Role of Ramadan specific diabetes education (RSDE); A prospective study

A Hybrid Model of In-Person and Telemedicine Diabetes Education and Care for Management of Patients with Uncontrolled Type 2 Diabetes Mellitus: Findings and Implications from a Multicenter Prospective Study

Background

Patients with uncontrolled type 2 diabetes mellitus (T2DM) require close follow-up, support, and education to achieve glycemic control, especially during the initiation or intensification of insulin therapy and self-care management. This study aimed to describe and evaluate the impact of implementing a hybrid model of in-person and telemedicine care and education on glycemic control for patients with uncontrolled T2DM (hemoglobin A1c [HbA1c] ≥9%) during the coronavirus disease pandemic.

Methods

This prospective multicenter-cohort pre-/post-intervention study was conducted on patients with uncontrolled T2DM. This study included three chronic illness centers affiliated with the Family and Community Medicine Department at Prince Sultan Military Medical City in Riyadh, Saudi Arabia. A hybrid model of in-person (onsite) and telemedicine care and education was developed. This involved implementing initial in-person care at the physicians' clinic and initial in-person education at the diabetes education clinic, followed by telemedicine services of tele-follow-ups, support, and education for an average 4-month follow-up period.

Results

Of the enrolled 181 patients, more than half of the participants were women (n = 103, 56.9%). The mean age of participants (standard deviation) was 58.64 ± 11.23 years and the mean duration of diabetes mellitus was 13.80 ± 8.55 years. The majority of the patients (n = 144; 79.6%) were on insulin therapy. Overall, in all three centers, the hybrid model had significantly reduced HbA1c from 10.47 ± 1.23% to 7.87 ± 1.59% (mean difference of reduction 2.59% [95% confidence interval (CI) = 2.34-2.85%], p < 0.001). At the level of each center, HbA1c was reduced significantly with mean differences of 3.17% (95% CI = 2.81-3.53%), 2.49% (95% CI = 1.92-3.06%), and 2.16% (95% CI = 1.76-2.57%) at centers A, B, and C, respectively (all p < 0.001).

Conclusion

The findings showed that the hybrid model of in-person and telemedicine care and education effectively managed uncontrolled T2DM. Consequently, the role of telemedicine in diabetes management could be further expanded as part of routine diabetes care in primary settings to achieve better glycemic control and minimize nonessential in-person visits when appropriate.

The impacts of Ramadan fasting for patients with non-alcoholic fatty liver disease (NAFLD): a systematic review

Background

Numerous studies have explored the impacts of Ramadan fasting on Non-alcoholic fatty liver disease (NAFLD). Therefore, the objective of this systematic review was to analyze and summarize all clinical studies regarding the impacts of Ramadan fasting for patients with NAFLD.

Methods

We performed a comprehensive search of the Embase, Cochrane, and PubMed databases from inception to September 1, 2023. All clinical studies concerning the impacts of Ramadan fasting on patients with NAFLD were included.

Results

In total, six studies with 397 NAFLD patients comprising five prospective studies and one retrospective study were included in the systematic review. All six studies were assessed as high-quality. Ramadan fasting may offer potential benefits for patients with NAFLD, including improvements in body weight, body composition, cardiometabolic risk factors, glucose profiles, liver parameters, and inflammation markers.

Conclusion

Ramadan fasting might be an effective dietary intervention for NAFLD. However, the number of studies examining the impacts of Ramadan fasting for patients with NAFLD is relatively limited. Therefore, more high-quality research is needed to further our understanding of the benefits of Ramadan fasting for NAFLD.

Systematic review registration

https://inplasy.com, identifier 202390102.

Glucagon-Like Peptide-1 (GLP-1) during Ramadan: Narrative Review of the Published Literature

Ramadan fasting, a religious practice observed by Muslims worldwide, involves abstaining from eating, drinking, smoking, and using oral medications from dawn to dusk during the ninth lunar month. Studies have demonstrated that fasting during Ramadan has been shown to increase HDL cholesterol, leptin, adiponectin, and insulin sensitivity, as well as lower several hemostatic risk factors for cardiovascular diseases. Additionally, it may result in a drop in blood sugar levels, especially in diabetics who are also on blood sugar-lowering medicine. Hypoglycemia, characterized by low blood sugar levels, could also result from fasting during Ramadan. The GLP-1 (glucagon-like peptide-1) hormone plays a significant role in regulating glucose metabolism and insulin secretion, and Ramadan fasting can affect its production and release in the gut. Research contributes to our understanding of the utilization of GL-1 medications during Ramadan among patients, broadening therapy alternatives and offering insightful information for well-informed decision-making. Therefore, this narrative review aims to explore the current evidence that studies the safety and efficacy of GLP-1 agonists during Ramadan for nondiabetic and diabetic patients to ensure healthy fasting during Ramadan.

Assessing the awareness and care of people with diabetes related to Ramadan fasting; a-cross sectional study from Pakistan

Aim

To assess the awareness level and care of people with diabetes related to Ramadan fasting across the country.

Methodology

This cross-sectional survey was conducted by Baqai Institute of Diabetology and Endocrinology, between November 2016 to March 2017, using convenient sampling. The physicians involved in the care of people with diabetes were invited to participate. A preformed validated questionnaire was used to conduct face to face interview on one to one basis.

Results

Altogether 2187 people with diabetes were enrolled. Knowledge related to Ramadan fasting was poor (35.64%), misconceptions were common (57.02%), and unsafe practices (55.62%) were highly prevalent. One third (31.9%) of the subjects did not receive pre-Ramadan education while medications adjustments were not made in nearly half of the study population.

Conclusion

In this cross-sectional survey, we observed lack of awareness, misconceptions and unsafe practices among fasting people with diabetes across the country. Large scale awareness campaign is needed as comprehensive care is not widely available.

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.

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.

Role of 24-hour Helpline Service in the Management of Diabetes During the Holy Month of Ramadan

Objective

To assess the role of the 24-hour helpline service in the management of diabetes during the holy month of Ramadan.

Methodology

This prospective study was conducted at the Baqai Institute of Diabetology & Endocrinology, Baqai Medical University, Karachi, Pakistan, between December 2017 and August 2018. Patients with type 1 and type 2 diabetes who were willing to observe the fast in Ramadan 2018 were included. Pre-Ramadan education on a one-to-one basis was given and the 24-hour helpline number was provided to each patient. Details of baseline characteristics, anthropometric measurements, and biochemical parameters (lipid profile, serum creatinine, urine D/R (protein), and glycated hemoglobin A1c pre- and post-Ramadan) were noted. Self-monitoring blood glucose (SMBG) recording books were provided to each patient to record blood sugar levels during Ramadan.

Results

A total of 102 patients, 41 (40.2%) with type 1 diabetes and 61 (59.8%) with type 2 diabetes were included. The mean age of patients with type 1 diabetes was 17.02±5.22 years and that of patients with type 2 diabetes was 49.48±9.68 years. Most of the patients were male in both groups. By using the 24-hour helpline service, 912 calls were made to patients, 502 calls for type 1, and 410 calls for type 2 diabetes. Mean HbA1c (%) level before and after Ramadan was 8.94±1.72 and 8.70±2.03 in patients with type 1 diabetes and 8.59±1.73 and 7.71±1.27 in patients with type 2 diabetes, respectively. In the last 10 days of Ramadan, the decreasing trends of mean self-monitoring of blood glucose (SMBG) in patients with type 1 diabetes was observed for pre-dawn meal (suhoor), pre-sunset meal (iftar), and before sleeping while this trend in type 2 diabetes was found in the pre-dawn meal (suhoor)and two hours after iftar.

Conclusion

Pre-Ramadan diabetes education and treatment adjustment by using a station-based, 24-hour helpline service during the holy month of Ramadan have a significant role in controlling blood sugar levels, thus minimizing the complications of diabetes, facilitating timely adjustments in treatment, and reducing unnecessary hospital visits and admissions.

Initial increase in glucose variability during Ramadan fasting in non-insulin-treated patients with diabetes type 2 using continuous glucose monitoring

There are no studies evaluating the glucose variability in different periods of Ramadan fasting in patients with type 2 diabetes using continuous glucose monitoring (CGM). This study examined the effect of Ramadan fasting on interstitial glucose (IG) variability in early,- late-, and post-Ramadan compared to pre-Ramadan days in non-insulin-treated type 2 diabetes patients. Participants had a CGM system connected 2 or 3 days before Ramadan start, which was removed on the third or fourth day of Ramadan. CGM performance continued for a total of 6 days. A second CGM performance started on the 27th or 28th day of Ramadan and ended on the 4th or 5th post-Ramadan day. First, CGM recordings were divided into pre-Ramadan and early-Ramadan CGM, and second recordings into late-Ramadan and post-Ramadan. At each visit, blood pressure, body weight, and waist circumference were measured, and fasting blood samples were collected for HbA1c and plasma glucose. All patients received recommended Ramadan education before Ramadan. Thirty-three patients (mean age 55.0 ± 9.8 years, 73% males) were prospectively included. IG variability, estimated as mean amplitude of glycaemic excursions (MAGE), increased significantly in early-Ramadan compared to pre-Ramadan (P = 0.006) but not in late-Ramadan and post-Ramadan recording days. Only patients on >2 anti-diabetic drugs (n = 16, P = 0.019) and those on sulphonylureas (n = 14, P = 0.003) showed significant increase in MAGE in early-Ramadan. No significant changes were seen in coefficient of variation, time in range, time in hyperglycaemia, or time in hypoglycaemia. Except for an initial increase in glucose variability, fasting Ramadan for patients with non-insulin-treated type 2 diabetes did not cause any significant changes in glucose variability or time in hypoglycaemia during CGM recording days compared to non-fasting pre-Ramadan period.

Diabetes and Ramadan: A multicenter study in Algerian population

OBJECTIVE

The aims of this study are to describe the behaviour of an Algerian population with diabetes and the consequences of fasting.

METHODS

In 2017, a prospective multicenter study was conducted in 26 counties before and after fasting. The study concerned 901 patients with 836 type 2 diabetes mellitus (T2DM) and 65 with type 1 diabetes mellitus (T1DM).

RESULTS

The average age for T2DM and T1DM was 57.86 ± 10.44 and 45.8 ± 17.69 years respectively. The duration of diabetes was 9.09 ± 8.19 for T1DM and 7.87 ± 5.97 years for T2DM. 89.1% of T2DM and 69.2% of T1DM fasted during Ramadan. 51.4% of T2DM were classified among the high and very high risk. The average glycemia increased (162 ± 49 mg/dL vs. 197 ± 65 mg/dl) (p 0.035 × 10-6)]. About 30% of patients had hypoglycemic episodes. Self-monitoring blood glucose (SMBG) during Ramadan was not conform to the physicians' advice and thus significantly lowered than suggested (2.6 vs. 3.4 per day). The therapeutic adjustment was mainly a reduction in insulin dose and glucose-lowering agents.

CONCLUSION

Diabetic patients insist on fasting regardless of their doctors' warnings. The main consequences were hyperglycemia and hypoglycemia. SMBG was less checked during Ramadan. Therapeutic education remains unsufficient and needs much more emphasis.

Assessment of Ramadan Education and Knowledge Among Diabetic Patients

Background:

During Ramadan, Muslims fast from dawn until dusk for one lunar month every year. Most of the Muslim patients with diabetes are unaware of the potential complications that can occur while fasting, such as hypoglycemia. The aim of this study is to assess the the patient education level and patients’ overall awareness of any possible complications that could occur while fasting during Ramadan and to determine how these patients deal with these complications.

Methods:

We conducted a cross-sectional study and surveyed diabetic patients about their diabetes-related knowledge over a period of 4 months from the outpatient clinic at the Obesity, Endocrine, and Metabolism Center at King Fahad Medical City. Patients were included if they were ≥16 years and if they had been receiving treatment for at least 1 year before the study, irrespective of the medications used; patients were also asked about the presence or absence of complications.

Results:

This study included 477 patients (325 women and 152 men). Most patients (297; 62.3%) had type 2 diabetes. The patients’ mean age was 39.72 ± 15.29 years, and the mean duration of diabetes was 10.80 ± 5.88 years. During the preceding Ramadan, 76% of patients reported fasting, whereas 58% said that they monitored their blood glucose levels once per day. Hypoglycemic episodes were reported in 60.3% of cases with type 2 diabetes and in 8.3% of cases with type 1 diabetes. Among those who had hypoglycemia, 2.8% of patients with type 1 diabetes and 17.8% with type 2 diabetes broke their fast. Finally, 54% of patients reported that their health care providers offered them instructions on diabetes management during Ramadan.

Conclusions:

Ramadan health education in diabetes can encourage, improve, and guide patients to change their lifestyles during Ramadan while minimizing the risk of acute complications.

To fast or not to fast during the month of Ramadan? A comprehensive survey on religious beliefs and practices among Moroccan diabetic patients

BACKGROUND

Diabetes represents a major public health concern. According to the International Diabetes Federation, about 8%-9% of the population have diabetes, and rates are even higher among Muslim communities. Despite the risks, about half (43%) with type 1 diabetes and most (86%) of those with type 2 diabetes fast during Ramadan. However, there is a dearth of information concerning the determinants that drive diabetic people to fast. Therefore, the present study was designed to fill this gap in knowledge.

MATERIALS AND METHODS

A sample of 201 subjects volunteered to take part in this study. Mean age was 45.39±15.74 years. Most participants were female, married and had received at least primary education. They fasted for 22.98±8.53 days.

RESULTS

For the overall questionnaire, the Cronbach's alpha coefficient was found to be excellent (α=0.910). The coefficient was good, yielding a value of 0.879, for the items concerning Ramadan fasting beliefs and practices, whereas the subscale for religious beliefs and practices obtained a score of 0.847. At the univariate analysis, patients with complicated diabetes (n=66, 32.8% of the sample) fasted for 20.77±9.21 days vs subjects with diabetes (n=135, 67.2% of the interviewees), who fasted for 24.05±7.99 days. The difference was statistically significant (P=0.014). The multivariate analysis indicated that religious beliefs and practices influenced the number of fasting days in a statistically significant way, after adjusting for confounders (beta coefficient =-0.199, t=-2.917, P=0.004). Another variable that impacted on the number of fasting days was the presence of complications (beta coefficient=-0.194, t=-2.775, P=0.006).

CONCLUSION

Our results warrant further studies in the field.