Guidelines for managing diabetes in Ramadan

What health inequalities exist in access to, outcomes from and experience of treatment for lung cancer? A scoping review

OBJECTIVES

Lung cancer (LC) continues to be the leading cause of cancer-related deaths and while there have been significant improvements in overall survival, this gain is not equally distributed. To address health inequalities (HIs), it is vital to identify whether and where they exist. This paper reviews existing literature on what HIs impact LC care and where these manifest on the care pathway.

DESIGN

A systematic scoping review based on Arksey and O'Malley's five-stage framework.

DATA SOURCES

Multiple databases (EMBASE, HMIC, Medline, PsycINFO, PubMed) were used to retrieve articles.

ELIGIBILITY CRITERIA

Search limits were set to retrieve articles published between January 2012 and April 2022. Papers examining LC along with domains of HI were included. Two authors screened papers and independently assessed full texts.

DATA EXTRACTION AND SYNTHESIS

HIs were categorised according to: (a) HI domains: Protected Characteristics (PC); Socioeconomic and Deprivation Factors (SDF); Geographical Region (GR); Vulnerable or Socially Excluded Groups (VSG); and (b) where on the LC pathway (access to, outcomes from, experience of care) inequalities manifest. Data were extracted by two authors and collated in a spreadsheet for structured analysis and interpretation.

RESULTS

41 papers were included. The most studied domain was PC (32/41), followed by SDF (19/41), GR (18/41) and VSG (13/41). Most studies investigated differences in access (31/41) or outcomes (27/41), with few (4/41) exploring experience inequalities. Evidence showed race, rural residence and being part of a VSG impacted the access to LC diagnosis, treatment and supportive care. Additionally, rural residence, older age or male sex negatively impacted survival and mortality. The relationship between outcomes and other factors (eg, race, deprivation) showed mixed results.

CONCLUSIONS

Findings offer an opportunity to reflect on the understanding of HIs in LC care and provide a platform to consider targeted efforts to improve equity of access, outcomes and experience for patients.

Intermittent fasting: A promising dietary intervention for autoimmune diseases

Intermittent fasting, which includes periods of fasting and nutrition, has been considered a dietary approach for weight loss and metabolic health improvement. However, its potential benefits in autoimmune diseases have not been widely studied. This study aims to review the existing studies on the role and effects of intermittent fasting on autoimmune diseases. A comprehensive search was conducted on electronic databases such as PubMed, Scopus, Embase, and Web of Science, and relevant studies were included based on inclusion criteria. Studies show that intermittent fasting may have beneficial effects on various autoimmune diseases, such as type 1 diabetes, rheumatoid arthritis, and systemic lupus erythematosus, by reducing inflammatory markers, modulating the immune system, altering and improving gut microbiota, and enhancing cellular repair mechanisms through autophagy. However, evidence regarding the effects of intermittent fasting on other autoimmune diseases such as multiple sclerosis, systemic lupus erythematosus, thyroid diseases, and psoriasis is limited and inconclusive. Nevertheless, further research is needed to determine optimal intermittent fasting guidelines and its long-term effects on autoimmune diseases. Overall, this literature review proves intermittent fasting may be a promising dietary intervention for managing autoimmune diseases.

[Diabetes and migration (update 2023)]

The practice recommendation is intended to supplement the existing guidelines on diabetes mellitus and provides practical recommendations for the diagnosis, therapy and care of people with diabetes mellitus who come from different linguistic and cultural back-grounds. The article deals with the demographic datas of migration in Austria and Germany; with therapeutic advice concerning drug therapy and diabetes education for patients with migration background. In this context socio-cultural spezifics are discussed. These suggestions are seen complementary to the general treatment guidelines of the Austrian Diabetes Society and German Diabetes Society. Especially for the fast months Ramadan thera are a lot of informations. The most important point is that the patient care must highly individualized and the management plan may differ for each patient.

Influence of sodium-glucose Co-transporter 2 inhibitors on clinical and biochemical markers of dehydration during the Holy Ramadan

BACKGROUND AND AIMS

Alteration of the hydration status with the use of sodium-glucose co-transporter- 2 inhibitors (SGLT2i) during the Holy Ramadan has not been studied in depth. Precisely, we aimed to detect the potential alteration of hydration status in adult Muslims with type 2 diabetes mellitus (T2D) who used SGLT2i during Ramadan.

METHODS

An observational non-interventional study included 245 patients with type 2 diabetes mellitus of matched age and sex. The study included 3 groups: empagliflozin group; 87 patients, dapagliflozin group; 85 patients and control group; 73 patients without the use of SGLT2i. Participants in each group were well-settled on their medications for more than 3 months before the onset of Ramadan. Clinical and biochemical parameters of hydration status were evaluated during the last week of Ramadan.

RESULTS

We noticed a higher prevalence of orthostatic dizziness and postural hypotension among SGLT2i users than non-SGLT2i users (p < 0.001). The mean arterial blood pressure was significantly lowered among users of empagliflozin and dapagliflozin than non-SGLT2i users; 93.7 ± 5.1 and 93.1 ± 6.9 versus 106.2 ± 4.3, p < 0.001, respectively. Moreover, patients who used empagliflozin or dapagliflozin exhibited significantly higher values of urine specific gravity; 1029.6 ± 1.5 and 1029.1 ± 1.6 versus 1016.9 ± 4.4, p < 0.001, serum osmolality; 300.7 ± 10.2 and 297.8 ± 8.9 versus 290.9 ± 6.7, p < 0.001, and BUN/creatinine ratio; 24.1 ± 4.1 and 23.2 ± 4.6 versus 16.3 ± 4.2, p < 0.001 than non-SGLT2i users.

CONCLUSION

Significant clinical and biochemical markers of dehydration were noticed among users of SGLT2i during the Holy Ramadan.

Ramadan fasting and weight change trajectories: Time-varying association of weight during and after Ramadan in low-income and refugee populations

Obesity is a significant driver of the global burden of non-communicable diseases. Fasting is one approach that has been shown to improve health outcomes. However, the effects of Ramadan fasting differ in that the type, frequency, quantity, and time of food consumption vary. This phenomenon requires in-depth evaluation considering that 90% of Muslims (~2 billion people) fast during Ramadan. To address this issue, we evaluated the pattern of weight change during and following Ramadan for a total of 52 weeks. The study was conducted in Amman, Jordan. Between 2012 and 2015, 913 participants were recruited as part of a trial investigating the efficacy of a weight loss intervention among those with or at risk for diabetes. Weight was measured weekly starting at the beginning of Ramadan, and changes were analyzed using discrete and spline models adjusted for age, sex, and trial group. Results show slight weight gain within the first two weeks and weight loss in the subsequent weeks. During the first week of Ramadan, the estimate for a weight reduction was 0·427 kg, (95% CI: -0·007, 0·861), increasing to 1·567 kg, (95% CI: 2·547, 3·527) at week 26. There was clear evidence of gradual weight gain from about 4 to 15 weeks and a drop towards the end of the investigation at week 28 (-0·12kg, 95% CI: -0·89, 0·56). Our results show that weight changes occurred during and after Ramadan. Weight fluctuations may affect health risks, and thus, findings from this study can inform interventions. Public health agencies could leverage this period of dietary change to sustain some of the benefits of fasting. The authors (DEZ, EFD) acknowledge the Mulago Foundation, the Horace W. Goldsmith Foundation, Robert Wood Johnson Foundation, and the World Diabetes Foundation. TRIAL REGISTRATION. Clinicaltrials.gov registry identifier: NCT01596244.

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.

[Ramadan fasting during treatment with external beam radiotherapy]

INTRODUCTION

Many Muslim cancer patients insist on fasting during the month of Ramadan, even during treatment. The purpose of this observational study is to study the practice of fasting, in patients receiving external radiation therapy.

METHODS

Our study was conducted during the month of Ramadan 1441 (2018) in the radiotherapy department of Ibn Rochd University Hospital of Casablanca. We included all patients who received external radiotherapy during this period. We thus collected the characteristics of patients, disease and treatment modalities. After an interview, with a pre-established questionnaire, we were able to establish the observance of the fast.

RESULTS

We collected a total of 209 patients. The most frequently represented locations were breast cancer followed by gynecological cancers in 35.4% and 18.7% respectively. All our patients were fasting Ramadan before the diagnosis of cancer, however, only 39.2% were fasting during the treatment by radiotherapy, and just 40% of patients have discussed the possibility of fasting with their oncologist. In multivariate analysis, the stage of the disease was the only factor related to the fasting status of our patients.

DISCUSSION

Even under treatment, many of our patients fast during the month of Ramadan. Further studies are needed to evaluate the tolerance of fasting in order to better answer the question "can I fast?".

Ramadan and Culturally Competent Care: Strengthening Tuberculosis Protections for Recently Resettled Muslim Refugees

To improve latent tuberculosis infection treatment completion rates, Tarrant County Public Health began providing after-dusk home delivery of a 12-dose latent tuberculosis infection regimen of weekly rifapentine plus isoniazid administered via directly observed preventive therapy during Ramadan, a month of prayer and daytime fasting observed by Muslims. In unadjusted difference-in-difference logistic regression analyses (n = 148), Muslim patients had lower treatment completion rates than non-Muslim patients during Ramadan prior to program implementation (68.8% vs 95.4%), whereas rates were comparable postimplementation (95.7% vs 96.4%; difference-in-difference P = .011). Similar results were found after adjusting for age and gender (pre: 71.4% vs 94.8%; post: 95.5% vs 96.3%; P = .032). These findings provide evidence of the need for and effectiveness of programmatic innovations tailored to the varying cultural norms of the widely diverse populations served by public health authorities and suggest that culturally competent clinical care may advance population health goals.

Knowledge gaps and perceptions of future research directions on management of diabetes during Ramadan fasting: An online survey of physicians

OBJECTIVES

Current knowledge and research on diabetes and Ramadan form the basis for evidence-based clinical practice. In this context, we aimed to explore physicians' perceptions of current knowledge gaps about research fasting (RF), barriers to, and foreseeable directions for advancement of the field.

METHODS

We conducted an online survey of a convenience sample of 260 physicians from 27 countries. The survey questionnaire addressed three main domains: perceived current knowledge gaps and unmet needs in research about RF and diabetes, barriers to the conduct of research, and future directions for furthering the evidence in this field.

RESULTS

Majority of respondents (65.7%) were senior physicians in adult endocrinology/diabetes (45.9%) working at tertiary centers (65.2%). The majority (67.3%) reported seeing an average of 20+ patients with diabetes weekly and felt "very or fairly confident" in managing diabetes during RF (67.7%). The knowledge gaps identified were the management of high-risk patients with diabetes (54.1%), such as renal impairment (59.8%), and pregnancy (61.5%). The main barriers to research were lack of adequate funding to academic centers (75.7%) and lack of interest of institutions in the subject (64.6%). Future efforts should be directed at the conduct of large epidemiological studies (49.5%) or double-blinded, placebo-controlled clinical trials (48.6%) to address the former gaps. Research findings should be widely disseminated via hands-on workshops (recommended by 70.3% of respondents) or international conferences (61.2%).

CONCLUSIONS

There is a wide agreement regarding the knowledge gaps in the management of diabetes during RF. Future efforts should focus on addressing these critical deficiencies.

Changes in fasting patterns during Ramadan, and associated clinical outcomes in adults with type 2 diabetes: A narrative review of epidemiological studies over the last 20 years

Although religious guidance exempts some Muslims with type 2 diabetes from fasting during Ramadan, many choose to fast. The associated risks for fasting adults with diabetes includes hypoglycemia, hyperglycemia, ketoacidosis, dehydration, and thrombosis. Thus, it is important that healthcare professionals support individuals who choose to fast to minimize risks. We reviewed three epidemiologic studies to understand how fasting patterns during Ramadan and associated clinical outcomes in adults with type 2 diabetes have evolved over two decades (2000-2020). Over a period of time people with diabetes choosing to fast during Ramadan are displaying increasingly complex profiles in terms of their diabetes, with increased disease duration, greater body mass index, and elevated pre-Ramadan mean glycated hemoglobin levels. Despite this, in the most recent study, >85% of adults with type 2 diabetes still chose to fast. Increased risk of hypoglycemia remains a major concern despite some improvements over time, which could be attributable to enhanced education programs, and changes in treatment type and/or dose prior to and/or during Ramadan. Our review highlights the evolution in fasting patterns over two decades and serves as an update for healthcare professionals to provide appropriate guidance to ensure that Ramadan fasting is safe and rewarding.

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.

Everestmab, a novel long-acting GLP-1/anti GLP-1R nanobody fusion protein, exerts potent anti-diabetic effects

In the present study, a novel single domain antibody (sdAb) fusion protein, named everestmab, composing of a mutated GLP-1(A8G) fused to the tandem bispecific humanized GLP-1R-targeting and albumin-binding nanobodies was designed and characterized for the therapies for type 2 diabetes mellitus (T2DM). Surface plasmon resonance (SPR) measurements demonstrated everestmab associates with serum albumins of rat and monkey species with high affinity, and tends to be cross-reactive with rat and monkey species. In vitro GLP-1R binding and activation assays revealed that everestmab can specifically activate the GLP-1R, and the antagonist exendin-4 (9-39) did not inhibit the activation yet. In vivo multiple oral glucose tolerance tests (OGTTs) and hypoglycaemic efficacy tests proved that a single injection of everestmab reduced the blood glucose for at least 144 h in Goto-Kakizaki (GK) rats. The plasma half-lives of 4.1 and 7.8 days were observed after a single s.c. administration of everestmab in SD rats and cynomolgus monkeys, respectively. Chronic treatment of everestmab to GK and diet induced obese (DIO) rats achieved beneficial effects on weight reducing, HbA1c lowering, glucose tolerance, liver and pancreas islet function impairment. In summary, everestmab is a unique G-protein-coupled receptor-targeted nanobody fusion protein and exerts potential as a therapeutic treatment for T2DM.

Experiences and views of people with diabetes during Ramadan fasting: A qualitative meta-synthesis

Objectives

To review and appraise the existing qualitative studies on Ramadan fasting in participants with diabetes and to integrate valuable qualitative evidence for optimizing diabetes management.

Methods

Twelve databases (PubMed, Embase, Cochrane Library, Science Direct, CINAHL, PsycINFO, JBI (Joanna Briggs institute), Web of Science, and four Chinese databases) were searched to identify qualitative studies on experiences and perspectives of Ramadan fasting in participants with diabetes. CASP (Critical Appraisal Skills Program) Qualitative Checklists were applied to appraise the included studies. A meta-synthesis approach was used to analyze the included studies. Through the strategy of inductive thematic synthesis and reciprocal interpretation, the findings and quotations of the included studies were integrated into new themes and categories. The CERQual (Confidence in the Evidence from Reviews of Qualitative Research) tool was used to grade the confidence of the new themes.

Results

A total of 11 qualitative studies were included, and 43 findings were isolated. Ten new themes were identified and synthesized from the findings. Finally, four new categories were integrated, including the knowledge and understanding of observing Ramadan fasting, well-being and challenges, self-efficacy, and needs and expectations of participants with diabetes during Ramadan.

Conclusions

Insulin-dependent individuals call for special concern during Ramadan fasting. Ramadan-focused education needs to be developed and generalized, and existing guidelines should be improved to optimize the management of diabetes. Professional HCPs contribute to weigh the health risks and mental satisfaction for their patients, partly, to balance health and religion. Participants’ psychological construction is another concern for religious scholars and psychologists.

Use of SGLT2 inhibitors during Ramadan: An expert panel statement

Fasting from dawn to sunset, during the holy month of Ramadan, constitutes one of the five main pillars in Islam and is observed by the majority of Muslims. Owing to important physiological changes, Ramadan fasting holds a crucial place in the context of diabetes management. Approximately one-fifth of the world's Muslim population resides in the Middle East and Africa (MEA) region. To discuss the challenges and management of diabetes during Ramadan fasting in the MEA region, a panel of 12 experts in the field of diabetes from across the MEA region attended two expert committee meetings held in Dubai. The key point of discussion was the safety and efficacy of the use of sodium-glucose co-transporter 2 inhibitors (SGLT2i) during Ramadan, based on outcomes of the recent clinical trials with SGLT2i. This is the first consensus recommendation on the management of diabetes with SGLT2i across the MEA region during Ramadan. The document summarizes expert views and opinions on the current management of diabetes with SGLT2i during Ramadan and aims to enhance the current knowledge and understanding on the issue of diabetes management during Ramadan. This will aid the physicians of the MEA region with appropriate decision-making for their patients during Ramadan.

Evolving physicians' perceptions and practices regarding use of SGLT2 inhibitors for type 2 diabetes during Ramadan fasting

OBJECTIVES

We followed up the evolving perceptions and practices regarding use of SGLT-2 inhibitors in Ramadan.

METHODS

We compared results of the three survey in 2015, 2017, 2019.

RESULTS

Senior doctors represented 43.5-66.4% and endocrinologists accounted for 38.1-60.2%. There was a steady reduction in the proportions of respondents who did not know SGLT2-Is at all, who have just heard about the class and those who are quite familiar with the class but have not yet used any. Whereas the proportions of those using the SGLT2-Is class occasionally only was stable. However those who use the SGLT2-Is regularly increased from 11.0% to 45.6% and 62.6%. The respondents' who SGLT2-Is are safe and may be used in all fasting diabetic patients increased from 15.5%, 14.7% to 23.1%. Whereas the view that SGLT2-Is should not be used decreased progressively. Majority of respondents in the three surveys suggested that specific advice is given if they allow the use of SGLT2-Is during Ramadan. More respondents advise taking the medication with the first evening meal than before the last pre-dawn meal and advised to attend to their hydration status. One third of respondents would resume SGLT2-Is immediately after the end of Ramadan; 15% after 1-2 weeks, or prefer to wait till the next medical or educator's clinic visit and others would re-evaluate patients' management plan.

CONCLUSIONS

The medical professions' knowledge and perceptions regarding the use of SGLT2-Is during Ramadan fasting have evolved over the last few years due to increasing research and experience.

Ramadan and Diabetes: A Narrative Review and Practice Update

Fasting in the Islamic month of Ramadan is obligatory for all sane, healthy adult Muslims. The length of the day varies significantly in temperate regions-typically lasting ≥ 18 h during peak summer in the UK. The synodic nature of the Islamic calendar means that Ramadan migrates across all four seasons over an approximately 33-year cycle. Despite valid exemptions, there is an intense desire to fast during this month, even among those who are considered to be at high risk, including many individuals with diabetes mellitus. In this review we explore the current scientific and clinical evidence on fasting in patients with diabetes mellitus, focussing on type 2 diabetes mellitus and type 1 diabetes mellitus, with brief reviews on pregnancy, pancreatic diabetes, bariatric surgery, the elderly population and current practice guidelines. We also make recommendations on the management of diabetes patients during the month of Ramadan. Many patients admit to a do-it-yourself approach to diabetes mellitus management during Ramadan, largely due to an under-appreciation of the risks and implications of the rigors of fasting on their health. Part of the issue may also lie with a healthcare professional's perceived inability to grasp the religious sensitivities of Muslims in relation to disease management. Thus, the pre-Ramadan assessment is crucial to ensure a safe Ramadan experience. Diabetes patients can be risk-stratified from low, medium to high or very high risk during the pre-Ramadan assessment and counselled accordingly. Those who are assessed to be at high to very high risk are advised not to fast. The current COVID-19 pandemic upgrades those in the high-risk category to very high risk; hence a significant number of diabetes patients may fall under the penumbra of the 'not to fast' advisory. We recognize that fasting is a personal choice and if a person chooses to fast despite advice to the contrary, he/she should be adequately supported and monitored closely during Ramadan and for a brief period thereafter. Current advancements in insulin delivery and glucose monitoring technologies are useful adjuncts to strategies for supporting type 1 diabetes patients considered to be high risk as well as 'high-risk' type 2 patients manage their diabetes during Ramadan. Although there is a lack of formal trial data, there is sufficient evidence across the different classes of therapeutic hypoglycaemic agents in terms of safety and efficacy to enable informed decision-making and provide a breadth of therapeutic options for the patient and the healthcare professional, even if the professional advice is to abstain. Thus, Ramadan provides an excellent opportunity for patient engagement to discuss important aspects of management, to improve control in the short term during Ramadan and to help the observants understand that the metabolic gains achieved during Ramadan are also sustainable in the other months of the year by maintaining a dietary and behavioural discipline. The application of this understanding can potentially prevent long-term complications.

ELECTRONIC SUPPLEMENTARY MATERIAL

The online version of this article (10.1007/s13300-020-00886-y) contains supplementary material, which is available to authorized users.

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.

Recommendations for management of diabetes during Ramadan: update 2020, applying the principles of the ADA/EASD consensus

Fasting the Holy month of Ramadan constitutes one of the five pillars of the Muslim faith. Although there is some evidence that intermittent fasting during Ramadan may be of benefit in losing weight and cardiometabolic risk factors, there is no strong evidence these benefits apply to people with diabetes. The American Diabetes Association/European Association for the Study of Diabetes consensus recommendations emphasize the importance of patient factors and comorbidities when choosing diabetes medications including the presence of comorbidities, atherosclerotic cardiovascular disease, heart failure, chronic kidney disease, hypoglycemia risk, weight issues and costs. Structured education and pre-Ramadan counseing are key components to successful management of patients with diabetes. These should cover important aspects like glycemic targets, self-monitoring of blood glucose, diet, physical activity including Taraweeh prayers, medication and dose adjustment, side effects and when to break the fast. The decision cycle adapted for the specific situation of Ramadan provides an aid for such an assessment. Children with type 1 diabetes should strongly be advised not to fast due to the high risk of acute complications such as hypoglycemia and probably diabetic ketoacidosis (DKA), although there is very little evidence that DKA is increased in Ramadan. Pregnant women with diabetes or gestational diabetes should be advised to avoid fasting because of possible negative maternal and fetal outcomes. Hypoglycemia is a common concern during Ramadan fasting. To prevent hypoglycemic and hyperglycemic events, we recommend the adoption of diabetes self-management education and support principles. The use of the emerging technology and continuous glucose monitoring during Ramadan could help to recognize hypoglycemic and hyperglycemic complications related to omission and/or medication adjustment during fasting; however, the cost represents a significant barrier.

Intermittent Fasting as Part of the Management for T2DM: from Animal Models to Human Clinical Studies

PURPOSE OF REVIEW

Diet is a pillar of type 2 diabetes mellitus (T2DM) management. Intermittent fasting (IF) is postulated as a novel approach, able to improve glucose control and potentially capable of reversing some of the pathophysiological alterations of this condition. In this review, the molecular and clinical evidence of diets based on intermittent energy restriction (IER) in laboratory animal models and subjects with type 2 diabetes is discussed. The mechanisms through which IF are thought to improve glucose homeostasis and reverse β cell failure are also reviewed.

RECENT FINDINGS

Studies derived from murine models suggest that IER is associated with improvements in β cell function and insulin resistance. Two main mechanisms have been demonstrated, one derived from the autophagy-lysosome pathway and, the other from an increase in neurogenin3 (Ngn3) levels (a marker for endocrine progenitor cells like β cells during development). Notably, IER also promotes reconstruction of gut microbiota. In mice, all effects were independent of weight loss. By contrast, in human studies, outcomes are widely attributable to weight loss. The more consistent results are reductions in body weight, visceral fat, and glucose and insulin levels. Increases in HDL cholesterol levels are also frequently reported. The decrease in insulin levels observed in humans is in opposition with the increase reported in mice, suggesting that the main mechanism in humans is an improvement in peripheral insulin action. Recommending diets based on intermittent fasting in humans is based on the promising results found in animal models where an improvement in β cell function has been recorded. β cell function after IF has not been assessed in human subjects with T2DM. This review provides information regarding different protocols for the implementation of IF in diabetic persons and also provides important safety advice in order to avoid adverse effects. Clinical studies do not show an increased risk of hypoglycemia, and a recent case series reported reversal of T2DM.

Qualitative evaluation of A Safer Ramadan, a structured education programme that addresses the safer observance of Ramadan for Muslims with Type 2 diabetes

AIMS

Muslims can choose to fast during Ramadan. Guidelines exist for providing clinical support for this group, but there is a lack of culturally tailored diabetes management interventions to provide guidance. The study evaluates the implementation of a programme developed to meet this need.

METHODS

A Safer Ramadan is a multi-faceted package comprising a self-management and community awareness programme, and healthcare professional training. Implementation of the programme took place in two cities in the UK, prior to Ramadan 2017. Uptake and attendance were determined, and qualitative interviews and focus groups were completed with people attending the programme, and with various stakeholders involved in implementation and delivery.

RESULTS

Success of the implementation varied and engagement by primary care was limited. Three central themes emerged from the interviews highlighting barriers and facilitators of the programme implementation. These were the referral pathway, programme content and feedback on the delivery of the programme.

CONCLUSIONS

Provision of interventions that provide support and education for Muslims during Ramadan was implemented in communities and valued by GPs and practice nurses. However, heavy workloads to support delivery made it difficult for practices to engage. Recommendations for future delivery of the programme indicate that greater attention should be given to marketing and its supporting practices. Furthermore, training for practice nurses to support patients prior to Ramadan and provision of funding is required.

Growth of Diabetes Research in United Arab Emirates: Current and Future Perspectives

BACKGROUND

Diabetes mellitus (DM) is one of the most prevalent metabolic diseases in the UAE. During the last two decades, the United Arab Emirates (UAE) has experienced tremendous development in all fields including DM research. The present study sheds light on the growth in DM research in UAE and represents a guide for DM researchers to create more focused future directions in DM research.

OBJECTIVES

The main objective of the present study is to investigate and document the changes that occurred in DM research in the UAE over the last two decades.

METHODS

Several research databases were reviewed and all the articles that involved any form of DM research within the UAE were selected. Inclusion criteria were: (i) Research studies related to DM and conducted by institutions based in UAE (ii) Research studies related to DM and conducted in the population of UAE and (iii) Research articles related to DM and the authors (principal investigators or co-investigators) are from UAE.

RESULTS

Between the years of 1996 and 2000, there was an average of 6.4 articles about DM being published per year. This pattern changed dramatically between years 2011 to 2015 where an average of 22.8 articles were being published. In addition, a significant increase was noticed in the year 2015 with 42 articles published per year. It was also found that 46.8% articles involved clinical study, 12.1% were basic research, 17.5% cross-sectional studies, 8.91% reviews, 8.2% were cohort and all the other types of research represented about 5.58%.

CONCLUSION

Significant progress has been noticed in DM research in the UAE during the last two decades. Based on the findings of the present study, more focus should be given to the case reports and clinical trials.

Fasting in Ramadan with type 1 diabetes: A dose adjustment for normal eating workshop in Kuwait

This pre-Ramadan workshop was aimed at educating and counselling people with type 1 diabetes, who graduated from the Dose Adjustment for Normal Eating (DAFNE) Kuwait programme, on safe fasting practices as well as determining their views on the challenges associated with fasting. The workshop also served as a pilot for a Ramadan-specific module to inform its implementation in all DAFNE programmes with the goal of meeting the needs of Muslim DAFNE graduates wishing to fast safely. A 2-day workshop (5 hours each) was conducted at DAFNE Kuwait 3 days before the start of Ramadan 2018 and all DAFNE graduates were invited to attend. The workshop consisted of group discussions about fasting-related challenges, followed by three interactive lectures and hands-on experience with popular Ramadan dishes. A qualitative approach was employed to determine the experiences of the participants with fasting by conducting three focus group discussions. The discussions were recorded via handwritten notes and analysed thematically. Seventy-two people with type 1 diabetes attended and 47 participated in the group discussions. Participants discussed their past experiences with fasting and the associated challenges, and shared practices adopted over the years. In addition, they confirmed the positive impact of DAFNE on their fasting experiences. The workshop provided a platform for people with type 1 diabetes to share their experiences with fasting and learn how to fast safely. Furthermore, it provided preliminary information that can be further explored to inform recommendations for safer fasting practices and the implementation of a specific fasting curriculum for people with type 1 diabetes.

[Migration and diabetes (Update 2019)]

The article deals with the demographic data of migration in Austria and with therapeutic advice concerning drug therapy and diabetes education for patients with migration background. In this context sociocultural specifics are discussed. These suggestions are seen complementary to the general treatment guidelines of the Austrian Diabetes Association.The fasting month Ramadan is widely practiced by the Muslim population worldwide. Ensuring the optimal care of the many people with diabetes who fast during Ramadan is crucial. The IDF-DAR Practical Guidelines (International Diabetes Federation - Diabetes and Ramadan International Alliance) provide healthcare professionals with relevant background information and practical recommendations to enable them to help patients with diabetes participate in fasting during Ramadan while minimizing the risk of complications.

Experiences of people with type 1 diabetes fasting Ramadan following structured education: A qualitative study

BACKGROUND AND AIMS

Although people with type 1 diabetes are exempt from fasting the month of Ramadan due to the risk to their health, many wish to fast nonetheless. Little is known about the impact of structured education on the fasting experiences of people with type 1 diabetes. This study aimed to explore how the Dose Adjustment for Normal Eating (DAFNE) course affected people with type 1 diabetes' fasting experiences to provide insight into the benefits of structured education for people wishing to fast while managing their diabetes.

METHODS

Semi-structured interviews were conducted with 40 DAFNE graduates who fasted Ramadan. The purposive sample was selected from the DAFNE registry at Dasman Diabetes Institute in Kuwait. The interviews were transcribed verbatim and analysed thematically in an iterative process. Topics discussed included fasting experiences prior to attending the DAFNE course, fasting experiences this year, and how DAFNE affected their fasting.

RESULTS

Five themes emerged; (1) Reduction in fluctuations and complications, (2) Improvement in confidence and self-reliance, (3) Tailored support for dose and pump programming adjustments, (4) Positive effect on wellbeing, and (5) Encouraging informed-decision making about fasting.

CONCLUSIONS

The findings have provided insight into the impact of DAFNE structured education on the fasting experiences of people with type 1 diabetes and has shown how overall, DAFNE had enhanced the quality of fasting. In addition, by assisting them in fulfilling their fasting wishes, DAFNE has had a positive effect on their wellbeing.

Fasting outcomes in people with diabetes and chronic kidney disease in East London during Ramadan 2018: The East London diabetes in Ramadan survey

OBJECTIVES

Fasting in summer months for Muslim people with diabetes during Ramadan is challenging, particularly in temperate climates, where duration of fasting is prolonged. Risk of fasting may be greater in people with diabetes and chronic kidney disease (CKD). We aimed to prospectively monitor the outcomes of patients with diabetes and CKD stage 3 during Ramadan 2018 in East London.

METHODS

Patients with type 2 diabetes (T2D) and CKD stage 3 attending community diabetes clinics were approached prior to Ramadan 2018 to discuss fasting. Patients were risk categorised according to Diabetes and Ramadan Alliance guidelines. If they chose to fast, Ramadan education was given, and biomedical assessments were undertaken within one week prior to and one week after fasting. Outcomes between patients fasting and non-fasting groups were compared.

RESULTS

Fasting (n = 68) and non-fasting groups (n = 71) were similar apart from slightly higher insulin use in the non-fasting group. Median days fasted was 21 (range 12-29). There were no significant changes in weight, blood pressure, creatinine, glycated haemoglobin, cholesterol and urinary PCR pre- and post-Ramadan, and no significant differences between the fasting and non-fasting groups. There was no difference in adverse events (acute kidney injury, hypoglycaemia or cardiovascular events) between the fasting and non-fasting groups.

CONCLUSIONS

No significant differences were seen in clinical or biochemical parameters, or adverse events between fasting and non-fasting patients. Patients with T2D and stable CKD stage 3 may be able to fast safely during Ramadan.

Differential effects of gender and patient background diversity on the changes in metabolic and biophysical profiles in people with type-2 diabetes from different ethnicities who fast during Ramadan (H1439); a prospective study from Qatar

OBJECTIVE

The 'PROspective Study of dose adjustment of multiple anti-diabetic therapy for Type-2 diabetic patients FASTing the Month of Ramadan aimed to assess the biophysical and metabolic effects of fasting during Ramadan, including HbA1c, weight, blood pressure and lipid profile.

STUDY DESIGN METHODS

We performed a prospective study of people with Type-2 diabetes who were on ≥3 drugs for lowering glucose before and after Ramadan of H1438 (May-June 2017) in Hamad Medical Corporation, Qatar. We enrolled 228 participants, of whom 181 completed the study and were included in the analysis.

RESULTS

There were 115 (63.5%) men and 66 (36.5%) women, mean age 53.6 ± 9.7 years and mean diabetes duration of 10 ± 6 years. Both HBA1c [7.8% (62 mmol/mol) vs. 7.6% (60 mmol/mol); p = 0.004]; and diastolic BP (75.7 ± 8.55 vs. 68.8 ± 23.1 mmHg, P = 0.001) improved significantly after Ramadan while there was an increase in total cholesterol (3.94 ± 0.89 mmol/l vs 4.11 ± 1.02 mmol/l; p = 0.008) and triglycerides (1.55 ± 0.72 mmol/l vs 1.71 ± 0.9 mmol/l; p = 0.012). Subgroup analysis showed that patients on sulphonylurea, South Asians and males had a significant reduction in both HBA1c and weight.

CONCLUSION

Patients with Type 2 diabetes who fast during Ramadan show an improvement in glycaemic control and diastolic blood pressure, but a worsening of total cholesterol and triglycerides, particularly those of South Asian origin and men.

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

INTRODUCTION

In order to achieve the recommended glycemic control, women with Gestational Diabetes Mellitus (GDM) are instructed to self-monitor blood glucose (SMBG) regularly. The purpose of this study was to evaluate glucose readings provided by Continuous Glucose Monitoring (CGM) and SMBG in GDM patients during Ramadan fasting.

METHODS

This is a prospective observational study that recruited GDM patients treated with diet ± metformin were enrolled. They agreed to wear the iPro®2 ProfessionalCGM device and to do SMBG by glucose reading meters, during fasting and after meals. We evaluated the rates of hypoglycemia and hyperglycemia in each approach. The frequency and timing of SMBG was investigated.

RESULTS

Twenty-five patients were recruited. A total of 36,628 readings by CGM device and 408 readings using glucose meters and were captured. Average glucose level was 103 ± 8 mg/dl (5.7 ± 0.4 mmol/l) and 113 ± 14 mg/d (6.28 ± 0.8 mmol/L) on CGM and glucose meters respectively. The rate of hyperglycemia was 5.65% and 14.2% and hypoglycemia was 4.35% and 1.5% using CGM and glucose meters respectively. While all hypoglycemic episodes occurred between 16:00-19:00 in both approaches, only 38 readings (9%) of SMBG readings were done in that time frame.

CONCLUSION

Although the frequency of SMBG using glucose meters for women with GDM and fasting Ramadan was acceptable, the timing was not. CGM detected more hypoglycemia and less hyperglycemia than SMBG. Relying on Intermittent SMBG in the management of GDM patients during Ramadan fasting might be misleading.

Bibliometric analysis of the literature on Ramadan fasting and diabetes in the past three decades (1989-2018)

OBJECTIVES

To quantify the research contribution related to Ramadan fasting and diabetes.

METHODS

We searched for the combination of "Ramadan" and Diabetes" in the title, abstract and keywords in the Scopus database between 1989 and 2018. Articles were analysed for standard bibliometric methodology and VOSviewer was used to construct bibliometric diagrams.

RESULTS

The total number of retrieved articles was 424 articles; 112 were "Open Access". Two-thirds of articles covered original research. Articles were published in medical journals of varying influence. UK-based authors and affiliated institutions were dominant. A single author has an evident dedication to Ramadan research whereas for many authors it Ramadan research was just one aspect of their academic interest. The number publications and the extent of international collaborations were lower than expected, given the world-wide practice of Ramadan fasting by many populations with an increased prevalence of diabetes. The need to share experiences and generalizable conclusions.

CONCLUSIONS

This is the first bibliometric study on diabetes in Ramadan. It is a good starting point to evaluate gaps in research activity in the field and should help identify future research directions and foster more collaboration.

Risk of diabetic ketoacidosis during Ramadan fasting: A critical reappraisal

OBJECTIVES

To evaluate the validity of the perceived increased risk and the actual occurrence of DKA observed during fasting in Ramadan.

METHODS

This is a non-systematic narrative review of the literature on the occurrence of DKA during Ramadan. Online databases (PubMed, Google Scholar, Cochrane Database, Medline OVID and CINAHL EBSCO) were searched. Three research questions are addressed 1. What is the basis of the expert opinion on the risk for DKA? 2. What is the likelihood that DKA is precipitated by Ramadan fast? and 3. What is the frequency of observed DKA during Ramadan?

RESULTS

The expert opinion suggesting a risk of DKA during Ramadan fasting was proposed with no evidence in the early writing on Ramadan fasting and has been reiterated and propagated since then. However, from first principles, DKA is not readily precipitated by the usual stress-free metabolic environment induced by Ramadan fasting with the exception of cases involved in the usual risk factors for metabolic decompensation. Furthermore, recent studies could not document any increase in observed DKA during Ramadan fasting in retrospective, prospective and database studies.

CONCLUSIONS

The current state of knowledge and evidence suggests the risk of DKA is not increased during Ramadan fasting.

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

OBJECTIVES

To describe the risk of hypoglycaemia during Ramadan and determine its risk factors, and the impact of hypoglycaemia on patients' behaviour.

METHODS

A cross-sectional multi-country observational study, with data captured within 6 weeks after Ramadan 2015. Patients' and disease characteristics and its management, the risk of hypoglycaemia and patients' response to hypoglycaemia were recorded.

RESULTS

A cohort of 1759 patients; majority with type 2 diabetes mellitus from North Africa, Arabian Gulf, Saudi Arabia, and the Indian subcontinent. Hypoglycaemia was reported by 290 patients (16.8%); particularly affecting type 1 diabetes patients and in insulin-treated patients in general. Age was significantly younger in the hypoglycaemia group (P < 0.001). The commonest responses were reducing the dose or frequency of medications (42%), attending primary care providers (24.5%) or increasing monitoring (20.7%). Fasting was interrupted by 67% only of those who experienced hypoglycaemia and recourse to emergency services was pursued by less than a quarter of patients with hypoglycaemia. The country-wise analysis of the rates of hypoglycaemia was greatest in Egypt (51.3%) and lowest in Pakistan (3.5%).

CONCLUSIONS

Hypoglycaemia is a significant complication of fasting during Ramadan. It may be predicted by type of diabetes, and use of insulin. Patients' responses are varied and call for more formal pre-Ramadan education.

Management of diabetes during Ramadan fasting in children and adolescents: A survey of physicians' perceptions and practices in the Arab Society for Paediatric Endocrinology and Diabetes (ASPED) countries

AIM

To ascertain the pattern of diabetes management during Ramadan fasting in childhood and adolescence among physicians in Arab countries.

METHODS

An online electronic survey questionnaire was distributed to physicians registered in the Arab society for Paediatric Endocrinology and Diabetes (ASPED).

RESULTS

Of the 167 responders, 114 (86.0%) were paediatricians and the remaining 14.4% were adult physicians. 117 (79.6%) would allow patients to fast and 60.7% of them emphasized providing education before fasting. 69.1% of physicians thought that their patients complete >50% of fasting days. 46.9% recognized those with hypoglycemia unawareness among the very high-risk group for fasting. 62% reported that fasting should be broken if symptomatic hypoglycemia regardless of glucose level and 48.2% indicated that blood glucose above 300 mg/dl is another indication. 63.4% of respondents would decrease basal insulin by 25%, and 52.8% reported that using insulin pump during fasting reduced the frequency of hypoglycemia. 81.1% recommend several dietary adjustments and 56.4% used rapid-acting insulin analog according to carbohydrate counting.

CONCLUSIONS

There is a wide variation in the management of children and adolescents with diabetes during Ramadan in ASPED countries. A targeted educational program for physicians and establishing a guideline for this challenging area is needed.

The incidence of diabetic ketoacidosis during Ramadan fasting: A 10-year single-centre retrospective study

CONTEXT

There has been an increased interest in the potential metabolic derangements and acute complications of diabetes related to the Muslims' fasting during the month of Ramadan.

OBJECTIVES

We compared the incidence of admissions due to diabetic ketoacidosis (DKA) during Ramadan with the admissions during other months.

METHODS

This is a retrospective electronic database and chart review study that included all Muslims who were admitted with DKA to Sheikh Khalifa Medical City in Abu Dhabi, United Arab Emirates. We explored the relationship of admissions to Ramadan over ten years (2005-2014).

RESULTS

There were 432 episodes of DKA involving 283 patients. Of these, 370 episodes (85.6%) involved 231 patients (81.6%) with type 1 diabetes. The number of admission episodes was not different during Ramadan from the average calendar month [3.6 ± 2.6 (Range 0-15) episodes/month versus 3.3 ± 2.1 (Range 1-7) episodes/month respectively, P = 0.77]. No recurrences of admissions were observed during Ramadan. There was a non-significant numerical tendency for more episodes in March and September (4.6 episodes for both) and fewer episodes in July (2.6 episodes) than other months; P values were 0.06; 0.13, and 0.32 respectively. This seasonality was not related to the month of Ramadan.

CONCLUSIONS

The present study confirmed that DKA admissions during Ramadan were not significantly higher than the average monthly admissions over ten years. Seasonality trends were not related to Ramadan.

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

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

Incidence of hypoglycaemia in patients with type-2 diabetes taking multiple glucose lowering therapies during Ramadan: the PROFAST Ramadan Study

Objective

To assess the incidence of hypoglycemia in people with type-2 diabetes mellitus (T2DM) on three or more anti-diabetic medications during Ramadan.

Study design methods

We have studied people with T2DM on three or more glucose-lowering drugs during Ramadan of H1438 (May-June 2017). The dose of each drug was adjusted according to a pre-specified protocol. The incidence of symptomatic or blood glucose confirmed hypoglycemia was recorded during the study.

Results

We enrolled 228 people with T2DM; 181 completed the study, and data on hypoglycaemia was available in 172 subjects. There were 115 males and 66 females, (mean age ± SD) 53.6 ± 9.7 years, diabetes duration 10 ± 6 yrs. The incidence of hypoglycaemia was 16.3% (28/172). Univariable logistic regression analysis showed that the risk of hypoglycaemia was increased in Arab subjects compared to Qatari; in those with longer duration of diabetes; and in those on four or more anti-diabetic medications compared to those on three anti-diabetic medications.

Conclusion

Despite the tailored advice, there is a high incidence of hypoglycemia in people with T2DM taking multiple glucose lowering therapies whilst fasting during Ramadan. Guidelines should address the increased complexity in anti-diabetic medications in patients who fast during Ramadan. Healthcare providers should individualize the modifications in anti-diabetic medications during Ramadan.

Development of a Collaborative Algorithm for the Management of Type 2 Diabetes during Ramadan: An Anchor on Empowerment

Empowerment plays significant roles in the complex management of type 2 diabetes. International guidelines have provided recommendations on management of Muslims who fast during Ramadan. However, there remains a lack of patient-centered epistemic tool to empower healthcare providers and patients in managing diabetes during Ramadan. This study discussed the development and evaluation of such tool. The collaborative algorithm was developed with reference to the nominal group technique by a board-certified clinical pharmacist and discussed with endocrinologists, nurses, and family physicians. The empowerment component of the algorithm was developed based on the Basic Psychological Needs Theory. The algorithm was evaluated through a randomized controlled trial. Glycated hemoglobin (HbA1c), fasting plasma glucose (FPG), and postprandial glucose (PPG) levels and safety profiles in terms of hypoglycemic events were assessed. The collaborative algorithm was developed with four components: screening, education, dose modification by healthcare provider, and dose adjustment by patient. A total of 62 individuals were recruited, with 30 and 32 randomized into the intervention and control groups, respectively. The mean age was 58.4 years, with majority being females (67.7%). There was a reduction in mean HbA1c from 7.9% ± 0.9% to 7.5% ± 0.8% (P < 0.001) in the intervention group, while no significant difference was observed in the control group (P = 0.270). FPG (P < 0.001) and PPG (P = 0.002) also improved significantly in the intervention group. There were no major hypoglycemic events and minor hypoglycemia comparable between both groups (P = 0.465). The collaborative algorithm incorporated empowerment and promoted shared decision-making in diabetes management, hence promoting safe and effective fasting.

Outcome of focused pre-Ramadan education on metabolic and glycaemic parameters in patients with type 2 diabetes mellitus

BACKGROUND

Ramadan fasting is associated with the risk of acute complications including hypoglycaemia. Therefore, patients' education before Ramadan and follow up during Ramadan is essential for safe fasting.

OBJECTIVES

To evaluate the effect of pre-Ramadan education program on biochemical parameters and the risk of hypoglycaemia in patients with type 2 diabetes mellitus.

METHODS

A prospective interventional controlled design was carried out on 320 Muslim patients with type 2 diabetes. They were divided into 2 groups; the control group (n = 200) who received standard diabetic care and the intervention group (n = 120) who received focused individualized diabetic education sessions before Ramadan. The study was carried out on 3 phases (before, during and after Ramadan). Post-education change of hypoglycaemia risk and biochemical parameters during Ramadan fasting were the primary outcomes.

RESULTS

Fasting blood glucose decreased significantly during, and after Ramadan in both groups (P < 0.001). Hypoglycaemia during fasting occurred in 4.1% of patients in the intervention group vs. 19.5% in the control group. Post Ramadan reduction of HbA1c < 7% increased statistically significantly in the intervention group (from 20.8% of patients before Ramadan to 55.8% after Ramadan). Low-density lipoprotein cholesterol decreased in the intervention group (P = 0.024). The body weight of the patients did not significantly change in both groups.

CONCLUSION

There was a significant impact of pre-Ramadan educational program on reduction of hypoglycaemic risk and other acute complications, reduction of low-density lipoprotein cholesterol and improvement of high-density lipoprotein cholesterol. Therefore, it is recommended for the fasting patients especially those with high and very high risk during Ramadan.

SMS-based intervention in type 2 diabetes: clinical trial in Senegal

Objective

Since 2014 Senegal has benefited from regular awareness-raising Short Message Service (SMS) campaigns (Be He@lthy, Be Mobile initiative) directed at people who have signed up, for free, to the ‘mDiabète’ programme. We report on an evaluation of its impact on diabetes control.

Design

The clinical trial was designed to send daily SMS during 3 months to people with type 2 diabetes. Due to centre randomisation, SMS were sent from inclusion (M0) to month 3 (M3) to people in centre S and from M3 to month 6 (M6) to people in centre P.

Setting

Medical centre S in the northwestern suburbs of Dakar; centre P in Popenguine, 70 km south of Dakar.

Participants

In February 2017, people with type 2 diabetes were consecutively recruited in the two centres. Complete data were available from 186 of these people.

Main outcome measures

HbA1c was measured in the two centres with the same assay throughout the study. The primary end point was the difference between centres for the change in HbA1c from M0 to M3. Secondary end points were the evolution of HbA1c in centres S and P between M3 and M6.

Results

The HbA1c change from M0 to M3 in centre S was better than in centre P, with a median difference of −0.4%, quartiles (−1.0; 0.3) versus 0.2% (-0.5; 0.8), respectively (p=0.0038). HbA1c decreased over the 3 months after having stopped SMS in centre S and was confirmed in centre P. The campaign cost was €2.5 (US$3.1) per person.

Conclusions

In Senegal, SMS sending was associated with an improved glycaemic control in people with type 2 diabetes. As SMS has a high penetration in low-income, middle-income countries where medical resources are scarce, health interventions using mobile telephones should be developed to facilitate exchanges between people with diabetes and medical teams; this may reduce diabetes-related complications.

Diabetes, driving and fasting during Ramadan: the interplay between secular and religious law

A large proportion of the Muslim population fasts during Ramadan. The risk of hypoglycemia is increased with fasting during Ramadan in people with diabetes who are on insulin and insulin secretagogues. Therefore, the combination of fasting with diabetes and driving presents a challenging situation, with legal implications for such individuals and their healthcare professionals. This novel, narrative, non-systematic review discusses the importance of addressing hypoglycemia in fasting with reference to secular legal guidance on driving with diabetes. We discuss religious aspects relating to fasting and driving in Islam. While there is no clear guidance or legal position on diabetes and driving for individuals who are fasting, Islamic law provides a logical framework to address this. Healthcare professionals need to raise and facilitate discussions on this often-overlooked topic with people with diabetes who are planning on fasting to minimize the potential for public harm. For some individuals fasting perhaps should be avoided when driving and that this religiously compatible position would best be adopted when one is dependent on driving for livelihood. Ultimately further research on glycemic control and management when fasting and driving, as well as a formal legal guidance on this topic, is required to safeguard healthcare professionals and the public from the potential dangers of driving with diabetes and fasting.