literature production related to Ramadan fasting and Diabetes remains modest. Observational studies of small size prevail. Greater improvements in both quality and quantity of research on Ramadan are needed.

Sudden death in epilepsy: There is room for intracranial pressure

INTRODUCTION

Sudden unexpected death in patients with epilepsy (SUDEP) remains a poorly understood entity, and it is unclear whether the same pathomechanisms underlie all sudden deaths occurring in patients with epilepsy. One aspect not included in current models of SUDEP is the role of increased intracranial pressure (ICP) which can be observed immediately upon seizure activity in neurosurgical practice.

METHODS

We conducted a systematic review of the occurrence of edema in patients with epilepsy reported to have died of sudden death who underwent brain autopsy or postmortem brain imaging and discuss how increased ICP may contribute to clinical features of SUDEP.

RESULTS

19 eligible studies comprising a total of 623 patients were identified. Edema-mostly mild or moderate-was reported in 17% of cases and 74% of studies. 1% (n = 6) of the overall cases were clearly identified as having Dravet syndrome or an SCN1A mutation. In these patients, edema was found in 4 (67%) of cases.

CONCLUSION

Edema is regularly found in patients with epilepsy classified to have died from SUDEP. We argue that seizures preceding SUDEP may in certain cases elicit acute edema which may represent an additional contributing factor in the cascade of events leading to sudden death of patients with epilepsy. Furthermore, we hypothesize that mild edema may especially progress to severe edema in patients with sodium channel mutations which may represent an important mechanism to investigate in the context of understanding the significantly elevated risk of SUDEP in patients with SCN1A mutations.

The impact of Ramadan fasting on glucose variability in type 2 diabetes mellitus patients on oral anti diabetic agents

Ramadan fasting is associated with changes in eating, physical activity, sleeping patterns, and medication. Unfortunately, only limited studies examine glucose variability in subjects with type 2 diabetes who fast in Ramadan. Our study aims to evaluate glucose variability in subjects with type 2 diabetes on oral antidiabetic agents using continuous glucose monitoring system (CGMS) during and after Ramadan fasting. This observational study was done in The Indonesian Medical Education and Research Institute, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia, which recruited 10 subjects with type 2 diabetes who underwent Ramadan fasting in 2019. These subjects were free from cardiovascular disease, kidney disease, severe liver disease, chronic gastrointestinal disease and autoimmune disease. Insertion of CGMS for measuring interstitial glucose was performed after at least 2 weeks of Ramadan fasting and 4 weeks after the end of the Ramadan fasting, with a minimum of 3 days observation. The mean amplitude of glycemic excursion (MAGE) during and after Ramadan were similar (p = 0.94). In line with this, the average interstitial glucose (p = 0.48), the maximum interstitial glucose (p = 0.35), the minimum interstitial glucose (p = 0.24), and the duration of hypoglycemia (p = 0.25) were also similar in both periods. Overall, nutritional intake and energy expenditure during both periods were comparable. Ramadan fasting is not associated with increased glucose variability in subjects with type 2 diabetes. Thus, Ramadan fasting is safe in subjects with type 2 diabetes with no complications.

The Role of Dietary Carbohydrates in Gestational Diabetes

Gestational diabetes (GDM) is hyperglycemia that is recognized for the first time during pregnancy. GDM is associated with a wide range of short- and long-term adverse health consequences for both mother and offspring. It is a complex disease with a multifactorial etiology, with disturbances in glucose, lipid, inflammation and gut microbiota. Consequently, its management is complex, requiring patients to self-manage their diet, lifestyle and self-care behaviors in combination with use of insulin. In addition to nutritional recommendations for all pregnant women, special attention to dietary carbohydrate (CHO) amount and type on glucose levels is especially important in GDM. Dietary CHO are diverse, ranging from simple sugars to longer-chain oligo- and poly- saccharides which have diverse effects on blood glucose, microbial fermentation and bowel function. Studies have established that dietary CHO amount and type can impact maternal glucose and nutritional recommendations advise women with GDM to limit total intake or choose complex and low glycemic CHO. However, robust maternal and infant benefits are not consistently shown. Novel approaches which help women with GDM adhere to dietary recommendations such as diabetes-specific meal replacements (which provide a defined and complete nutritional composition with slowly-digested CHO) and continuous glucose monitors (which provide unlimited monitoring of maternal glycemic fluctuations) have shown benefits on both maternal and neonatal outcomes. Continued research is needed to understand and develop tools to facilitate patient adherence to treatment goals, individualize interventions and improve outcomes.

Ultrasonication assisted synthesis of NiO nanoparticles anchored on graphene oxide: an enzyme-free glucose sensor with ultrahigh sensitivity

In recent years, the cost-effective fabrication of inorganic materials has received considerable attention from researchers working in various fields.

A Review of Research Progress on Glycemic Variability and Gestational Diabetes

Gestational diabetes mellitus (GDM) is associated with many adverse obstetric outcomes and neonatal outcomes, including preeclampsia, Cesarean section, and macrosomia. Active screening and early diabetes control can reduce the occurrence of adverse outcomes. Glycosylated hemoglobin (HbA1c) only reflects average blood glucose levels, but not glycemic variability (GV). Studies have shown that GV can cause a series of adverse reactions, and good control of GV can reduce the incidence of adverse pregnancy outcomes in patients with GDM. In order to provide clinicians with a better basis for diagnosis and treatment, this study reviewed the measurement, evaluation, and control of GV, the importance of GV for patients with GDM, and correlations between GV and maternal and neonatal outcomes.