Impact of optimum diabetes care on the safety of fasting in Ramadan in adult patients with type 2 diabetes mellitus on insulin therapy

Asia-Pacific Perspectives on the Role of Continuous Glucose Monitoring in Optimizing Diabetes Management

Diabetes is prevalent, and it imposes a substantial public health burden globally and in the Asia-Pacific (APAC) region. The cornerstone for optimizing diabetes management and treatment outcomes is glucose monitoring, the techniques of which have evolved from self-monitoring of blood glucose (SMBG) to glycated hemoglobin (HbA1c), and to continuous glucose monitoring (CGM). Contextual differences with Western populations and limited regionally generated clinical evidence warrant regional standards of diabetes care, including glucose monitoring in APAC. Hence, the APAC Diabetes Care Advisory Board convened to gather insights into clinician-reported CGM utilization for optimized glucose monitoring and diabetes management in the region. We discuss the findings from a pre-meeting survey and an expert panel meeting regarding glucose monitoring patterns and influencing factors, patient profiles for CGM initiation and continuation, CGM benefits, and CGM optimization challenges and potential solutions in APAC. While CGM is becoming the new standard of care and a useful adjunct to HbA1c and SMBG globally, glucose monitoring type, timing, and frequency should be individualized according to local and patient-specific contexts. The results of this APAC survey guide methods for the formulation of future APAC-specific consensus guidelines for the application of CGM in people living with diabetes.

Effects of structured Ramadan Nutrition Plan on glycemic control and variability using continuous glucose monitoring in individuals with type 2 diabetes: A pilot study

BACKGROUND AND AIMS

Continuous glucose monitoring (CGM) has been increasingly used in recent years to evaluate glycemic control and variability in individuals with diabetes observing Ramadan fasting. However, the effectiveness of the Ramadan Nutrition Plan (RNP) in individuals with type 2 diabetes (T2D) using CGM-derived measures has not been investigated. The study aimed to evaluate the effects of structured RNP versus standard care using CGM in individuals with T2D.

METHODS

This parallel non-randomized interventional study with patients' preference design involved 21 individuals with T2D (mean age: 49 ± 10 years, BMI: 30.0 ± 6.2 kg/m²). Participants chose to receive either structured RNP (sRNT; structured Ramadan Nutrition Therapy group; n = 14) or standard care (SC; n = 7). Participants wore CGM 5 days before Ramadan and during Ramadan. CGM-derived measures of glycemic variability were calculated using Glyculator version 2.0.

RESULTS

Compared to the SC group, the sRNT group significantly reduced their fasting blood glucose levels, HbA1c, total cholesterol, diastolic blood pressure, and increased dietary fiber intake. CGM data showed the sRNT group had significantly lower average sensor glucose, peak sensor value, estimated A1c, percentage and duration of time-above-range, J-index, mean amplitude of glycemic excursion (MAGE), and continuous overall net glycemic action (CONGA); and a significantly higher percentage of time-in-range (TIR).

CONCLUSIONS

The structured RNP significantly improved clinical outcomes, glycemic control and variability in individuals with T2D. The study highlights the importance of utilizing CGM sensor data to monitor glycemic excursions during Ramadan fasting. Adequately powered randomized controlled trials are needed to confirm the findings.

The Effect of Coronavirus Disease-19 Pandemic Lockdown and the Overlapping Ramadan Fasting Period on Glucose Control in Insulin-Treated Patients With Diabetes: A Flash Glucose Monitoring Study

Background

A strict lockdown was enforced during coronavirus disease (COVID-19) pandemic in many countries including the UAE. Lockdown period overlapped with Ramadan which is accompanied by its own drastic changes in lifestyle that include meal timings.

Aims

We report the impact of COVID-19 lockdown (between 22/3/2020 and 24/6/2020) on glucose control pre- and postlockdown and during Ramadan, in patients with type 1 diabetes (T1D) and type 2 diabetes (T2D) on insulin therapy.

Methods

A number of twenty-four patients (19 men, 6 women) who were monitoring their glucose levels using flash glucose monitoring (FGM) and remotely connected to the diabetes clinic in Imperial College London Diabetes Centre (ICLDC), Abu Dhabi, UAE were included. Using the international consensus on the use of continuous glucose monitoring guidelines, analyses of data were performed on glucose management indicator (GMI), time in range (TIR), time in hyperglycemia, time in hypoglycemia, low blood glucose index (LBGI) and high blood glucose index (HBGI). Variables were calculated for each period: 30 days before lockdown 14/2/2020-14/3/2020, 30 days into lockdown and pre-Ramadan 20/3/2020-18/4/2020, and 30 days into lockdown and Ramadan 24/4/2020-23/5/2020, using cgmanalysis package in R-studio software.

Results

Mean average glucose (MAG) remained steady before and during lockdown, and no significant differences were observed in TIR, time in hypoglycemia, and LBGI between prelockdown and lockdown periods. However, there was a statistically significant difference in GMI and percentage of time in hyperglycemia (>10.0 mmol/L) between Ramadan and pre-Ramadan during the lockdown period in p = 0.007, 0.006, and 0.004, respectively. Percentage of TIR (3.9-10.0 mmol/L) was significantly lower in Ramadan as compared to pre-Ramadan (50.3% vs. 56.1%; p = 0.026). Mean absolute glucose (MAG) (182.0 mmol/L vs. 166.6 mmol/L, p = 0.007) and HBGI (10.2 (6.8, 14.8) vs. 11.9 (7.9, 17.8), p = 0.037) were significantly higher in Ramadan compared to pre-Ramadan period. There was no statistically significant difference in percentage of time in hypoglycemia (<3.9 mmol/L) and LBGI between Ramadan and pre-Ramadan periods.

Conclusion

The lockdown period had no significant effects in the markers of glycemic control in the population studied. However, Ramadan fasting period embedded within this time was associated with several changes that include increase in GMI, HBGI, and glycemic variability similar to what has been reported in other Ramadan studies.

Evidence-based risk factors for major complications during Ramadan fasting in people with diabetes grouped under IDF-DAR risk categories

AIM

To identify evidence-based risk factors for major complications during Ramadan fasting in people with diabetes grouped under IDF-DAR risk categories.

METHODS

This prospective observational multicenter study was conducted by Baqai Institute of Diabetology and Endocrinology (BIDE) between April-June 2019. People with diabetes having intention to fast during Ramadan were recruited. Demographic data collection along with risk categorization was done during pre-Ramadan visit. Structured education was given on one- to-one basis to each of the study participants. Assessment of complications was done during post Ramadan visit.

RESULTS

A total of 1045 people with diabetes participated with near equal gender distribution. Two thirds of study population was grouped into very high- and high-risk categories. Frequencies of major hypoglycemia, major hyperglycemia, hospitalization & need to break the fast were 4.4%, 10.8%, 0.8% & 3.1% respectively. On multivariate analysis, the risk factors found for major hypoglycemia during Ramadan were male gender, use of sedatives & antidepressants & having type1 diabetes mellitus, history of DKA/HHS during last 3 months for major hyperglycemia, major hypoglycemia & hospitalization for breaking of fast while older age, acute illness, and major hypoglycemia were identified factors for hospitalization.

CONCLUSION

In this prospective study evidence-based risk factors for fasting related major complications were identified in people with diabetes. It is imperative to recognize these factors during pre-Ramadan risk assessment visit.

Changes in dietary intake improve glycemic control following a structured nutrition therapy during Ramadan in individuals with type 2 diabetes

BACKGROUND AND AIMS

It is unknown whether dietary modifications during Ramadan could influence glycemic control in diabetes. This study assessed dietary intake following structured Ramadan nutrition therapy and determined the association between changes in dietary intake and glycemic control parameters in patients with type 2 diabetes.

METHODS

This was an 8-week, parallel-group, non-randomised study of 60 type 2 diabetes patients who opted for structured Ramadan Nutrition Therapy (sRNT; n = 38) or standard care (SC; n = 22) group. The sRNT group received a structured Ramadan Nutrition Plan incorporated with diabetes-specific formula throughout the study, while SC received standard nutrition care. The 3-day food records assessed dietary intake at three-time points.

RESULTS

At baseline, dietary characteristics were comparable; both groups had macronutrient intakes within the recommended range, but inadequate intakes of fiber and 11 essential micronutrients. After 8 weeks, the sRNT group significantly reduced intakes of carbohydrate, dietary glycemic index, glycemic load, and increased percentage of total energy intake from protein, fiber, pyridoxine, vitamin C, vitamin D, calcium, and chromium compared with the SC group. In the sRNT group, compliance to diabetes-specific formula predicted changes in HbA1c (p = 0.024), while fiber intake predicted fasting plasma glucose (p = 0.035), after adjusting for age, sex, weight changes and other dietary variables.

CONCLUSION

Intakes of certain nutrients improved significantly in sRNT group after 8 weeks of receiving a structured Ramadan Nutrition Plan compared to the standard care. The structured Ramadan Nutrition Plan with the incorporation of diabetes-specific formula significantly improved glycemic control and dietary adequacy during Ramadan fasting.

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.

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.

Ramadan-focused nutrition therapy for people with diabetes: A narrative review

AIMS

This narrative review aimed to synthesize the evidence on the effects of Ramadan-focused nutrition therapy for people with diabetes.

METHODS

We searched MEDLINE (via PubMed) and Science Direct databases for articles that included the component of nutrition for adult patients with type 2 diabetes (T2D), published in English between 2010 and 2020.

RESULTS

Fourteen studies met the criteria. Eight of 14 studies had an intervention with a control arm. In comparison to the control group, all studies (n = 8) showed a reduction in hypoglycemic events. However, only half of these studies (n = 4) had shown at least one positive clinical outcome. Features of nutrition therapy that appeared to have favorable clinical outcomes include individualized caloric prescription; distributing carbohydrates equally between Suhoor, Iftar and snacks; providing meal plans; adjusting food intake to suit Ramadan; and incorporating diabetes-specific formula as part of Suhoor or snack.

CONCLUSIONS

The review provides evidence for the effectiveness of Ramadan-focused nutrition therapy among people with T2D and identifies key features of nutrition therapy that may provide favourable clinical outcomes. Additional data on dietary quality and adequacy during Ramadan fasting warrants further studies.

Impact of Ramadan Diurnal Intermittent Fasting on Hypoglycemic Events in Patients With Type 2 Diabetes: A Systematic Review of Randomized Controlled Trials and Observational Studies

Ramadan is the 9th month of the lunar calendar during which Muslims abstain from food and drink between dawn and sunset for 30 consecutive days. Ramadan fasting is observed by all healthy Muslim adults, as well many Muslims with type 2 diabetes (T2DM). Hypoglycemic events (HE) are a serious complication associated with diabetes management and are associated with increased cardiovascular disease risk. Conflicting results have been reported concerning the incidence of HE among people with T2DM observing Ramadan fasting. This review summarizes available scientific evidence on the occurrence of HE and the effects of different moderators on the incidence of HE among patients with T2DM during Ramadan. We conducted a systematic review of available observational studies and randomized controlled trials (RCTs) for patients with T2DM who fasted during Ramadan, with HE as the primary outcome. Ten databases were searched for relevant studies from inception until October 31, 2020. In total, 68 studies (35 RCTs and 33 observational studies) met the inclusion criteria. Non-sulfonylureas hypoglycemic medications showed superior effects in lowering the incidence of HE over sulfonylureas hypoglycemic medications. Variable moderators were associated with experiencing HE during Ramadan in both observational studies and RCTs, including sex, geographical location, body anthropometric indicators, season, dietary behaviors, fasting duration, time since diagnosis, and pre-fasting education. This comprehensive systematic review covered the largest number of observational and clinical studies investigating the impact of Ramadan on HE among patients with T2DM. The study highlights the significance of different moderators that influence the effect of Ramadan fasting on HE, including dietary behaviors, fasting time duration, sex, season, country, pre-fasting education, age, and time since diagnosis. The study also highlighted the impact of different hypoglycemic medications on HE and noted the superiority of non-sulfonylureas over sulfonylureas hypoglycemic medications in lowering the risk for hypoglycemia in people with T2DM during Ramadan fasting.

Managing People with Diabetes Fasting for Ramadan During the COVID-19 Pandemic: A South Asian Health Foundation Update

The month of Ramadan forms one of the five pillars of the Muslim faith. Adult Muslims are obligated to keep daily fasts from dawn to sunset, with exceptions. This year Ramadan is due to begin on 23 April 2020 and the longest fast in the UK will be approximately 18 hours in length. In addition, due to the often high-calorie meals eaten to break the fast, Ramadan should be seen as a cycle of fasting and feasting. Ramadan fasting can impact those with diabetes, increasing the risk of hypoglycaemia, hyperglycaemia and dehydration. This year, Ramadan will occur during the global COVID-19 pandemic. Reports show that diabetes appears to be a risk factor for more severe disease with COVID-19. In addition, the UK experience has shown diabetes and COVID-19 is associated with dehydration, starvation ketosis, diabetic ketoacidosis and hyperosmolar hyperglycaemic state. This makes fasting in Ramadan particularly challenging for those Muslims with diabetes. Here, we discuss the implications of fasting in Ramadan during the COVID-19 pandemic and make recommendations for those with diabetes who wish to fast.

The South Asian Health Foundation (UK) guidelines for managing diabetes during Ramadan

BACKGROUND

Fasting in the holy month of Ramadan is among the five pillars of Islam and is considered as a religious obligation by the Muslim population. People with diabetes observing the practice of fasts are at a higher risk of complications such as hypoglycaemia, hyperglycaemia and ketoacidosis due to changes in eating patterns and circadian rhythms. With the objective of mitigating these complications, the South Asian Health Foundation (UK) has developed the present guidelines based on robust evidence derived from epidemiological studies and clinical trials.

METHODS

We have highlighted the role of pre-Ramadan risk stratification and counselling by healthcare professionals with emphasis on the need for advice on adequate dietary and fluid intake, blood glucose monitoring and awareness of when to break the fast.

RESULTS

We reviewed the current literature and have given clinically-relevant recommendations on lifestyle modifications and glucose-lowering therapies such as metformin, sulphonylureas, dipeptidyl peptidase-4 inhibitors, sodium glucose co-transporter-2 inhibitors, thiazolidinediones, glucagon-like peptide-1 receptor agonists and insulin.

CONCLUSIONS

An individualised patient-centric treatment plan is essential to not only achieve optimal glycaemic outcomes but also enable people with diabetes to observe a risk-free month of fasting during Ramadan.

A systematic review on the safety of Ramadan fasting in high-risk patients with Diabetes

INTRODUCTION

Fasting the holy month of Ramadan is passionately practiced by all Muslim population around the world. Patients with diabetes are generally considered to have a higher risk of fasting. The current international guidelines have risk-stratified the patients with diabetes and other comorbidities to different categories, and the decision of fasting or not is made based on this categorization. Many studies looked at the impact of Ramadan fasting on those high-risk patients, and many are currently being in progress.

METHODS

In this systematic review, we conducted an extensive search in PubMed and google scholar engines. Studies filtration focused only on the Randomized controlled trial (RCT) and prospective observational studies accomplished between the year 2007 up to March2019 on impact of Ramadan on patients with diabetes at high risk of fasting.

RESULTS

The global dissemination and implementation of the guidelines for the management of diabetes during Ramadan broke the inertia among health care providers. Additionally, the concept of pre-Ramadan assessment for risk categorization, therapeutic doses modification in hand with self -monitoring blood glucose; have markedly reduced the risk and hospitalisation during Ramadan.

CONCLUSIONS

There is still limited data on fasting Ramadan by high risk patients with diabetes. There was minimal diversity in the published results, however, Generally and despite the education, self-titration; the incidences of complications during Ramadan is minimally higher than other times of the year in this group.

Comparison of Structured Nutrition Therapy for Ramadan with Standard Care in Type 2 Diabetes Patients

(1) Background: Structured nutrition therapy (NT) is essential for the management of type 2 diabetes (T2D), but the optimal delivery during Ramadan fasting remains unclear. The present study aimed to evaluate the effect of structured NT program versus standard care in patients with T2D during Ramadan. (2) Methods: The present study was an 8-week, parallel, non-randomized study with patients’ preference design involving 64 patients with T2D. The participants were asked to choose their preferred group, i.e., structured NT (Structured Ramadan NT, sRNT) or standard care (SC). The participants in the sRNT group received a Ramadan-focused nutrition plan, including a diabetes-specific formula throughout the study, whereas the patients in the SC group received standard nutrition care. Study outcomes included clinical outcomes and quality of life (QoL). Data was analyzed using two-way repeated-measures ANOVA and linear mixed-effects model. (3) Results: More than half of the participants (n = 38, 63%) chose sRNT as their preferred group. Both groups had comparable baseline characteristics. After 8-weeks of the respective intervention, participants in the sRNT group had lower levels of fasting plasma glucose (−0.9 ± 0.3 mmol/L vs. 0.2 ± 0.3 mmol/L, p < 0.05), triglycerides (−0.21 ± 0.08 mmol/L vs. 0.20 ± 0.17 mmol/L, p < 0.05), and self-monitoring glucose at pre-dawn (6.9 mmol/L vs. 7.8 mmol/L, p < 0.05) and pre-bedtime (7.6 mmol/L vs. 8.6 mmol/L, p < 0.05) than participants in the SC group. Although not different between groups, HbA1c levels decreased significantly in the sRNT (−0.72 ± 0.16%, p < 0.001) but not in the SC group (−0.35 ± 0.24%, p = 0.155). QoL and satisfaction scores improved significantly in sRNT group, but not in SC group. (4) Conclusions: The structured NT regimen for Ramadan is a feasible and beneficial program for T2D patients observing Ramadan fasting as it showed an improvement in clinical outcomes and QoL.

Use of flash glucose monitoring system in assessing safety of the SGLT2 inhibitors during Ramadan fasting in high risk insulin treated patients with type 2 diabetes

BACKGROUND

The risks of hypoglycemia, dehydration and kidney injury may theoretically be aggravated by people with type 2 diabetes treated with Insulin and SGLT2 inhibitors during Ramadan. Data on safety and efficacy of SGLT2-I in people with type 2 diabetes treated with insulin is scanty. We aimed to assess the impact of SGLT2 inhibitors during Ramadan in high-risk patients with type 2 diabetes treated with insulin, on hypoglycemia, glycemic control and kidney function.

METHODS

This is a prospective interventional study on high-risk diabetes patients who insisted on fasting. All patients were treated with insulin ± SGLT2I. All patients received a FGMS and Ramadan focused education. All patients attended clinic before and post Ramadan where they were advised on treatment modification as well as biometric and biochemical measurements.

RESULTS

95 patients enrolled in the study and 49 of them were on SGLT2i. There was a no significant change in creatinine in both groups. FGMS showed an improvement in the sensor-calculated HbA1c from 7.3 ± 1.5 to 6.8 ± 1.1 and from 8 ± 1.6 to 7.7 ± 1.5 in the SGLT2 group and the non-SGT2i groups, respectively. The hypoglycemia was predominantly reported during Ramadan between 12:00 to 18:00 h, while in pre-Ramadan readings was during 2400-0600 and 1200-1800 slots.

CONCLUSIONS

This is the first study that assesses the use of SGLT2i along with insulin during Ramadan, using FGMS in high-risk patients with type 2 diabetes under optimal care. There was minimal interruption of fasting, significant improvement in glycemic control, and no significant change in the kidney function after Ramadan.