Dietary patterns and glycemic control and compliance to dietary advice among fasting patients with diabetes during Ramadan

Ramadan Fasting Among Older Children and Adolescents With Type 1 Diabetes Mellitus: A Real-World Study From the UAE

Background

Ramadan fasting (RF) is a religious obligation for all healthy adult Muslims. The sick and pre-pubertal children are exempt, but many choose to fast for various reasons. In this “real world” study, glycaemic control has been investigated in the context of RF in children and adolescents with type 1 diabetes mellitus (T1DM) and compared multiple daily injections (MDI) and continuous subcutaneous insulin infusion (CSII) outcomes.

Methods

Children and adolescents with T1DM seen at Imperial College London Diabetes Centre who decided to fast in the ensuing Ramadan were educated with their families about diabetes mellitus management during RF using an adapted CHOICE (Carbohydrate, Insulin, and Collaborative Education) educational programme. Pertinent data including hypoglycaemia episodes and diabetic ketoacidosis (DKA) were obtained through patient/family interviews. Information on weight, glycated hemoglobin (HbA1c), and blood glucose levels from continuous glucose monitoring (CGM)/flash glucose monitoring (FGM) before (1 month prior), during, and after (1 month afterwards) Ramadan were retrieved retrospectively from the electronic database. Data are presented as mean ± SD.

Results

Forty-two patients [age 13.5 ± 2.4 years; 27 (64.3%) males; T1DM duration 4.9 ± 3.1 years] were included in the study and were able to fast for 22 ± 9 days during Ramadan. Twenty-three (54.8%) of the patients were on MDI and 19 (45.2%) were on CSII. No statistically significant differences were seen in CGM/FGM generated mean blood glucose level before, during, and after Ramadan [one-way ANOVA (F_{(2, 80)} =1.600, p = 0.21)]. HbA1c and weight after Ramadan did not change significantly compared to baseline (paired t-test; p = 0.02 and p = 0.08, respectively). Between MDI and CSII groups, there was no significant difference in fasting days (p = 0.49), frequency of hypoglycaemia episodes (p = 0.98), DKA frequency (p = 0.37), HbA1c level (p = 0.24), and weight (p = 0.11) after Ramadan.

Conclusion

Data show no significant deterioration in indicators of overall glycaemic control which remained inadequate. RF should be discouraged in children with poorly controlled T1DM.

Safety Assessment of Glucose-Lowering Drugs and Importance of Structured Education during Ramadan: A Systematic Review and Meta-Analysis

BACKGROUND

Ramadan is the sacred month of the Islamic Hijri (lunar) calendar, and during this entire month, healthy adult Muslims abstain from eating and drinking from dawn to sunset. Muslims with Type 2 Diabetes Mellitus (T2DM) who choose to fast during Ramadan encounter major risks such as hypoglycemia, hyperglycemia, diabetic ketoacidosis, dehydration, and thrombosis. Although patients with poor glycemic control and on multiple insulin injections are at high risk and exempt from fasting, many still insist on it. Thus, healthcare professionals play a pivotal role in managing diabetes-related complications in patients who fast during Ramadan. However, there is a lack of standard guidelines to be followed in association with structured education and administration of drugs and dosage. Therefore, we performed a systematic review and meta-analysis of the literature to determine the safety and efficacy of different classes of drugs and the importance of structured education during Ramadan.

METHODS

In this review, an extensive PubMed search was performed to obtain literature on T2DM patients who fast during the month of Ramadan until the year 2020. Preference was given to fully downloadable articles. The articles were extracted based on the eligibility criteria. The extracted data were analyzed using Review Manager software version 5.3.

RESULTS

A total of 32 articles were included for the review and 7 studies for meta-analysis. Majority of the studies demonstrated the importance of structured education either as a group session or as a one-on-one session with the healthcare professionals in preventing diabetes-related risks during Ramadan. As far as glucose-lowering drugs are concerned, DPP-4 inhibitor combined with metformin remains the drug of choice for T2DM patients who fast during Ramadan. The newer class of glucose-lowering agents appear to lower the risk of hypoglycemia in comparison with sulphonylureas, while among sulphonylureas gliclazide is relatively safe. The meta-analysis indicates that DPP-4 inhibitors would significantly reduce the risk of hypoglycemia as compared to sulphonylurea (odds ratio = 0.38, 95% CI: 0.26 to 0.55, p < 0.00001).

CONCLUSION

The results of our systematic review show that structured education and counselling by healthcare professionals can be an effective tool in preventing complications associated with fasting during Ramadan in people with T2DM. Additionally, the safest class of oral glucose-lowering drugs preferred during Ramadan fasting in T2DM patients is DPP-4 inhibitors.

Association between dietary patterns and glycaemic control in a middle-aged Chinese population

OBJECTIVE

The present work was performed to analyse the association of dietary patterns with glycaemic control (Hb A1c < 7 %) in a large group of Chinese adults aged between 45 and 59 years.

DESIGN

Habitual dietary intakes in the preceding 12 months were assessed by well-trained interviewers using a validated semi-quantitative FFQ. Factor analysis with principal component method was used to obtain the dietary patterns, and the associations between dietary patterns and glycaemic control were determined using multivariable logistic regression models. Poor glycaemic control was defined as HbA1c ≥ 7·0.

SETTING

Despite decades of research, data on the relationship between dietary patterns and glycaemic control (HbA1c < 7 %) in China are sparse.

PARTICIPANTS

A total of 1739 participants aged 45-59 years from Hangzhou were included in the final analysis.

RESULTS

Three dietary patterns were ascertained and labelled as traditional southern Chinese, Western and grains-vegetables patterns. After controlling of the possible confounders, participants in the highest quartile of Western pattern scores had greater OR for HbA1c ≥ 7·0 (OR = 1·05; (95 % CI 1·000, 1·095); P = 0·048) than did those in the lowest quartile. Compared with those in the lowest quartile of grains-vegetables pattern, participants in the highest quartile had lower OR for HbA1c ≥ 7·0 (OR = 0·82; (95 % CI 0·720, 0·949); P = 0·038). Besides, no significant relationship between the traditional southern Chinese pattern and HbA1c ≥ 7·0 was observed (P > 0·05).

CONCLUSIONS

This study indicated that the Western pattern was associated with a higher risk, and the grains-vegetables pattern was associated with a lower risk for HbA1c ≥ 7·0. Future prospective studies are needed to confirm our findings.

Association of Adherence to Diabetics Feeding Recommendation with Glycaemic Control and with Malnutrition Risk Among Normal Weight Persons with Type 2 Diabetes in Ghana

BACKGROUND

Diabetes mellitus (DM) is public health problem. Feeding-recommendations help persons with diabetes control glycaemia. The aim was to access the association between adherence to diabetics' feeding recommendation with glycaemic control and with malnutrition risk.

METHODS

Cross-sectional study was conducted among 530 baseline normal weight (body mass index [BMI] 18.5 kg/m2-24.9 kg/m2) persons with type 2 diabetes (T2DM) in Brong Ahafo region of Ghana, from August 2018 to September 2019. Adherence to feeding recommendation was evaluated with perceived dietary adherence questionnaire (PDAQ). Malnutrition-risk was assessed using malnutrition universal screening tool. Multinomial logistics regression models were used to assess the association between adherence to diabetics' feeding recommendation with glycaemic control and with malnutrition risk.

RESULTS

Participants were generally healthy. Weight (P = 0.011), total cholesterol (P = 0.003) and glycated haemoglobin (HbA1c)% (P < 0.001) were significant with adherence to diabetics feeding recommendation. Low adherence to diabetics' feeding recommendation (adjusted odds ratio [AOR] 2.56; 95% CI: 1.44, 4.56; P < 0.001), low adherence to fruit and vegetables (AOR 2.71; 95% CI: 1.48, 4.99; P < 0.001), low adherence to whole grain, beans, starchy-fruits and plantain (AOR 3.29; 95% CI: 1.81, 6.02; P < 0.001), and low adherence to foods prepared with walnut, canola, sunflower, cotton seed and fish oils (AOR 2.62; 95% CI: 1.49, 4.58; P < 0.001) were significant with poor glycaemic control. Furthermore, low adherence to food prepared with walnut, canola, sunflower, cotton seed, fish or soy oils (AOR 0.54; 95% CI: 0.31, 0.95; P = 0.034) and low adherence to fish and lean meat (AOR 2.09; 95% CI: 1.14, 3.86; P = 0.017) were significant with moderate malnutrition risk.

CONCLUSION

This study demonstrates that poor adherence feeding recommendation could be related to glycaemic control and malnutrition risk.

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.

Diabetes and Ramadan: Utility of flash-glucose monitoring derived markers of glycaemic control and comparison with glycosylated haemoglobin

AIMS

Flash glucose monitoring (FGM)-derived markers of glucose control and variability and laboratory measured HbA1c among patients with diabetes on insulin in context of Ramadan fasting (RF) were examined and compared.

METHODS

FGM data on insulin-treated patients (n = 20, age 42.3 ± 11.4 years; 18 male, 2 female; 13 with type 1 and 7 with type 2 diabetes) who fasted during Ramadan were used to calculate Q-score as an indicator of glycaemia before, during and after RF. Post-hoc analysis in a group of patients (n = 12) who had HbA1c available and appropriate for these periods was performed. Other relevant data were extracted from patient records.

RESULTS

Mean glucose (9.6 ± 1.32 v 10.78 ± 1.64 mmol/l; P < 0.0001) and Q-score increased significantly with Ramadan fasting and reduced after Ramadan. Post-hoc subgroup analysis showed a significant rise in eA1c (7.2 ± 0.4%; 55.0 ± 4.4 mmol/mol v 7.7 ± 0.5%; 61.0 ± 5.5 mmol/mol) but not in laboratory HbA1c with Ramadan fasting; eA1c reduced after Ramadan (P = 0.018).

CONCLUSIONS

Ramadan fasting was associated with a deterioration in overall glucose control and time in hyperglycaemia in insulin-treated patients. FGM-derived markers are useful and a preferable alternative to HbA1c in Ramadan studies.

Ramadan and diabetes - knowledge, attitude and practices of general practitioners; a cross-sectional study

Background and aims:

Fasting during Ramadan is obligatory for all Muslims across the world. Through literature review, it has been found out that there are various articles published for the awareness of patients and general population regarding safe fasting during Ramadan. But very few studies highlight the Ramadan specific knowledge of general practitioners engaged in providing care to people with diabetes. This study aims to describe the practice, knowledge and attitude of general practitioners regarding treatment and dietary modifications for people with diabetes during Ramadan across Pakistan.

Methods:

A cross-sectional descriptive study was undertaken among a sample of 274 general practitioners. Data was collected by means of a questionnaire that consisted of 25 questions that were structured according to three categories i-e. Ramadan specific knowledge, diet and physical activity and treatment modification related knowledge and practices of GPs.

Results:

Out of the total population of GPs surveyed, 70% responded correctly to the questions while 30% responded incorrectly. 1/4^th of GPs incorrectly responded to questions regarding basic concepts of diabetes and Ramadan. 1/3^rd of GPs responded incorrectly regarding questions on diet.

Almost 40% of the GPs responded incorrectly to the questions regarding drug dosage adjustment in people with diabetes during Ramadan. However, more than 80% responded in agreement regarding alteration in medication timings.

Conclusion:

Almost one third of the studied populations of general practitioners across Pakistan lack the knowledge of basic principles that are important to be employed in the management of diabetes during Ramadan. Hence there is need to promote educational programmes and CMEs to improve the knowledge of our GPs that should be reflected by their sound clinical practices in the field of diabetes.

Characteristics and Ramadan-specific diabetes education trends of patients with diabetes (CARE): a multinational survey (2014)

AIMS

To observe characteristics of fasting patients, trends of Ramadan-specific diabetes education and implementation of diabetes management recommendations in patients with diabetes during Ramadan.

METHODOLOGY

This observational study was conducted in seven countries. Patients were recruited in the study immediately after the end of Ramadan (August 2014) until December 2014. Standardized questionnaire-based, face-to-face interview conducted on one-to-one basis. An identical questionnaire used in each country.

RESULTS

A total of 6610 patients with diabetes participated in the survey. Ramadan-specific diabetes education was received by 3142 (47.5%) patients, drug dosage and timings altered in 4371 (66.1%) patients and dietary advice received by 4636 (70.1%) patients with diabetes before Ramadan. Severe hypoglycaemia observed in 29 (1.0%) patients and severe hyperglycaemia noticed in 44 (1.7%) patients with diabetes during Ramadan. Patients who received Ramadan-specific diabetes education before Ramadan were significantly better (p < 0.0001) in following Ramadan-specific diabetes management recommendations during Ramadan. On further analysis, patients who received Ramadan-specific diabetes education through any mode i.e. one to one session, group session or written education material were found to be significantly better (p < 0.05) in following Ramadan-specific diabetes management recommendations during Ramadan compared with patients who did not receive education.

CONCLUSION

It was observed that patients who received Ramadan-specific diabetes education followed Ramadan-specific diabetes management recommendations better compared with patients who did not receive education. Ramadan-specific diabetes management recommendations are still not completely implemented.

Filling the Knowledge Gap in Diabetes Management During Ramadan: the Evolving Role of Trial Evidence

Muslim patients with type 2 diabetes (T2D) who fast during Ramadan face challenges in diabetes management due to substantial alterations in lifestyle and treatment that frequently accompany the decision to fast. International guidelines for treating T2D do not fully address the clinical issues unique to fasting, and other guidance documents lack the large and high-quality evidence base available for non-fasting conditions. We reviewed 10 randomized controlled trials and 20 observational studies in T2D during Ramadan to assess the quality of evidence and identify issues in trial design that should be addressed in future studies. Results indicated that heterogeneity in key aspects of trial design precluded meaningful comparisons across studies. These included patients' baseline treatment at entry; use of a cutoff for glycemic control [glycated hemoglobin (HbA1c)] for eligibility; exclusion of patients with a history of recurrent hypoglycemia or hypoglycemia unawareness, or with other serious systemic diseases; duration of treatment and follow-up, selection of safety versus efficacy as primary end point; and definition and measurement of those end points. Fructosamine was rarely used as an efficacy end point, despite the advantage of reflecting glycemic control over a period more closely aligned with the duration of Ramadan fasting than HbA1c. Adherence to treatment, definition and adherence to fasting, and changes in diet and exercise were reported inconsistently, and when reported, not in a fashion that would allow adequate control of confounding due to these variables. Despite a large body of evidence demonstrating their safety and efficacy in non-fasting populations, only two trials reported data for glucagon-like peptide-1 analogs, and neither involved a head-to-head comparison against dipeptidyl peptidase-4 inhibitors. More rigorous studies using trial designs suited to the unique conditions of a fasting population and capturing both standardized efficacy and safety end points are needed to provide better guidance to optimal treatment of T2D during Ramadan fasting.

FUNDING

Novo Nordisk AG.

Effects of exercise on brain functions in diabetic animal models

Human life span has dramatically increased over several decades, and the quality of life has been considered to be equally important. However, diabetes mellitus (DM) characterized by problems related to insulin secretion and recognition has become a serious health problem in recent years that threatens human health by causing decline in brain functions and finally leading to neurodegenerative diseases. Exercise is recognized as an effective therapy for DM without medication administration. Exercise studies using experimental animals are a suitable option to overcome this drawback, and animal studies have improved continuously according to the needs of the experimenters. Since brain health is the most significant factor in human life, it is very important to assess brain functions according to the different exercise conditions using experimental animal models. Generally, there are two types of DM; insulin-dependent type 1 DM and an insulin-independent type 2 DM (T2DM); however, the author will mostly discuss brain functions in T2DM animal models in this review. Additionally, many physiopathologic alterations are caused in the brain by DM such as increased adiposity, inflammation, hormonal dysregulation, uncontrolled hyperphagia, insulin and leptin resistance, and dysregulation of neurotransmitters and declined neurogenesis in the hippocampus and we describe how exercise corrects these alterations in animal models. The results of changes in the brain environment differ according to voluntary, involuntary running exercises and resistance exercise, and gender in the animal studies. These factors have been mentioned in this review, and this review will be a good reference for studying how exercise can be used with therapy for treating DM.

Improving diabetes care in developing countries: the example of Pakistan

Pakistan is a developing country with limited recourses and diverse economic social patterns. Pakistan has high prevalence of diabetes and its complication, which is a huge challenge to the existing health care system. The major contributing risk factors are urbanization and change in lifestyle, maternal and fetal malnutrition and genetic factors. National action plans for control of diabetes have been made since 1995 but actions in this regard were not perfect. Training of primary care physicians and development of multidisciplinary diabetes care teams was initiated. Prioritization strategies were defined according to the International Diabetes Federation (IDF) guidance, mainly focusing on diabetic foot, diabetes education and children with diabetes. Researches for better understanding and management of diabetes in Pakistan were undertaken. Collaboration between various stakeholders was promoted at national and international level. In summary, public private relationships and development of multifaceted approaches is expected to improve the lives of millions of diabetics of Pakistan.