Management of DiabetesDuring Ramadan

1. Management of DiabetesManagement of Diabetes
During RamadanDuring Ramadan
Dr Shahjada Selim
MBBS MD (EM)
Registrar, Department of Medicine
Shaheed Suhrawardy Medical College Hospital, Dhaka

2. Introduction
• Estimated 1.5-2.0 billion Muslims worldwide.
• Globally more than 20 million diabetic people
fast during Ramadan.
• Approximately
• 43% patients with type 1 diabetes and 79% of
patients with type 2 diabetes fast during Ramadan.
Bravis V, Hui E, Salih S, Mehar S, Hassanein M, Devendra D: Ramadan Education and Awareness in Diabetes (READ) programme for Muslims
with Type 2 diabetes who fast during Ramadan. Diabet Med 2010, 27:327–331.

3. Introduction
• Fasting during Ramadan is obligatory on every
adult Muslim.
• Muslims fast for 29-30 days of lunar based month
each year.
• Fasting starts before sunrise and end at sunset
and the duration of the day varies as the season. It is
about 14 hours this year.
Salti I, Benard E, Detournay B, Bianchi-Biscay M, Le Brigand C, Voinet C, Jabbar A: EPIDIAR study group. A population-based study of
diabetes and its characteristics during the fasting month of Ramadan in 1 countries: results of the Epidemiology of Diabetes and Ramadan
1422⁄2001(EPIDIAR) study. Diabetes Care 2004, 27:2306–2311.

4. The physiological state of diabetics
during Ramadan
1. Carbohydrate metabolism in healthy persons
 Most of the studies show slight decrease in
serum glucose to 3.3 mmol to 3.9 mmol occurs in
normal adults a few hours after fasting has begun.
 Changes in serum glucose may occur in
individuals depending upon food habits and
individual differences in metabolism and energy
regulation.

5. 2.Body weight
Weight losses of 1.7-3.8 kg have been reported in
normal weight individuals after they have fasted for
the month of Ramadan.
Some studies also show no change or slight increase.
The physiological state of diabetics during
Ramadan

6. 3.Blood glucose variations in patients with diabetes
Most patients show no significant change in their
glucose control.
In some patients, serum glucose concentration may
fall or rise (unstable glycemic status).
This variation may be due to the amount or type of
food consumption, regularity of taking medications,
engorging after the fast is broken, or decreased
physical activities.
The physiological state of diabetics
during Ramadan

7. HbAIC values show no change during Ramadan.
Only two studies have reported slight increases in
glycated hemoglobin levels. (1-3)
The amount of fructosamine , insulin, C-peptide
also has been reported to have no significant change
before and during Ramadan fasting.(4-5)
The physiological state of diabetics
during Ramadan

8. Pathophysiology of Fasting
• Insulin secretion in healthy individuals is stimulated
with feeding, which promotes the storage of glucose
in liver and muscle as glycogen.
• In contrast, during fasting, circulating glucose levels
tend to fall, leading to decreased secretion of
insulin, levels of glucagon and catecholamines rise,
stimulating the breakdown of glycogen, while
gluconeogenesis is augmented

9. Pathophysiology of Fasting
• As fasting becomes protracted for more than
several hours, glycogen stores become depleted,
and the low levels of circulating insulin allow
increased fatty acid release from adipocytes.
• Oxidation of fatty acids generates ketones that can
be used as fuel by skeletal and cardiac muscle,
liver, kidney, and adipose tissue, thus sparing
glucose for continued utilization by brain and
erythrocytes.

10. Major risks associated with fasting in
patients with diabetes
Hypoglycemia
Hyperglycemia
Diabetic ketoacidosis
Dehydration and
thrombosis
DIABETES CARE, VOLUME 28, NUMBER 9 SEPTEMBER 2005

11. …….Risks associated with fasting in patients with diabetes
 Hypoglycemia:
It has been estimated that hypoglycemia accounts for
2–4% of mortality in patients with T1DM (much lesser
with T2DM).
The recent EPIDIAR study showed that fasting during
Ramadan increased the risk of severe hypoglycemia
(4.7-fold in patients with T1DM and 7.5-fold in
patients with T2DM).
Diabetes Care 2004;27:2306–2311

12.  Hyperglycemia
The EPIDIAR study showed
 5 fold increase in the incidence of severe
hyperglycemia (requiring hospitalization) in
patients with T2DM.
 3 fold increase in the incidence of severe
hyperglycemia with or without ketoacidosis in
patients with T1DM.
…….Risks associated with fasting in patients with diabetes
Diabetes Care 2004;27:2306–2311

13. Diabetic ketoacidosis
 Patients with diabetes, who fast during Ramadan,
are at increased risk for development of diabetic
ketoacidosis, particularly if poorly controlled
before Ramadan.
 The risk may further increase due to excessive
reduction of insulin dosage based on the
assumption that food intake is reduced during the
month.
…….Risks associated with fasting in patients with diabetes
Diabetes Care 2004;27:2306–2311

14. Dehydration and thrombosis
 Reports have suggested an increased incidence of
retinal vein occlusion.
 However, hospitalizations due to coronary events or
stroke were not increased during Ramadan
 Limitation of fluid intake during the fast, especially if
prolonged, is a cause of dehydration.
 In addition, hyperglycemia produces an osmotic
diuresis, further contributing to volume and electrolyte
depletion.
…….Risks associated with fasting in patients with diabetes
DIABETES CARE, VOLUME 33, NUMBER 8, AUGUST 2010

15. M. al-Arouj et al, “Recommendations for management of diabetes during
Ramadan,” Diabetes Care, 28(2005), 2305-2311.
Risks during fasting
“Most often, the recommendation will be to not
undertake fasting.
However, patients who insist on fasting need
to be aware of the associated risks and be
ready to adhere to the recommendations of
their health care providers to achieve a safer
fasting experience.”

16. Categories of risks in patients
with type 1 or type 2 diabetes
who fast during Ramadan

17. Very High Risk
• Severe hypoglycemia within the last 3
months prior to Ramadan
• Patient with a history of recurrent
hypoglycemia
• Patients with hypoglycemia unawareness
• Acute illness
• Pregnancy
• Patients on chronic dialysis

18. ...........Very High Risk
• Patients with sustained poor glycemic
control (HbA1C > 9.0%)
• Ketoacidosis within the last 3 months prior
to Ramadan
• Type 1 diabetes
• Hyperosmolar hyperglycemic state within
the previous 3 months
• Patients who perform intense physical
labor

19. High Risk
• Patients with moderate hyperglycemia
(average blood glucose between 8.3 and
16.6 mmol/L, HbA1C 7.5–9.0%)
• Patients with renal insufficiency
• Patients living alone
• On drugs that may affect mentation

20. .....High Risk
• Patients with advanced macrovascular
complications
• People living alone that are treated with
insulin or sulfonylureas
• Patients with comorbid conditions that
present additional risk factors
• Old age with ill health

21. Moderate risk
•Well-controlled diabetes treated with
short-acting insulin secretagogues.

22. Low risk
•Well-controlled diabetes treated with
 Medical nutrition therapy
 Metformin
 Acarbose,
 Thiazolidinediones, and/or
incretin-based therapies in otherwise
healthy patients

23. The principles of Pre-Ramadan
considerations
(a) Physical well being assessment
(b) Assessment of metabolic control
(c) Adjustment of the diet protocol for Ramadan fasting
(d) Adjustment of the drug regimen (e.g. change long-acting
hypoglycemic drugs to short-acting drugs to prevent
hypoglycemia)
(e) encouragement of continued proper physical activity
(f) recognition of warning symptoms of dehydration,
hypoglycemia and other possible complications.

24. Recommendations during Ramadan
fasting
I. Nutrition and Ramadan fasting:
Abstain from the high-calorie and highly-refined
foods prepared during this month.
II. Physical activity and Ramadan fasting:
It has been shown that fasting does not interfere
with tolerance to exercise.
It is necessary to continue their usual physical
activity especially during non-fasting periods.
Lancet. 1989; 1:1396
N Engl J Med. 1991; 325: 196-199.

25. Recommendations during Ramadan
fasting
III. Other health tips for reduction of
complications:
1. Implementation of the 3D Triangle of Ramadan --
Drug regimen adjustment,
Dietary management and
Daily activity -- as the three pillars for more
successful fasting during Ramadan.

26. Recommendations during Ramadan
fasting
2. Diabetic home management that consists of:
 Monitoring home blood glucose especially for T1DM
 Checking urine for acetone (T1DM)
 Measuring daily weights and informing physicians of
weight reduction (dehydration, low food intake,
polyuria) or weight increase (excessive calorie intake)
above two kilograms;
 Recording daily diet intake (prevention of excessive
and very low energy consumption).

27. Recommendations during Ramadan
fasting
3. Education about warning symptoms/signs of
dehydration, hypoglycemia and hyperglycemia.
4. Education about breaking fast as soon as any
complication or new harmful condition occurs.
5. Immediate medical help for diabetics who need
medical help quickly, rather than waiting for
medial assistance the next day.

28. Ramadan Education and Awareness in Diabetes
(READ) program for Muslims with Type 2
diabetes who fast during Ramadan
Diabet. Med. 27, 327–331 (2010)

29. Benefits of Education & Counseling
according to the READ study
Diabet. Med. 27, 327–331 (2010)

30. Management

31. General considerations
• Several important issues deserve special
attention:
– Individualization
– Frequent monitoring of glycemia
– Nutrition
– Exercise
– Breaking the fast

32. Adjustment of DrugsAdjustment of Drugs

33. Before Ramadan During Ramadan
Patients on “diet and
exercise”
(MNT)
- No change is needed
- Modify time & intensity
of exercise
- Ensure adequate fluid
intake
Treatment RecommendationsTreatment Recommendations

34. Before Ramadan During Ramadan
Sulfonylurea Once Daily:
Morning dose.
e.g., Gliclazide MR
Glimepiride
Iftar: Full Morning Dose
Sulfonylurea Twice Daily:
Morning & Evening dose.
e.g., Gliclazide
Glibenclamide
Iftar: Full Morning Dose
Suhur: ½ Evening Dose
Treatment RecommendationsTreatment Recommendations
Majority of our type 2 diabetic patients are treatedMajority of our type 2 diabetic patients are treated
with Sulfonylurea & Metforminwith Sulfonylurea & Metformin

35. Before Ramadan During Ramadan
Metformin 500 mg thrice
daily
Iftar: 1,000 mg,
Suhur: 500 mg
Treatment RecommendationsTreatment Recommendations

36. Before Ramadan During Ramadan
DPP4 inhibitor As usual at night
Glitazone As usual at night
Glinide As usual at night
Treatment RecommendationsTreatment Recommendations

37. Before Ramadan During Ramadan
Premixed insulin 30
(Mistard/Novomix)
Morning: (30U)
Dinner: (20U)
Iftar: Full Morning Dose
(30U)
Suhur: ½ Dinner Dose (10U)
Basal Analogue
(Glargine/
Levemir/Degludec)
At the same time
20-30% dose reduction
Split Mixed (R+N)
R+0+R
N+0+N
R+0+50%of R
N+0+50%of N
R+R+R
0+0+N
R+R+50% of R
0+0+50% of N
Treatment RecommendationsTreatment Recommendations

38. Management of patients with T1DM
• Fasting at Ramadan carries a very high risk for
people with T1DM.
• Risk is particularly exacerbated in poorly
controlled patients and those with limited access to
medical care, hypoglycemic unawareness, unstable
glycemic control or recurrent hospitalizations.
• The risk is also very high in patients who are
unwilling or unable to monitor their blood glucose
levels several times daily at home.

39. Management of T1DM during Ramadan
• If patients choose to fast against medical advice, it is
advantageous if they are on a basal bolus regime and
are familiar with carbohydrate counting.
• A small study (n = 9) of patients with T1DM using
insulin glargine and insulin Lispro or aspart, divided
in a 6 : 4 ratio of the total 24-h insulin dose, reported
no episodes of severe hypoglycaemia or diabetic
ketoacidosis requiring hospitalization, and the
haemoglobin A1c remained stable at the end of
Ramadan.

40. Management of patients with T1DM
• A recent small study with insulin glargine suggests the
relative safety and efficacy of this agent in 15 relatively
well-controlled patients with T1DM who fasted for 18 h
and experienced a minimal decline in mean plasma
glucose from 125 to 93 mg/dl with only two episodes of
mild hypoglycemia
• Another study in patients with T1DM using insulin
glulisine, Lispro, or aspart instead of regular insulin in
combination with intermediate-acting insulin injected
twice a day led to improvement in postprandial glycemia
and was associated with fewer hypoglycemic events
Mucha GT et al. Diabetes Care, 2004.
Kadiri A et al. Diabetes Metab, 2001.

41. Management of patients with T1DM
• Continuous subcutaneous insulin infusion
(pump) management is an appealing alternative
strategy, but at a substantially greater expense.
Benbarka MM et al. Diabetes Technol Ther, 2010.

42. Recommendations – Pregnancy
Muslim pregnant women are exemptd from
fasting during Ramadan
type 1
type 2 or
Gestational
They should be strongly advised to not fast during
Ramadan
These women constitute a high-risk group and their
management requires intensified care
Diabetes Care. 2005; 28 (9).

43. Management of Hypertension and
Dyslipidemia
• Dehydration, volume depletion, and a tendency
toward hypotension may occur with fasting during
Ramadan.
• Hence, the dosage of antihypertensive
medications may need to be adjusted to prevent
hypotension.
• It is common practice that the intake of foods rich
in carbohydrates and saturated fats is increased
during Ramadan. Appropriate counselling should
be given to avoid this practice.

44. Post-Ramadan supervision
The patients therapeutic regimen should be changed
back to its previous schedule.
Patients should also be required to get an overall
education about the impact of fasting on their
physiology
Degenerative complications check up
Monthly weight, blood pressure, HbA1c and renal
function evaluation every six months.
Diabetes Care. 1997; 20:1925-1926.

45. Monitoring RecommendationsMonitoring Recommendations
 Patients should monitor their blood glucose evenPatients should monitor their blood glucose even
during the fast to recognize subclinical hypo andduring the fast to recognize subclinical hypo and
hyperglycemiahyperglycemia
 Islam allows diabetics to have regular blood testIslam allows diabetics to have regular blood test
while fastingwhile fasting
 If blood glucose is noted to be low (<60mg/dl), theIf blood glucose is noted to be low (<60mg/dl), the
fast must be brokenfast must be broken
 If blood glucose is noted to be (>300mg/dl),If blood glucose is noted to be (>300mg/dl),
ketonesketones
in urine should be checked & medical advicein urine should be checked & medical advice
soughtsought

46. Awareness: Physician’s GuidelineAwareness: Physician’s Guideline

47. Conclusion
 Majority of uncomplicated type 2 diabetic patients can fast
during Ramadan with minimum risks.
 Pre-Ramadan medical assessment, education and motivation
are very important to prevent diabetes related complications
 Islam allows diabetics to have regular blood test while
fasting
 Fasting along with regular prayer have been proved to aid in
better control of diabetes
 Individualization and frequent monitoring of glycemia can
significantly reduced the major risks associated with fasting

48. Thank YouThank You