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

Effects of Intermittent Fasting on Regulation of Metabolic Homeostasis: A Systematic Review and Meta-Analysis in Health and Metabolic-Related Disorders

Intermittent fasting (IF) is an emerging dietetic intervention that has been associated with improved metabolic parameters. Nowadays, the most common IF protocols are Alternate-Day Fasting (ADF) and Time-Restricted Fasting (TRF), but in this review and meta-analysis we have also considered Religious Fasting (RF), which is similar to TRF but against the circadian rhythm. The available studies usually include the analysis of a single specific IF protocol on different metabolic outcomes. Herein, we decided to go further and to conduct a systematic review and meta-analysis on the advantages of different IF protocols for metabolic homeostasis in individuals with different metabolic status, such as with obesity, diabetes mellitus type 2 (T2D) and metabolic syndrome (MetS). Systematic searches (PubMed, Scopus, Trip Database, Web of Knowledge and Embase, published before June 2022) of original articles in peer-review scientific journals focusing on IF and body composition outcomes were performed. Sixty-four reports met the eligibility criteria for the qualitative analysis and forty-seven for the quantitative analysis. Herein, we showed that ADF protocols promoted the major beneficial effects in the improvement of dysregulated metabolic conditions in comparison with TRF and RF protocols. Furthermore, obese and MetS individuals are the most benefited with the introduction of these interventions, through the improvement of adiposity, lipid homeostasis and blood pressure. For T2D individuals, IF impact was more limited, but associated with their major metabolic dysfunctions-insulin homeostasis. Importantly, through the integrated analysis of distinct metabolic-related diseases, we showed that IF seems to differently impact metabolic homeostasis depending on an individual's basal health status and type of metabolic disease.

Safety of sodium-glucose cotransporter 2 inhibitors (SGLT2i) during the month of Ramadan in patients with type 2 diabetes mellitus in Pakistani population-an observational study from a tertiary care center in Karachi

BACKGROUND AND AIMS

Primary aim was to assess the safety of SGLT2-i in patients with Type 2 Diabetes Mellitus (T2D) in a real-life scenario during Ramadan by finding the frequency and severity of hypoglycemic/hyperglycemic events, dehydration, and Diabetic ketoacidosis (DKA). Secondary aim was to assess changes in glycated hemoglobin (HbA1c), weight and creatinine levels.

METHODS

This prospective, observational, controlled cohort study was conducted at Aga Khan University Hospital, Karachi, Pakistan from March 15 to June 30, 2021. Participants were over 21 years of age, on stable doses of SGLT2-I, which was started at least 2 months before Ramadan. Endpoint assessments were done 1 month before and within 6 weeks after Ramadan.

RESULTS

Of 102 participants enrolled, 82 completed the study. Most (52%) were males, with mean age 52.2 ± 9.5 years and average duration of T2D 11.2 ± 6.5 years. 63% were on Empagliflozin (mean dose; 14.8 ± 7.2 mg/day) whereas 37% were on Dapagliflozin (mean dose; 8.2 ± 2.7 mg/day). Six (7.3%) documented symptoms of hypoglycemia. However, no episode of severe hypoglycemia, hyperglycemia, dehydration, DKA, hospitalization or discontinuation of SGLT2i was reported. HbA1c changes were (7.7 ± 1.2% from 7.9 ± 2.3%, p 0.34), weight (78.4 ± 12.9 kgs from 78.9 ± 13.3, p 0.23) and eGFR (87.8 ± 27.9 from 94.3 ± 37.6, p < 0.001). The reasons of study participants drop outs were: six did not keep any fasts; four discontinued study participation for personal reasons; three were out of city and missed post Ramadan follow-up, two protocol violation and five could not be contacted for post-Ramadan follow up during the third wave of COVID-19.

CONCLUSION

Results showed the safety of SGLT2i agents during Ramadan in the Pakistani population recommending it as a treatment option in adults with T2D, without any additional adverse events.

Effect of Ramadan fasting in patients with type 2 diabetes mellitus treated with sodium-glucose cotransporter 2 inhibitors: A systematic review and meta-analysis

AIMS/INTRODUCTION

Sodium-glucose cotransporter 2 inhibitors (SGLT-2i) improve glycemic control and weight, but might be associated with dehydration, hypotension and ketoacidosis, especially in patients with type 2 diabetes mellitus who fast during Ramadan. This meta-analysis evaluates the effects of Ramadan fasting on patients with type 2 diabetes mellitus treated with SGLT-2i.

MATERIALS AND METHODS

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

RESULTS

A total of five studies were included in this meta-analysis. During Ramadan, there was a significant reduction in glycated hemoglobin (P < 0.00001) and diastolic blood pressure (P = 0.006), with a non-significant trend for a reduction in weight (P = 0.44) and systolic blood pressure (P = 0.67). The number and severity of hypoglycemic episodes was lower in patients with type 2 diabetes mellitus treated with SGLT-2i compared with sulfonylureas. There was no significant change in estimated glomerular filtration rate, β-hydroxybutyrate, bicarbonate or anion gap. However, we identified considerable heterogeneity among studies, and a lack of head-to-head studies with structured outcome reporting on the risks and benefits of SGLT-2i during Ramadan.

CONCLUSIONS

This systematic review and meta-analysis shows that patients with type 2 diabetes treated with SGLT2i's during Ramadan have an improvement in HbA1c, less hypoglycemia and no major adverse effects.

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.

“I am my own doctor”: A qualitative study of the perspectives and decision-making process of Muslims with diabetes on Ramadan fasting

Background

Many Muslims with diabetes choose to fast against medical advice during Ramadan, potentially increasing their risk of acute complications. Patients are often reluctant to disclose fasting to their health care providers, and their needs regarding Ramadan are not met in consultations. For healthcare professionals to provide patient-centred care, it is important to gain more insight into patients’ decision-making process. This study therefore aims to explore how Muslims with diabetes decide whether to fast during Ramadan.

Methods

A qualitative study was conducted consisting of 15 focus groups with Muslims with diabetes within a constructivist paradigm. Convenience sampling was used. All focus groups were transcribed verbatim and analyzed using Braun and Clarke’s reflexive thematic analysis.

Results

Four themes were found to be important in the decision on whether to fast: (1) values and beliefs concerning Ramadan, (2) experiences and emotions concerning Ramadan, (3) the perception of illness, and (4) advice from health care professionals, imams and family. Many participants indicated fasting against medical advice and trusting their subjective assessments on whether they could fast. Moreover, three main stages in the decision-making process for eventually refraining from fasting were identified: (1) the stage where positive experiences with fasting dominate, (2) the stage where one encounters challenges but their determination to fast prevails and (3) the stage where one decides to refrain from fasting after experiencing too many physical difficulties with fasting.

Conclusions

Muslims with diabetes experience autonomy in their decisions on Ramadan fasting. The decision to refrain from fasting often resulted from a difficult and dynamic decision-making process and was often made after participants reached their physical limits. These findings highlight the importance of not only shared decision-making to empower patients to make well-informed decisions on Ramadan fasting but also pre-Ramadan diabetes education to help people with diabetes have a safe Ramadan.

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.