Effects of Ramadan fasting on platelet reactivity in diabetic patients treated with clopidogrel

Risk Stratification in People with Diabetes for Fasting During Ramadan: Consensus from Arabic Association for the Study of Diabetes and Metabolism

BACKGROUND

Current international guidelines recommend a pre-Ramadan risk assessment for people with diabetes (PwDM) who plan on fasting during the Holy month. However, a comprehensive risk assessment-based recommendation for the management of PwDM intending to fast is still controversial. Therefore, the Arabic Association for the Study of Diabetes and Metabolism (AASD) developed this consensus to provide further insights into risk stratification in PwDM intending to fast during Ramadan.

METHODS

The present consensus was based on the three-step modified Delphi method. The modified Delphi method is based on a series of voting rounds and in-between meetings of the expert panel to reach agreements on the statements that did not reach the consensus level during voting. The panel group comprised professors and consultants in endocrinology (both adult and pediatric). Other members included experts in the fields of cardiovascular medicine, nephrology, ophthalmology, and vascular surgery, affiliated with academic institutions in Egypt.

RESULT

In PwDM who intend to fast during Ramadan, risk stratification is crucial to optimize patient outcomes and prevent serious complications. The present consensus provides risk assessment of those living with diabetes according to several factors, including the type of diabetes, presence, and severity of complications, number of fasting hours, and other socioeconomic factors. According to their risk factors, patients were classified into four categories (very high, high, moderate, and low risk).

CONCLUSION

Future research is warranted due to the controversial literature regarding the impact of fasting on certain comorbidities.

The impact of Ramadan intermittent fasting on anthropometric measurements and body composition: Evidence from LORANS study and a meta-analysis

Background

Although the effect of Ramadan intermittent fasting (RIF) on anthropometry and body composition has been questioned, none of the previous studies tried to explain the reported changes in these parameters. Also, systematic reviews that investigated the topic were limited to healthy individuals or a specific disease group.

Methods

The London Ramadan Study (LORANS) is an observational study on health effects of RIF. We measured weight, waist circumference (WC), hip circumference (HC), body mass index (BMI), waist-to-hip ratio (WHR), basal metabolic rate (BMR), fat percentage (FP), free-fat mass (FFM), extremities predicted muscle mass, total body water (TBW), trunk FM, trunk FFM and trunk predicted muscle mass before and immediately after Ramadan. Using mixed-effects regression models, we investigated the effect of RIF with adjustment for potential confounders. We also conducted a meta-analysis of the results of LORANS with other studies that investigated the effect of RIF on anthropometry and body composition. The review protocol is registered with PROSPERO registry (CRD42020186532).

Results

We recruited 146 participants (Mean ± SD age = 43.3 ± 15 years). Immediately after Ramadan, compared with before Ramadan, the mean difference was-1.6 kg (P<0.01) in weight,-1.95cm (P<0.01) in WC,-2.86cm (P <0.01) in HC, -0.60 kg/m2 (P < 0.01) in BMI and -1.24 kg (P < 0.01) in FM. In the systematic review and meta-analysis, after screening 2,150 titles and abstracts, 66 studies comprising 7,611 participants were included. In the general population, RIF was followed by a reduction of 1.12 Kg in body weight (-1.89- -0.36, I2 = 0), 0.74 kg/m2 reduction in BMI (-0.96- -0.53, I2 = 0), 1.54cm reduction in WC (-2.37- -0.71, I2 = 0) and 1.76cm reduction in HC (-2.69- -0.83, I2 = 0). The effect of fasting on anthropometric and body composition parameters starts to manifest in the second week of Ramadan and starts to diminish 3 weeks after Ramadan.

Conclusion

RIF is associated with a reduction in body weight, BMI, WC, HC, FM, FP and TBW. Most of these reductions are partially attributed to reduced FM and TBW. The reductions in these parameters appear to reverse after Ramadan.

The safety of Ramadan Fasting following Percutaneous Coronary Intervention

BACKGROUND

This work aimed to assess the safety of Ramadan Fasting following the Percutaneous Coronary Intervention.

METHODS

In our two centers' Prospective Cohort Study, We included 303 patients who had successful Percutaneous Coronary Intervention before the first day of Ramadan. We advised the patients that recent Percutaneous Coronary Intervention could be a valid excuse for not fulfilling Ramadan Fasting. However, many patients intended to fast the following Ramadan, and we included them in the fasting Group I. We added the patients who decided not to fast the following Ramadan as a control Group II. We followed all the patients during Ramadan and for 6 months after Ramadan.

RESULTS

The demographic data of both groups and the complexity of the coronary anatomy showed no statistically significant difference. Group I (n = 153) showed a statistically significant difference in the incidence of Major Adverse Cardiac Events compared to Group II with a P value (0.005). The logistic multivariate regression analysis showed that the duration from index PCI till the start of RF, SYNTAX score > 22, and Complex procedure were independent predictors of Major Adverse Cardiac Events in the fasting Group I with {P = 0.001, OR (2.302), P = 0.026, OR (2.419), and P = 0.032 OR (1.952)}, respectively. Major Adverse Cardiac Events in Group I occurred mainly during Ramadan Fasting, with 19 patients having Major Adverse Cardiac Events during Ramadan and four patients during the remaining of the follow-up period. The Receiver Operating Characteristic curve analysis showed the decline of the incidence of Major Adverse Cardiac Events after 90 days from Percutaneous Coronary Intervention till the start of Ramadan Fasting with Sensitivity and specificity (90% and 65%), respectively.

CONCLUSIONS

We suggest that low-risk patients with a normal systolic function who underwent Percutaneous Coronary Intervention may safely fast Ramadan. At the same time, Ramadan Fasting during the first 3 months following the Percutaneous Coronary Intervention may not be safe.

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.