Diabetic hypoglycaemia during Ramadan fasting: A trans-national observational real-world study

Intermittent Fasting: Socio-Economic Profile of Spanish Citizens Who Practice It and the Influence of This Dietary Pattern on the Health and Lifestyle Habits of the Population

Intermittent fasting (IF) is a dietary approach that has gained popularity in recent years. More and more Spanish people are following this eating pattern, which consists of alternating periods of fasting with periods of food intake. Its benefits include improved metabolic and vascular health and weight loss.

OBJECTIVES

1. To study the prevalence of IF among the Spanish population. 2. To explore how demographic factors influence the choice to adopt this dietary approach.

METHODS

A descriptive cross-sectional study was conducted on the Spanish population using the NutSo-HH questionnaire, which was constructed, validated, and disseminated by the research team through a non-probabilistic snowball sampling approach, collecting socio-demographic data and nutritional, social and lifestyle habits of the population.

RESULTS AND CONCLUSIONS

A valid sample of 22,181 people participated, of whom 4.59% (n = 1018) said they practiced IF. The data show that more middle-aged men than women practice IF. In addition, individuals who follow IF methods are less likely to have no control over their food intake, are less scared to gain weight and have a higher body image, but no differences were found related to unhealthy food and nights out. There were also no significant differences in terms of the level of education, income, size of municipality, or region of residence. In conclusion, a person who practices IF seems to have adopted a healthier lifestyle and social habits.

Safety and effectiveness of iGlarLixi in adults with type 2 diabetes mellitus from Gulf countries during Ramadan holy month: A subgroup analysis of the SoliRam observational study

AIM

To investigate safety and effectiveness of iGlarLixi in adults with type 2 diabetes mellitus (T2DM) observing fast during Ramadan from Gulf countries.

METHODS

This planned subgroup analysis of the SoliRam - a multinational, prospective, non-interventional, real-world, observational study - focused on participants from Gulf countries. Primary endpoint was proportion of participants experiencing ≥1 episode of severe and/or symptomatic documented (<70 mg/dL [<3.9 mmol/L]) hypoglycemia.

RESULTS

A total of 241 individuals with T2DM (mean age: 58.1 years; male: 54.4%; mean duration of diabetes: 13.3 years) were included. All 234 eligible participants followed during Ramadan were able to fast for ≥25 days and no participants broke fast due to hypoglycemia. Primary endpoint was reported in one participant (0.5%) during fasting hours during Ramadan. Improvements (mean ± SD change) in HbA1c (-1.0 ± 1.0% [-11 ± 10 mmol/mol]), FPG (-22.5 ± 29.7 mg/dL), and body weight (-1.5 ± 2.0 kg) were observed from pre-Ramadan to post-Ramadan. Three participants (1.2 %) reported an adverse event (AE) of any cause and one (0.4%) reported a gastrointestinal AE.

CONCLUSIONS

iGlarLixi is an effective and well-tolerated treatment in people with T2DM from Gulf countries, including during Ramadan fasting, and is associated with low risk of hypoglycemia.

Towards a better understanding between non-Muslim primary care clinicians and Muslim patients: A literature review intended to reduce health care inequities in Muslim patients

Although Muslims are a growing population within many non-Muslim countries, there are insufficient Muslim clinicians to care for them. Studies have shown that non-Muslim clinicians have limited knowledge and understanding of Islamic practices affecting health, which may lead to disparities in the quality of healthcare delivery and outcomes when caring for Muslim patients. Muslims come from many different cultures and ethnicities and have variations in their beliefs and practices. This literature review provides some insights which may strengthen therapeutic bonds between non-Muslim clinicians and their Muslim patients resulting in improved holistic, patient-centered care in the areas of cancer screening, mental health, nutrition, and pharmacotherapy. Additionally, this review informs clinicians about the Islamic perspective on childbirth, end of life issues, travel for Islamic pilgrimage, and fasting during the month of Ramadan. Literature was sourced by a comprehensive search in PubMed, Scopus, and CINAHL along with hand screening of citations. Title and abstract screening followed by full-text screening excluded studies including less than 30% Muslim participants, protocols, or reporting results deemed irrelevant to primary care. 115 papers were selected for inclusion in the literature review. These were grouped into the themes of general spirituality, which were discussed in the Introduction, and Islam and health, Social etiquette, Cancer screening, Diet, Medications and their alternatives, Ramadan, Hajj, Mental health, Organ donation and transplants, and End of life. Summarizing the findings of the review, we conclude that health inequities affecting Muslim patients can be addressed at least in part by improved cultural competency in non-Muslim clinicians, as well as further research into this area.

Burden and Patterns of Medical Emergencies during Ramadan Fasting: A Narrative Review

Introduction Acute medical problems may occur more frequently during Ramadan fasting (RF). We aimed to provide a narrative overview of the global literature on medical emergencies during RF.

Methods This is a nonsystematic review of the international literature from one major medical online database (PubMed, National Institutes of Health, United States). The relevant literature was narrated in a concise thematic account.

Results There is a variable impact in the burden and time distribution of emergency services and hospitalization during RF that may require readjustment of resource allocation. Studies of the risk of accidents and injuries may be increased overall or at specified times, around Iftar time. A classical impact of emergencies has been the risk of worsening peptic ulcer disease. RF impacts diabetic emergencies such as severe hypoglycemia, hyperglycemia, and diabetic ketoacidosis, particularly in type 1 diabetes and poorly controlled patients. Glucocorticoid replacement therapy may represent a challenge to patients and physicians that require education and dose adjustment. Acute neurological conditions of interest include the “first day of Ramadan headache,” epilepsy, and strokes. Several studies evaluated the risk of the acute coronary syndrome and heart failure with inconsistent findings. RF may impact the renal and urological systems through stone disease, renal colic, and acute kidney. The impact on hematological conditions was mostly focused on the safety of anticoagulant therapy during Ramadan.

Conclusion The review addresses the emergency medical encounters of the fasting patient during Ramadan to allow a holistic and ethnically sensitive approach to medical care under circumstances where decisions have to be taken with no delay.

Eid-al-Fitr festivity and Ramadan fasting attitude among individuals with diabetes from Saudi Arabia and Pakistan: a cross-sectional study

OBJECTIVES

The present study aimed to assess the attitude of Saudi and Pakistani individuals with diabetes regarding Eid-al-Fitr festivities, exploring diabetes care during the month of Ramadan and these individuals' dietary patterns on Eid day.

DESIGN

Cross-sectional study.

SETTING

Jeddah (Saudi Arabia) and Karachi (Pakistan).

PARTICIPANTS

Of the total 405 subjects, 204 individuals with diabetes from Saudi Arabia (SA) and 201 from Pakistan (Pak) were enrolled.

DATA COLLECTION AND ANALYSIS

This survey-based study was carried out in SA and Pak after Eid-al-Fitr 2020. An online questionnaire was circulated via various social media platforms. The data analyses were performed using SPSS V.26.

RESULTS

There were 80 subjects with type 1 diabetes mellitus (DM) and 325 subjects with type 2 DM. Among our study subjects, 73 were on insulin, 260 were on oral antidiabetics (OADs) and 72 were taking both OADs and insulin. Two-thirds of the participants, 276 (68%) visited their physicians before Ramadan. Many participants (175, 43.2%) broke their fast a day or more because of diabetes. Many participants consumed sugary food on Eid day. The use of chocolates, sugary foods and fresh juices on Eid-al-Fitr was higher in Saudi subjects than in Pakistani ones (p<0.001). Saudi subjects with diabetes adhered more strictly to medications during Ramadan than Pakistani subjects (p=0.01). Saudi participants were more compliant with monitoring DM during Eid-al-Fitr compared with Pakistani subjects. Many participants in both groups felt stressed or depressed and stated that their Eid celebrations were restrictive because of their DM conditions.

CONCLUSIONS

Most Saudi and Pakistani participants enjoyed Eid celebrations by abstaining from dietary restrictions. The sugar consumption attitude during Eid day was not up to the mark. Many subjects broke their fasts for a day or more because of diabetes. Saudis were more vigilant in monitoring DM than Pakistanis during Eid-al-Fitr. Individuals with diabetes should consult their physicians before Ramadan for checkups and counselling.

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.

Safety and Effectiveness of Insulin Glargine 300 U/mL in Participants with Type 2 Diabetes Who Fast During Ramadan in The Gulf Region: A Subgroup Analysis of the Real-World ORION Study

INTRODUCTION

To evaluate the safety and effectiveness of insulin glargine 300 U/mL (Gla-300) in people with type 2 diabetes mellitus (T2DM) in the Gulf region who fast during Ramadan.

METHODS

ORION was a real-world, prospective, observational study in people with T2DM treated with Gla-300 during pre-Ramadan, Ramadan, and post-Ramadan periods. This subgroup analysis included 222 participants from the Gulf region (Kuwait, Saudi Arabia, United Arab Emirates, and Qatar). The primary endpoint was the percentage of participants experiencing severe and/or symptomatic documented hypoglycemia (self-monitored plasma glucose [SMPG] ≤ 70 mg/dL) during Ramadan. Changes in glycated hemoglobin (HbA_1c), fasting plasma glucose (FPG), SMPG, body weight, insulin dose, and adverse events (AEs) were also evaluated.

RESULTS

The primary endpoint was reported in one (0.5%) participant during Ramadan. The incidence rate of symptomatic documented hypoglycemia (SMPG ≤ 70 mg/dL) decreased from the pre-Ramadan (3.2%) to Ramadan period (0.5%), and no severe hypoglycemia events were reported during the study. Reductions were observed in HbA_1c (mean ± standard deviation: - 0.51 ± 0.95% [- 5.5 ± 10.4 mmol/mol]), FPG (- 13.9 ± 47.5 mg/dL), and SMPG (- 6.1 ± 27.1 mg/dL). No significant changes were observed in body weight or Gla-300 dose. AEs were reported in 11 (5.0%) participants.

CONCLUSION

In a real-world setting in the Gulf region, Gla-300 treatment in people with T2DM during Ramadan was associated with a low incidence of hypoglycemia and improved glycemic control.

TRIAL REGISTRATION

CTRI/2019/02/017636.

Intermittent Fasting and Metabolic Health

Given the ongoing strain that the obesity epidemic has placed on public health outcomes, new and effective approaches to weight control are needed. One approach to improving weight and metabolic outcomes is intermittent fasting, which consists of multiple different timing schedules for temporary food avoidance, including alternate-day fasting, other similar full-day fasting patterns, and time-restricted feeding (where the day’s food is consumed over a 6-h period, allowing for 18 h of fasting). These feeding schedules have favorable metabolic effects by intermittently inducing the metabolism of fatty acids to ketones. The regimens overall lead to a decrease in weight and have been linked to improvements in dyslipidemia and blood pressure. While more research is needed on longer-term outcomes and this approach should be avoided in particular health conditions, intermittent fasting should be considered as an option for individuals who have a pattern of unhealthy weight gain using standard eating patterns.

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.

Impact of COVID-19 on Children and Young Adults With Type 2 Diabetes: A Narrative Review With Emphasis on the Potential of Intermittent Fasting as a Preventive Strategy

Background: The world is still struggling to control the COVID-19 pandemic caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The level of uncertainty regarding the virus is still significantly high. The virus behaves differently in children and young adults. Most children and adolescents are either asymptomatic or have mild symptoms. They generally have a very good prognosis. However, it is not well-known whether children and young adults with type 2 diabetes are at risk of getting a severe infection of COVID-19. Many Muslim children with type 2 diabetes have been performing dawn to dusk fasting during the month of Ramadan, before and during the COVID-19 pandemic, and the impact of this on their health has not been well investigated. Previous studies in adults have suggested that intermittent fasting may be beneficial in different ways including reversal of type 2 diabetes and prevention of COVID-19 infection. Objective: The primary aim of this narrative review is to summarise the impacts of the COVID-19 pandemic on children and young adults with type 2 diabetes, and to identify the knowledge gaps in the literature. It also explores the potential of intermittent fasting in reversing the pathogenesis of diabetes and highlighting how this approach could prevent these patients from developing chronic complications. Methods: This narrative review has been produced by examining several databases, including Google Scholar, Research Gate, PubMed, Cochrane Library, MEDLINE (EBSCO), and Web of Science. The most common search terms used were "COVID-19 AND Children", "SARS-CoV-2 AND/OR Children", "COVID-19 AND Diabetes" "COVID-19 Epidemiology", "COVID-19 AND Ramadan fasting", "COVID-19 and Intermittent fasting." All the resources used are either peer-reviewed articles/reports and/or official websites of various media, governmental and educational organisations. Results: Having reviewed the currently limited evidence, it has been found that the incidence of COVID-19 among children with type 2 diabetes seems to be not much different from children without diabetes. However, these patients are still vulnerable to any infection. Several studies have reported that prevention programmes such as intermittent fasting are effective to protect these groups of patients from developing any complications. Moreover, observing Ramadan fasting as a type of intermittent fasting could be beneficial for some children with established diabetes, prediabetes and people at risk. Conclusion: Children and young adults with type 2 diabetes are not at risk of severe COVID-19 infection as the case in adults with diabetes. More research is needed to identify the impact of COVID-19 and to investigate the efficacy and safety of intermittent fasting, including Ramadan fasting, among these age groups. Implementing these cost-effective programmes may have a great impact in minimising the incidence of diabetes. Moreover, this could be effective particularly at prediabetes stage by preventing these people from going onto develop type 2 diabetes and taking medications for the rest of their life and protecting people from complications linked to disease and infection.

Religious dietary rules and their potential nutritional and health consequences

BACKGROUND

The vast majority of the world population declares affiliation to a religion, predominantly Christianity and Islam. Many religions have special dietary rules, which may be more or less strictly adhered to.

METHODS

Religious food rules were collected from holy books and religious websites as well as their translation into dietary practices. The literature was searched for potential associations between these rules and potential nutritional consequences.

RESULTS

Jewish, Islamic and Indian religions support prolonged breastfeeding. Religious avoidance of alcohol is probably beneficial to health. When strictly applied, a few rules may lead to nutritional inadequacies, mainly in populations living in unfavourable socio-economic or environmental conditions. In Jewish and Muslim observants, animal slaughtering procedures may increase the risk of iron deficiency. Jews may be at risk of excess sodium intake related to home-prepared foods. A vegan diet, as observed by some believers, often by drifting from original precepts, or by some Hindus or Buddhists, may result in vitamin B12, calcium, iron, zinc, selenium and n-3 fatty acids deficiencies.

CONCLUSION

When implemented in accordance with the rules, most religious food precepts are not detrimental to health, as suggested by the fact that they have more or less been followed for millennia. Nevertheless, some practices may lead to nutritional inadequacies, such as iron, calcium, vitamin D and vitamin B12 deficiencies. Patients with low socio-economic status, children and women of childbearing age are of particular risk of such deficiencies. Being aware of them should help health professionals to take an individualized approach to decide whether to supplement or not.

Risk factors for hyperglycemia and hypoglycemia in adults with pharmacologically treated type 2 diabetes mellitus: a quantitative systematic review protocol

OBJECTIVE

The objective of this review is to identify and synthesize the risk factors for hyperglycemia or hypoglycemia in adults with pharmacologically treated type 2 diabetes mellitus in any scenarios and environments for health care.

INTRODUCTION

Studies around the world have investigated which factors are associated with episodes of alteration of blood glucose level. It is through the characterization of these factors that nurses can plan and intervene accurately in the control of serum glucose levels in people with diabetes.

INCLUSION CRITERIA

This review will include studies conducted among adults with pharmacologically treated type 2 diabetes mellitus in any scenarios and environments for health care. Studies should focus on risk factors for the variation of fasting glycemic levels lower than 3.9 mmol/L and higher than 7.21 mmol/L, as well as postprandial glycemic levels lower than 3.9 mmol/L and higher than 10 mmol/L.

METHODS

Databases to be searched include MEDLINE, Embase, CINAHL, PsycINFO, Web of Science, Scopus, LILACS, and ScienceDirect. Following the search, titles and abstracts will be screened by two independent reviewers for assessment against the inclusion criteria for the review. The full text of selected citations will be assessed in detail against the inclusion criteria, and studies selected for retrieval will be assessed by two independent reviewers for methodological validity using JBI critical appraisal tools. Studies will not be excluded based on their quality assessment. Data will be extracted using the standardized data extraction tools. Quantitative data will, where possible, be pooled in statistical meta-analysis.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO (CRD42019134755).

Evaluating the effect of Ramadan Fasting on patients with chronic diseases

Objective:

The study aimed to investigate the effect of Ramadan Fasting on Patients with Chronic Diseases and their experience during fasting.

Methods:

This study was a descriptive research that used a researcher-designed questionnaire in face-to-face interviews with individuals who have at least one chronic disease and visit, for any reason, the Istanbul Sisli Etfal Training and Research Hospital polyclinics. We first asked each participant about fasting during Ramadan. If the participant was not fasting, we asked only the reason(s) and collected socio-demographic data. If a participant was fasting, we administered a researcher-designed questionnaire in face-to-face interviews. Our survey consisted of 19 questions that were designed to evaluate the fasting behaviors, current chronic disease and treatment status of individuals, encountered complications during fasting and their socio-demographic data.

Results:

The study participants were 253 people (168 females [66.4%]; mean age: 58.06 ± 11,13) with non-infectious diseases. One hundred sixty (63.2%) participants were fasting during Ramadan and 33 of them (20.6%) had consulted a doctor before fasting, 62.5% (n = 100) said they never faced any symptoms during fasting. Most experienced symptom during fasting was fatigue (56.7%; n = 34). A significant relationship occurred between experiencing symptoms while fasting and gender (p = 0.023) and waking regularly for sahur (p = 0.029).

Conclusions:

Many people with chronic diseases fast and experience symptoms while fasting. Being woman and not waking up for sahur was related with the symptoms during Ramadan fasting. Most participants with NIDs fasted during Ramadan without consulting their doctors.

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.

Efficacy and safety of the newer oral hypoglycemic agents in patients with T2DM during Ramadan: A systematic review and meta-analysis

AIMS

This systematic review and meta-analysis aims to evaluate the safety and efficacy of the newer glucose lowering treatments on glycemic control, weight, blood pressure and hypoglycemia in patients with T2DM during Ramadan.

METHODS

A literature search was done in PubMed, Embase, and the Cochrane Library. Quality assessment was done using the ROBINS-I and Cochrane tools for risk of bias and analyses were performed using RevMan version 5.3.

RESULTS

A total of 20 studies were included in the meta-analysis. Dipeptidyl peptidase-4 inhibitors (DPP-4i) led to a significant reduction in Hb_A1c (%) (SMD -0.25) and a non-significant decrease in weight (kg) (SMD -1.06) during Ramadan. Glucagon-like peptide (GLP-1) agonist therapy was associated with a significant decrease in Hb_A1c (%) (SMD -0.68) and a non-significant decrease in weight (kg) (SMD -2.57) and systolic blood pressure (SBP) (mmHg) (SMD -3.50) after Ramadan. Sodium-glucose co-transporter 2 inhibitor (SGLT-2i) therapy was associated with a significant decrease in Hb_A1c (%) (SMD -0.51) and a non-significant decrease in weight (kg) (SMD -1.41), SBP (SMD -1.10) and diastolic blood pressure (DBP) (mmHg) (SMD -2.08) after Ramadan.

CONCLUSIONS

This systematic review and meta-analysis shows clinical benefits with the newer glucose lowering medications in patients with T2DM who fast during Ramadan.

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.

Safety of lixisenatide plus basal insulin treatment regimen in Indian people with type 2 diabetes mellitus during Ramadan fast: A post hoc analysis of the LixiRam randomized trial

AIMS

Hypoglycemia is one of the most important complications associated with Ramadan fasting in people with type 2 diabetes. LixiRam (NCT02941367) was the first randomized trial comparing safety and efficacy of lixisenatide + basal insulin (BI) vs. sulphonylurea + BI in people with type 2 diabetes who fast during Ramadan. This post hoc analysis focuses on the LixiRam study population from India.

METHODS

Adults with type 2 diabetes insufficiently controlled with sulphonylurea + BI ± another oral anti-hyperglycemic drug were randomized 1:1 to receive lixisenatide + BI or to continue sulphonylurea + BI treatment.

RESULTS

In total, 150 participants were randomized in India. One participant (1.3%) with lixisenatide + BI vs. 5 participants (6.8%) with sulphonylurea + BI experienced ≥1 documented symptomatic hypoglycemic event during the Ramadan fast (odds ratio [OR]: 0.22; 95% confidence interval [CI]: 0.02-1.93). Incidence of any hypoglycemia was numerically lower with lixisenatide + BI vs. sulphonylurea + BI during Ramadan fasting (1.3% [1/75] vs. 14.7% [11/75], respectively; OR: 0.09; 95% CI: 0.01-0.69). No new safety signals were identified.

CONCLUSIONS

A combination of lixisenatide prandial GLP1-RA + BI may be a suitable treatment option for people with type 2 diabetes who elect to fast during Ramadan. Clinical Trial Registry: clinicaltrials.gov (NCT02941367).

The effect of Ramadan focused education on patients with type 2 diabetes: A systematic review and meta-analysis

AIM

The aim of this systematic review and meta-analysis was to assess the effect of Ramadan focused education on clinical and metabolic parameters in patients with type 2 diabetes who fast during Ramadan.

METHODS

Literature search was done in PubMed, Embase (Ovid), and the Cochrane Library. Quality assessment was done using the ROBINS-I and Cochrane tools for risk of bias and analyses were performed using RevMan version 5.1.

RESULTS

From 770 records, 430 full text studies were assessed. After exclusions, the final quantitative analysis included 16 studies. Pre-Ramadan education was associated with a significant reduction in Hb_A1c (SMD -0.46, 95% CI -0.65 to -0.27P < 0.05) and LDL (SMD -0.09, 95% CI -0.13 to -0.04P < 0.05), an increase in TG (SMD 0.07, 95% CI -0.23 to 0.93P < 0.05) and weight (SMD 0.44, 95% CI 0.06 to 0.81P < 0.05) and no change in hypoglycemic events, BMI, TC, HDL or blood pressure (P > 0.05) during Ramadan.

CONCLUSIONS

This systematic review and meta-analysis shows that Ramadan-focused diabetes education leads to a decrease in Hb_A1c and LDL, but an increase in TG and weight during Ramadan. It also identifies a lack of head to head studies and limited observational studies with adequately assessed end-points.

Continuous subcutaneous insulin infusion versus multiple daily insulin injections in patients with Type 1 diabetes mellitus who fast during Ramadan: A systematic review and meta-analysis

BACKGROUND

The benefits and risks of continuous subcutaneous insulin infusion (CSII) or multiple daily injections (MDI) in patients with Type 1 diabetes mellitus (T1DM) who fast during Ramadan are not known.

METHODS

Systematic review and meta-analysis of observational studies conducted in PubMed, Embase (Ovid), and the Cochrane Library. Quality of included studies was assessed using the ROBINS-I tool for risk of bias assessment and analyses were performed using RevMan version 5.1.

RESULTS

From 709 records, 306 full text studies were assessed. After exclusions, the final analysis included a total of 9 studies. Heterogeneity for outcomes was I² = 0%. There was no significant difference for the change in glycemic control (HbA_1c) between CSII and MDI (P > 0.05). There was no change in weight or the lipid profile in patients with T1DM on MDI during Ramadan. There were insufficient data to assess the impact on glucose profiles and the incidence of hypoglycemia or diabetic ketoacidosis (DKA) in patients on CSII or MDI during Ramadan.

CONCLUSIONS

Studies assessing the effect of CSII or MDI in patients with T1DM who fast during Ramadan are limited to observational studies and show no difference in the change in Hb_A1c, weight or lipids during Ramadan.

Intermittent Fasting in Cardiovascular Disorders-An Overview

Intermittent fasting is a form of time restricted eating (typically 16 h fasting and 8 h eating), which has gained popularity in recent years and shows promise as a possible new paradigm in the approach to weight loss and the reduction of inflammation, and has many potential long term health benefits. In this review, the authors will incorporate many aspects of fasting, mainly focusing on its effects on the cardiovascular system, involving atherosclerosis progression, benefits for diabetes mellitus type 2, lowering of blood pressure, and exploring other cardiovascular risk factors (such as lipid profile and inflammation).