Comparison of Structured Nutrition Therapy for Ramadan with Standard Care in Type 2 Diabetes Patients

How quality of life is measured in studies of nutritional intervention: a systematic review

BACKGROUND

Nutrition care can positively affect multiple aspects of patient's health; outcomes are commonly evaluated on the basis of their impact on a patient's (i) illness-specific conditions and (ii) health-related quality of life (HRQoL). Our systematic review examined how HRQoL was measured in studies of nutritional interventions. To help future researchers select appropriate Quality of Life Questionnaires (QoLQ), we identified commonly-used instruments and their uses across populations in different regions, of different ages, and with different diseases.

METHODS

We searched EMCare, EMBASE, and Medline databases for studies that had HRQoL and nutrition intervention terms in the title, the abstract, or the MeSH term classifications "quality of life" and any of "nutrition therapy", "diet therapy", or "dietary supplements" and identified 1,113 studies for possible inclusion.We then reviewed titles, abstracts, and full texts to identify studies for final inclusion.

RESULTS

Our review of titles, abstracts, and full texts resulted in the inclusion of 116 relevant studies in our final analysis. Our review identified 14 general and 25 disease-specific QoLQ. The most-used general QoLQ were the Short-Form 36-Item Health Survey (SF-36) in 27 studies and EuroQol 5-Dimension, (EQ-5D) in 26 studies. The European Organization for Research and Treatment of Cancer Quality of life Questionnaire (EORTC-QLQ), a cancer-specific QoLQ, was the most frequently used disease-specific QoLQ (28 studies). Disease-specific QoLQ were also identified for nutrition-related diseases such as diabetes, obesity, and dysphagia. Sixteen studies used multiple QoLQ, of which eight studies included both general and disease-specific measures of HRQoL. The most studied diseases were cancer (36 studies) and malnutrition (24 studies). There were few studies focused on specific age-group populations, with only 38 studies (33%) focused on adults 65 years and older and only 4 studies focused on pediatric patients. Regional variation in QoLQ use was observed, with EQ-5D used more frequently in Europe and SF-36 more commonly used in North America.

CONCLUSIONS

Use of QoLQ to measure HRQoL is well established in the literature; both general and disease-specific instruments are now available for use. We advise further studies to examine potential benefits of using both general and disease-specific QoLQ to better understand the impact of nutritional interventions on HRQoL.

Ramadan-specific nutrition education improves cardio-metabolic health and inflammation-a prospective nutrition intervention study from Pakistan

There are recent reports that Ramadan fasting (RF) results in weight gain instead of weight loss. In addition, the data on the efficacy of brief nutrition education on healthy eating practices in Ramadan for better health are scarce. Therefore, a study was conducted to investigate the effects of brief nutrition education before the start of RF on healthy eating practices during RF. For this purpose, a prospective observational study focused on "Dietary Education and Awareness for Ramadan (DEAR)" as an intervention was carried out. The participants (n = 74) were recruited and divided into two groups, i.e., intervention and control groups (n = 37 each). As an intervention, nutrition education lessons were given before and during RF month. The control group did not attend these nutrition education lessons. Data on anthropometrics, dietary intake, and other parameters were collected at three time points: before, in the end, and 4 weeks after RF. Weight was measured in kg; height, waist circumference (WC), and hip circumference (HC) were measured in cm; and body mass index (BMI) was calculated. Waist-to-hip ratio (WHR) was calculated by dividing the waist value by the hip value. Body composition analysis was performed by the body composition analyzer (BF-907). Blood pressure (BP) was measured using a validated automated blood pressure. A 3-5 ml of venous blood was collected, and plasma and serum were separated. Serum and plasma samples were processed for general blood chemistry (blood lipid profile, glucose, and CRP) within 2 h. CRP was determined by the immunoturbidimetry method using an auto-analyzer. An enzyme-linked immunosorbent assay (ELISA) was used to determine cytokine/chemokines. Adherence to nutrition education (intervention) was assessed. The results show that nutrition education has positive effects on overall nutrition. Significant improvement in dietary adherence to dietary advice in the intervention group was noted. Significant BW loss (mean loss: 1.21 kg) in the intervention group was observed. The majority (63.3%) had lost BW ≥ 1.0 kg. Other changes observed as a result of the intervention included improvements in blood glucose, cholesterol, CRP levels, and systolic and diastolic BP. There was a notable shift in pro- and anti-inflammatory cytokine concentrations: IL-7, IL-4, and TGF-α decreased, while IL-2, TNF-α and resistin, IL-1 RA, IL-17 A, and sCD40 increased. In conclusion, RF resulted in a loss in mean BW and an improvement in related blood chemistry and cytokine profiles. Furthermore, nutrition education before RF resulted in better nutrition practices during RF and a desirable healthy BW, blood lipid, and cytokine profiles.

Management of hyperglycaemia in type 2 diabetes, 2022. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD)

The American Diabetes Association and the European Association for the Study of Diabetes convened a panel to update the previous consensus statements on the management of hyperglycaemia in type 2 diabetes in adults, published since 2006 and last updated in 2019. The target audience is the full spectrum of the professional healthcare team providing diabetes care in the USA and Europe. A systematic examination of publications since 2018 informed new recommendations. These include additional focus on social determinants of health, the healthcare system and physical activity behaviours including sleep. There is a greater emphasis on weight management as part of the holistic approach to diabetes management. The results of cardiovascular and kidney outcomes trials involving sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide-1 receptor agonists, including assessment of subgroups, inform broader recommendations for cardiorenal protection in people with diabetes at high risk of cardiorenal disease. After a summary listing of consensus recommendations, practical tips for implementation are provided.

Management of Hyperglycemia in Type 2 Diabetes, 2022. A Consensus Report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD)

The American Diabetes Association and the European Association for the Study of Diabetes convened a panel to update the previous consensus statements on the management of hyperglycemia in type 2 diabetes in adults, published since 2006 and last updated in 2019. The target audience is the full spectrum of the professional health care team providing diabetes care in the U.S. and Europe. A systematic examination of publications since 2018 informed new recommendations. These include additional focus on social determinants of health, the health care system, and physical activity behaviors, including sleep. There is a greater emphasis on weight management as part of the holistic approach to diabetes management. The results of cardiovascular and kidney outcomes trials involving sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide 1 receptor agonists, including assessment of subgroups, inform broader recommendations for cardiorenal protection in people with diabetes at high risk of cardiorenal disease. After a summary listing of consensus recommendations, practical tips for implementation are provided.

Effects of structured Ramadan Nutrition Plan on glycemic control and variability using continuous glucose monitoring in individuals with type 2 diabetes: A pilot study

BACKGROUND AND AIMS

Continuous glucose monitoring (CGM) has been increasingly used in recent years to evaluate glycemic control and variability in individuals with diabetes observing Ramadan fasting. However, the effectiveness of the Ramadan Nutrition Plan (RNP) in individuals with type 2 diabetes (T2D) using CGM-derived measures has not been investigated. The study aimed to evaluate the effects of structured RNP versus standard care using CGM in individuals with T2D.

METHODS

This parallel non-randomized interventional study with patients' preference design involved 21 individuals with T2D (mean age: 49 ± 10 years, BMI: 30.0 ± 6.2 kg/m²). Participants chose to receive either structured RNP (sRNT; structured Ramadan Nutrition Therapy group; n = 14) or standard care (SC; n = 7). Participants wore CGM 5 days before Ramadan and during Ramadan. CGM-derived measures of glycemic variability were calculated using Glyculator version 2.0.

RESULTS

Compared to the SC group, the sRNT group significantly reduced their fasting blood glucose levels, HbA1c, total cholesterol, diastolic blood pressure, and increased dietary fiber intake. CGM data showed the sRNT group had significantly lower average sensor glucose, peak sensor value, estimated A1c, percentage and duration of time-above-range, J-index, mean amplitude of glycemic excursion (MAGE), and continuous overall net glycemic action (CONGA); and a significantly higher percentage of time-in-range (TIR).

CONCLUSIONS

The structured RNP significantly improved clinical outcomes, glycemic control and variability in individuals with T2D. The study highlights the importance of utilizing CGM sensor data to monitor glycemic excursions during Ramadan fasting. Adequately powered randomized controlled trials are needed to confirm the findings.

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.

Changes in dietary intake improve glycemic control following a structured nutrition therapy during Ramadan in individuals with type 2 diabetes

BACKGROUND AND AIMS

It is unknown whether dietary modifications during Ramadan could influence glycemic control in diabetes. This study assessed dietary intake following structured Ramadan nutrition therapy and determined the association between changes in dietary intake and glycemic control parameters in patients with type 2 diabetes.

METHODS

This was an 8-week, parallel-group, non-randomised study of 60 type 2 diabetes patients who opted for structured Ramadan Nutrition Therapy (sRNT; n = 38) or standard care (SC; n = 22) group. The sRNT group received a structured Ramadan Nutrition Plan incorporated with diabetes-specific formula throughout the study, while SC received standard nutrition care. The 3-day food records assessed dietary intake at three-time points.

RESULTS

At baseline, dietary characteristics were comparable; both groups had macronutrient intakes within the recommended range, but inadequate intakes of fiber and 11 essential micronutrients. After 8 weeks, the sRNT group significantly reduced intakes of carbohydrate, dietary glycemic index, glycemic load, and increased percentage of total energy intake from protein, fiber, pyridoxine, vitamin C, vitamin D, calcium, and chromium compared with the SC group. In the sRNT group, compliance to diabetes-specific formula predicted changes in HbA1c (p = 0.024), while fiber intake predicted fasting plasma glucose (p = 0.035), after adjusting for age, sex, weight changes and other dietary variables.

CONCLUSION

Intakes of certain nutrients improved significantly in sRNT group after 8 weeks of receiving a structured Ramadan Nutrition Plan compared to the standard care. The structured Ramadan Nutrition Plan with the incorporation of diabetes-specific formula significantly improved glycemic control and dietary adequacy during Ramadan fasting.

Ramadan-focused nutrition therapy for people with diabetes: A narrative review

AIMS

This narrative review aimed to synthesize the evidence on the effects of Ramadan-focused nutrition therapy for people with diabetes.

METHODS

We searched MEDLINE (via PubMed) and Science Direct databases for articles that included the component of nutrition for adult patients with type 2 diabetes (T2D), published in English between 2010 and 2020.

RESULTS

Fourteen studies met the criteria. Eight of 14 studies had an intervention with a control arm. In comparison to the control group, all studies (n = 8) showed a reduction in hypoglycemic events. However, only half of these studies (n = 4) had shown at least one positive clinical outcome. Features of nutrition therapy that appeared to have favorable clinical outcomes include individualized caloric prescription; distributing carbohydrates equally between Suhoor, Iftar and snacks; providing meal plans; adjusting food intake to suit Ramadan; and incorporating diabetes-specific formula as part of Suhoor or snack.

CONCLUSIONS

The review provides evidence for the effectiveness of Ramadan-focused nutrition therapy among people with T2D and identifies key features of nutrition therapy that may provide favourable clinical outcomes. Additional data on dietary quality and adequacy during Ramadan fasting warrants further studies.