“ O you who believe! Fasting has beenprescribed to you as it was prescribed tothose before you so that you attainTaqwa(self restraint , God Awareness)”
1. Physically sick ( Quran 2: 184-185)2.Traveler on a journey ( Quran 2: 184-185)3.Women during menstruation4. ? Pregnant and lactating women5. Pre pubertal children
Diabetes MellitusType 1 Chronic Renal Failure including RenalTransplant and Nephrolithiasis Severe cardiac and pulmonary conditions G.I. Bleed and acute ulcers Severe Epilepsy Severe Migraine
Estimated 1.1-1.5 billion Muslims worldwide. Fasting during Ramadan is obligatory onevery adult Muslim. Muslims fast for 29-30 days of lunar basedmonth. Fasting starts before sunrise and end atsunset and the duration of the day varies asthe season.
What are evidences we have to supporttoday’s talk Epidemiology of Diabetes and Ramadan 2001(EPIDIAR) Approximately▪ 43% patients with type 1 diabetes▪ 79% of patients with type 2 diabetes fast duringRamadan
Insulin secretion in healthy individuals isstimulated with feeding, which promotes thestorage of glucose in liver and muscle asglycogen. In contrast, during fasting, circulating glucoselevels tend to fall, leading to decreasedsecretion of insulin, levels of glucagon andcatecholamines rise, stimulating thebreakdown of glycogen, whilegluconeogenesis is augmented
As fasting becomes protracted for more thanseveral hours, glycogen stores becomedepleted, and the low levels of circulatinginsulin allow increased fatty acid release fromadipocytes. Oxidation of fatty acids generates ketonesthat can be used as fuel by skeletal andcardiac muscle, liver, kidney, and adiposetissue, thus sparing glucose for continuedutilization by brain and erythrocytes.
HypoglycemiaHyperglycemiaDiabetic ketoacidosisDehydration and thrombosisRecommendations for Diabetic Individuals during Ramadan, Diabetes Care , vol 33, num. 8, August2010
Threefold increase in the risk of severehypoglycemia in patients who were in theintensively treated group and had an averageHbA1c (A1C) value of 7.0%. 2–4% of mortality in patients with type 1diabetes. Severe hypoglycemia was more frequent inpatients in whom the dosage of oralhypoglycemic agents or insulin were changedand in those who reported a significant changein their lifestyle.
There is no information linking repeatedyearly episodes of short-term hyperglycemia(e.g., 4-week duration) and diabetes relatedcomplications. Control of glycemia in patients with diabeteswho fasted during Ramadan has beenreported to deteriorate, improve, or show nochange.
Fivefold increase in the incidence of severehyperglycemia (requiring hospitalization)during Ramadan in patients with type 2diabetes (from 1 to 5 events 100 people1month1) and An approximate threefold increase in theincidence of severe hyperglycemia with orwithout ketoacidosis in patients with type 1diabetes
Patients with diabetes, especially those withtype 1 diabetes, who fast during Ramadan areat increased risk for development of diabeticketoacidosis, particularly if they are grosslyhyperglycemic before Ramadan.
Limitation of fluid intake during thefast, especially if prolonged, is a cause ofdehydration. Hyperglycemia can result in osmotic diuresis andcontribute to volume and electrolyte depletion. Orthostatic hypotension, syncope, falls, injuriesand bone fractures may result. Patients with diabetes exhibit a hypercoagulablestate due to an increase in clotting factors, adecrease in endogenous anticoagulants, andimpaired fibrinolysis.
Most often recommendation will be not toundertake fasting. However, patients who insist on fasting needto be aware of the associated risks and beready to adhere to the recommendations oftheir doctors for safe Ramadan. Risk stratification
1.Very high risk Severe hypoglycaemia within the last 3 months prior toRamadan. A history of recurrent hypoglycaemia. Hypoglycaemia unawareness. Sustained poor glycemic control. Ketoacidosis within the last 3 months prior to Ramadan. Type 1 Diabetes Acute illness Pregnancy Patients on chronic dialysis Patients who perform intense labourRecommendations for Diabetic Individuals during Ramadan, Diabetes Care , vol 33, num. 8, August2010
2. High risk Patients with moderate hyperglycemia (averageblood glucose between 150 and 300 mg/dl,A1C 7.5–9.0%) Patients with renal insufficiency Patients with advanced macrovascular complications People living alone that are treated with insulin orsulfonylureas Patients living alone Patients with comorbid conditions that presentadditional risk factors Old age with ill health Drugs that may affect mentation
3. Moderate risk Well-controlled patients treated with short-acting insulin secretagogues such asrepaglinide or nateglinide4. Low risk Well-controlled patients treated with dietalone, metformin, or a thiazolidinedione whoare otherwise healthy
Individualization Frequent monitoring of glycemia Nutrition The diet during Ramadan should not differsignificantly from a healthy and balanced diet. The common practice of ingesting large amountsof foods rich in carbohydrate and fat, especially atthe sunset meal, should be avoided.
Because of the delay in digestion andabsorption, ingestion of foods containing“complex” carbohydrates may be advisable atthe predawn meal. While foods with more simple carbohydratesmay be more appropriate at the sunset meal. It is also recommended that fluid intake beincreased during nonfasting hours and that thepredawn meal be taken as late as possiblebefore the start of the daily fast.
Slow energy release foods (such aswheat, semolina, beans, rice) should be takenbefore and after fasting, whereas foods high insaturated fat (such as ghee, samosas, andpakoras) should be minimised. Advise patients to use only a small amount ofmonounsaturated oils (such as rapeseed or oliveoil) in cooking Before and after fasting include high fibre foodssuch as wholegrain cereals, granarybread, brown rice; beans and pulses;fruit, vegetables, and salads
Individualization Frequent monitoring of glycemia Nutrition Exercise Normal levels of physical activity may be maintained. Breaking the fast All patients should understand that they must alwaysand immediately end their fast if hypoglycemia (bloodglucose of 60 mg/dl [3.3 mmol/l]) Fast should be broken if blood glucose exceeds 300mg/dl (16.7 mmol/l). Patients should avoid fasting on “sick days.”
Medical assessment This assessment should take place within 1–2months before (Rajab, Shaban)Ramadan. Overall well-being of the patient and to thecontrol of their glycemia, blood pressure, andlipids. During this assessment, necessary changes intheir diet or medication regimen should be made
EducationalCounselling It is essential that the patients and family receivethe necessary education concerning self-care, including signs and symptoms of hyper andhypoglycemia, blood glucose monitoring, mealplanning, physical activity, medicationadministration, and management of acutecomplications.
In general, patients with type 1diabetes, especially if “brittle” or poorlycontrolled, are at very high risk of developingsevere complications and should be stronglyadvised to not fast during Ramadan. Glycemic control at near-normal levelsrequires use of multiple daily insulininjections (three or more)
Diet-Controlled patients Potential risk for occurrence of postprandialhyperglycemia after the predawn and sunsetmeals if patients overindulge in eating. Distributing calories over two to three smallermeals during the nonfasting interval may helpprevent excessive postprandial hyperglycemia. The exercise program should be modified in itsintensity and timing to avoid hypoglycemicepisodes
In general, agents that act by increasinginsulin sensitivity are associated with asignificantly lower risk of hypoglycemia thancompounds that act by increasing insulinsecretion.
Metformin. Patients treated with metformin alone may safelyfast because the possibility of hypoglycemia isminimal. However, it is suggested that the timing of thedoses be modified. Recommendation is that two thirds of the totaldaily dose be administered immediately beforethe sunset meal, while the other third be givenbefore the predawn meal.
Glitazones. Patients on insulin sensitizers (rosiglitazone andpioglitazone) have a low risk of hypoglycemia.Usually no change in dose is required.
Sulfonylureas.T his group of drugs was believed to be unsuitable foruse during fasting because of the inherent risk ofhypoglycemia. Hence, their use should beindividualized and they should be utilized withcaution. Use of chlorpropamide is absolutely contraindicatedduring Ramadan because of the high possibility ofprolonged and unpredictable hypoglycemia. Newer members of the sulfonylurea family (gliclazideMR or glimepiride) have been shown to beeffective, resulting in a lower risk of hypoglycemia
Short-acting insulin secretagogues. Members of this group (repaglinide andnateglinide) are useful because of their shortduration of action. They could be taken twice daily before the sunsetand predawn meals.
Patients treated with insulin A major objective is to suppress hepatic glucoseoutput to near-physiologic levels during the fastingperiod. Judicious use of intermediateor long-acting insulinpreparations plus a short-acting insulin administeredbefore meals would be an effective strategy. Using one injection of a long-acting insulinanalog, such as insulin glargine, or two injections ofNPH, lente, or detemir insulin before the sunset andpredawn meals may provide adequate coverage.
Patients treated with insulin However, most patients will still require short-acting insulin administered in combination withthe intermediate- or long- acting insulin at thesunset meal to cover the large caloric load of Iftar. Moreover, many will need an additional dose ofshort-acting insulin at predawn.
Dehydration, volume depletion, and a tendencytoward hypotension may occur with fastingduring Ramadan. Hence, the dosage of antihypertensivemedications may need to be adjusted toprevent hypotension. It is common practice that the intake of foodsrich in carbohydrates and saturated fats isincreased during Ramadan. Appropriatecounselling should be given to avoid thispractice.
Fasting during Ramadan for patients withdiabetes carries a risk of an assortment ofcomplications. Patients with type 1 diabetes should bestrongly advised to not fast. Hypo- and hyperglycemia may also occur inpatients with type 2 diabetes but generallyless frequently and with less severeconsequences compared with patients withtype 1 diabetes.
Patients who insist on fasting should undergopre-Ramadan assessment and receiveappropriate education and instructions relatedto physical activity, meal planning, glucosemonitoring, and dosage and timing ofmedications. The management plan must be highlyindividualized. Close follow-up is essential to reduce the risk fordevelopment of complications.