C11 review of diabetes management and guidelines during ramadan 2010

Review of diabetes management
and guidelines during Ramadan
Muhammad Ali Karamat1
+ Ateeq Syed2
+ Wasim Hanif3
1
University of Birmingham – Diabetes and Endocrinology, Birmingham, UK
2
University Hospital of Coventry and Warwickshire – Diabetes, Coventry, UK
3
Selly Oak Hospital – Diabetes, Birmingham, UK
Correspondence to: Wasim Hanif. E-mail: wasim.hanif@uhb.nhs.uk
Introduction
Demographics of the Muslim population
Islam is the second largest religion in the world
and Muslims constitute approximately 22% of the
world’s population. According to latest data, the
total number of Muslims in the world is over 1.5
billion. In Europe Muslims constitute approxi-
mately 7% of the overall population. In the UK the
size of the Muslim population is estimated to be
close to 1.6 million, constituting 2.7% of the overall
population.1
While diabetes affects 4% of the white
Caucasian population, it affects 22% of Pakistani
and 27% of the Bangladeshi Muslim population
(aged 25–74 years).2
The approximate number of
Muslims in the UK with diabetes is estimated at
325,000.3
Most patients with diabetes are asymptomatic;
they do not consider themselves as having an ill-
ness and fast during Ramadan. The concerns are
fasting may lead to hypoglycaemia, hyperglycae-
mia with or without ketoacidosis, and dehydra-
tion. Another problem is the reluctance of patients
in taking their medications during the fast, there-
fore timing and dosage of anti-diabetic agents has
to be adjusted for individual patients. Despite all
this, it must be pointed out that very few compli-
cations are actually seen in clinical practice.4
Man-
aging Muslim patients with diabetes during
Ramadan continues to be a challenge for health-
care professionals. This review is intended to offer
a guide towards care of the Muslim patient with
diabetes during Ramadan.
Why do Muslims fast?
The five pillars of Islam that form an integral part
of faith are:
(1) Shahadah – the declaration of faith;
(2) Salah – five compulsory daily prayers;
(3) Zakat – annual alms tax, to poor and needy;
(4) Sawm – fasting during month of Ramadan;
(5) Hajj – pilgrimage to Mecca.
The literal meaning of the word Sawm is ‘to
refrain’ and here it means abstaining from food,
drinks, smoking, intravenous fluids, intravenous
and oral medications, and sexual activity from
sunrise to sunset.5
What is Ramadan?
Ramadan is the ninth month in the Islamic calen-
dar. It is based on a lunar calendar thus the dura-
tion of the daily fast and the overall length of the
month of Ramadan vary according to geographi-
cal location and season; it precedes by 10–11 days
every year.4
In Britain a fast can last for up to
19 hours during the summer months, and 10
hours during the winter months. The month of
Ramadan generally lasts 28–30 days. Most
Muslims eat two meals, before sunrise (known as
Sehar) and after sunset (known as Iftar).5
Fasting
is said to cultivate the spirit of sacrifice and
teaches Muslims moral and self-discipline and
sympathy for the poor.5,6
Fasting is obligatory upon each sane, respon-
sible and healthy Muslim. Certain individuals,
however, are exempt from fasting:
+ children under the age of puberty;
+ those with learning difficulties (those unable to
understand the nature and purpose of the fast);
+ the old and frail;
+ the acutely unwell;
+ those with chronic illnesses in whom fasting
may be detrimental to health;
DECLARATIONS
Competing interests
None declared
Funding
None
Ethical approval
Not applicable
Guarantor
WH
Contributorship
All authors
contributed equally
Acknowledgements
None
REVIEW
J R Soc Med 2010: 103: 139–147. DOI 10.1258/jrsm.2010.090254 139

+ those travelling a distance greater than 50
miles in single journey.7
Methods
PubMed databases were searched using the key
words ‘fasting’, ‘diabetes’ and ‘Ramadan’ between
1989 and 2009 for the purpose of this review. We
identified 73 articles and classified them according
to hierarchy of evidence:
+ systematic reviews of randomized controlled
trials;
+ randomized controlled trials;
+ controlled observational studies – cohort and
case-control studies;
+ uncontrolled observational studies.
There is a paucity of randomized controlled
trials in this field, hence we had to rely on observa-
tional studies and international consensus guide-
lines and recommendations.
Physiology of fasting
Effects of fasting in normal people
Fasting has been advocated as a means for achiev-
ing spiritual purification from ancient times. Most
research on the effects of fasting on metabolism has
been conducted on the Muslim fast during the holy
month of Ramadan.4
Effects on body weight
A study on the effects of fasting on body weight
was conducted in 137 Jordanian adults. During
this study the patients were divided into over-
weight, normal weight (controls) and underweight
groups all of which showed significant weight re-
duction.8
A study of 81 healthy volunteer univer-
sity students carried out at the Tehran University
of Medical Sciences indicated that Ramadan fast-
ing led to a decrease in glucose and weight.
Weight, BMI, glucose and lipids were evaluated
before and after Ramadan. Glucose levels reduced
significantly during Ramadan and this effect was
irrespective of gender; however, it had a significant
correlation with weight. There were no changes in
triglycerides and total cholesterol levels before and
after Ramadan.9
Effects of fasting on glucose metabolism in
normal healthy individuals
In normal healthy individuals eating stimulates
the secretion of insulin from the islet cells of the
pancreas. This in turn results in glycogenesis and
storage of glucose as glycogen in liver and muscle.
On the contrary, during fasting secretion of insulin
is reduced while counter-regulatory hormones
glucagon and catecholamines are increased. This
leads to glycogenolysis and gluconeogenesis. The
low levels of insulin in circulation also lead to
increased fatty acid release and oxidation that
generates ketones which are used for nutrition by
the body (Figure 1).5
Effects on lipid metabolism and other
metabolic parameters during fasting
A recent study from Turkey suggested maternal
serum cortisol level was elevated while the LDL/
HDL ratio was reduced in healthy women with
uncomplicated pregnancies of 20 weeks or more,
who were fasting during Ramadan. No untoward
effects of fasting were observed on intrauterine
fetal development.10
A study of 30 healthy volun-
teers in Tunisia showed significant increase of
plasma total and HDL-cholesterol. The most
striking finding was a significant increase of 20%
(p <0.02) in HDL-cholesterol during Ramadan.
This increase was lost after Ramadan.11
These find-
ings have been confirmed in other studies.9
Figure 1
Pathophysiology of fasting in normal individuals
Journal of the Royal Society of Medicine
J R Soc Med 2010: 103: 139–147. DOI 10.1258/jrsm.2010.090254140

Pathophysiology of fasting in
patients with diabetes
Effects of fasting on metabolism in
patients with diabetes
Patients with type 1 diabetes and severe insulin
deficiency may have excessive glycogenolysis,
gluconeogenesis and ketogenesis. All of this may
lead to hyperglycaemia and ketoacidosis that may
be life-threatening. Some patients with diabetes
have autonomic neuropathy leading to an inad-
equate response to hypoglycaemia (Figure 2).5
Effects on body weight
The EPIDIAR study revealed weight was un-
changed in the vast majority of patients with type 1
and type 2 diabetes.12
Other studies also con-
cluded either no change in weight or weight loss
during Ramadan in patients with diabetes.10,11
Effects on glycaemic control
Several studies have shown no significant change
in glucose concentration in patients with dia-
betes.10,11
However, there is an increased risk of
severe hypoglycaemia, hyperglycaemia and keto-
acidosis. The EPIDIAR study showed an increase
in the risk of severe hypoglycaemia (defined as
hypoglycaemia leading to hospitalization) of
around 4.7-fold in patients with type 1 and 7.5-fold
in patients with type 2 diabetes. On the other hand,
the incidence of severe hyperglycaemia (requiring
hospitalization) increased five-fold in patients
with type 2 and three-fold in type 1 diabetes.12
Effects on lipid metabolism
Patients with diabetes show no change or a slight
decrease in concentration of cholesterol and tri-
glycerides. Several studies report an increase in
HDL cholesterol therefore suggesting a theoretical
decrease in cardiovascular risk.13,14
Effects on other parameters
A survey from Saudi Arabia suggested an increase
in the incidence of retinal vein occlusion during
Ramadan: 29.5% of the attacks happened during
Ramadan, which, when compared with other
months of the Gregorian year, was statistically sig-
nificant. The authors proposed dehydration might
be responsible for this.15
Exemptions from fasting
An international consensus meeting of healthcare
professionals and research scholars with interest in
diabetes and Ramadan was held at Morocco in
1995. The aim of the meeting was to establish
guidelines regarding patient groups who should
be exempt from fasting. They concluded that the
following groups should be exempt:
+ type 1 diabetes;
+ type 2 diabetes with unstable disease;
+ diabetes with complications;
+ pregnant women with diabetes;
+ elderly patients with diabetes.
At the same time they also concluded that
patients with diabetes who have stable disease
should be allowed to fast even if they are on medi-
cations like biguanides or sulfonylurea.16
Current evidence of diabetes and
fasting
A number of studies have looked at the manage-
ment of diabetes during Ramadan. Most have
targeted specific treatment modalities. However,
Figure 2
Pathophysiology of fasting in diabetes
Review of diabetes management and guidelines during Ramadan

the largest study looking at the management of
diabetes during Ramadan is the EPIDIAR study,
which had 12,243 participants.
The EPIDIAR study
This was a retrospective population-based study
conducted in 13 countries including Algeria,
Bangladesh, Egypt, India, Indonesia, Jordan,
Lebanon, Malaysia, Morocco, Pakistan, Saudi
Arabia, Tunisia and Turkey. Data were analysed
from 12,243 participants: 8.7% had type 1 diabetes
and the rest had type 2 diabetes. Nearly 43% of
patients with type 1 diabetes and 79% of patients
with type 2 diabetes reported fasting at least 15
days during Ramadan. Physical activity, sleep
duration, food intake, fluid intake, and sugar in-
take were unchanged in half of the study popu-
lation. Insulin dose was unchanged in 64%
patients (type 1 and type 2 diabetes), and the doses
of oral medications were unchanged in 75% of
patients with type 2 diabetes. Severe hypogly-
caemic episodes were significantly more frequent
compared with other months (type 1 diabetes, 0.14
vs. 0.03 episode/month, P=0.0174; type 2 diabetes,
0.03 vs. 0.004 episode/month, P <0.0001). Similarly
incidence of severe hyperglycaemia was higher
during Ramadan (P=0.1635 and <0.001, respect-
ively, for type 1 and 2 diabetes).12
Recommendations on
management of diabetes during
Ramadan
Pre-Ramadan medical assessment and
counselling
All patients with diabetes wishing to fast during
Ramadan should receive proper counselling 1–2
months before the onset of Ramadan. Assessment
should include a full annual review, detection
of complications along with measurements of
HbA1c, blood pressure and lipids, as well as
specific advice including potential risks of fasting.
This is an ideal time to suggest any changes regard-
ing diet as well as medications for treatment of
diabetes. Educational counselling should focus not
only on the patient but also his or her family about
the awareness of symptoms of hypo- and hyper-
glycaemia, planning of meals, blood glucose
monitoring, administration of medicines, physical
activity as well as management of acute complica-
tions including when to break the fast (Figure 3).5
This consultation also provides an opportunity to
reinforce healthy living advice to the entire family
and encourage patients to quit smoking. As
patients are not allowed to smoke during fasting,
this provides a unique opportunity to encourage
patients to quit and offer help and advice as
needed. A study looking at smoking cessation in-
terventions among UK Bangladeshi and Pakistani
adults noted how participants described a positive
impact of fasting during Ramadan and pilgrimage
to Mecca in helping them to quit smoking.17
Health
promotional material is published regularly by
Figure 3
Pre-Ramadan medical assessment and risk stratification

the Department of Health and is available for
use.18
In the EPIDIAR study, 68% of patients with
type 1 diabetes and 61% of those with type 2 dia-
betes received pre-Ramadan diabetes advice.12
Bain and colleagues from Birmingham showed
only 40% of patients received any pre-Ramadan
counselling.19
Nutrition
Patients should be advised to avoid food high in
fat and sugar. It has been suggested that eating
complex carbohydrate meals at dawn and simple
carbohydrates at dusk may be more appropriate.5
Others suggest eating foods with long glycaemic
indices when breaking the fast.7
Slow energy re-
lease foods like grains, wheat and rice are best
before and after a period of fasting. The intake of
ghee and fried snacks as well as high-fat and
sugar-rich sweets should be minimized.20
Physical activities
Taraweeh (Night prayer) is part of the customs of
Ramadan and most men would normally walk to
the local mosque; this should be considered a part
of the daily exercise program.6
While normal levels
of physical activity are encouraged, excessive exer-
cise may lead to hypoglycaemia and should be
avoided.5
Management of patients with
type 1 diabetes
The general advice for patients with poorly-
controlled type 1 diabetes is that they should not
fast.5
However, data from the EPIDIAR study
suggest approximately 43% of patients with type 1
diabetes fast during Ramadan.12
If the patients
decide to fast then they should be on a basal bolus
regime, preferably on analogues and test sugars
regularly. In two small studies, glargine has been
shown to cause less hypoglycaemia.21,22
In another
study insulin lispro was given together with NPH
insulin, twice daily before morning and evening
meals, for two weeks each. Glycaemic control
was improved and hypoglycaemia significantly
reduced with insulin lispro compared to regular
human insulin.23
Management of patients with
type 2 diabetes
Diet-controlled patients
This is a low-risk group that should be able to fast
without problems. Caloric redistribution over
smaller meals rather than eating one major meal
may lead to less postprandial hyperglycaemia.
Adequate fluid intake should be ensured in order
to prevent the risk of thrombotic events.5
Patients treated with oral hypoglycaemic
agents
Metformin
These patients should be able to fast safely as met-
formin is not associated with hypoglycaemia.
However, it is advised that patients should change
the timing of medications and take one-third at
dawn and two-thirds at dusk.5,7
Thiozolidinediones
Patients should be able to take their medications as
usual with no adjustment in dosage required.5,7
For those on combination treatments the dose
should be adjusted to take half the tablet at dawn
and 1.5 at dusk.7
Sulfonylurea and prandial regulators
These medications should be used with caution
because of the risk of hypoglycaemia.Astudy from
Turkey looked at the effects of diet, sulfonylurea
and repaglinide therapy. Most parameters were
not changed and only one hypoglycaemic event
occurred in a patient taking glimepride.24
A study
by Belkhadir looked at the use of glibenclamide in
591 patients and concluded it was safe.25
An open-
labelled prospective observational study from six
countries looked at the use of glimepiride in 332
patients with type 2 diabetes. The incidence of
hypoglycaemic episodes was 3% in newly-
diagnosed patients and 3.7% in already-treated
patients. These figures were similar to the pre- and
post-Ramadan periods.26
Mafauzy carried out a study in which 235
patients, previously treated with a sulfonylurea,
were randomized to receive either repaglinide or
glibenclamide. A statistically significant reduction

in serum fructosamine and no difference in
HbA1C were identified. The number of hypogly-
caemic events was significantly lower in the repa-
glinide group (2.8%) compared to glibenclamide
group (7.9%).27
A study from Turkey looked at
comparing glycaemic effects of glimepiride,
repaglinide and insulin glargine. No difference
between the therapies was identified.28
General
advice is to use prandial regulators and short act-
ing agents for the purpose of managing diabetes
during Ramadan.
Incretin-based therapies (exenatide and
gliptins)
Incretin-based therapies like DPP 4 inhibitors
and GLP 1 analogues have shown to cause less
hypoglycaemia when compared to conventional
treatments and hence may be suitable for
Ramadan. This is because GLP-1 acts in a glucose-
dependent manner and, therefore, the risk of
severe hypoglycaemia is less compared to other
agents. When used alone they do not require any
adjustments to their doses but the risk of hypogly-
caemia in combination with sulfonylureas remain
high. However, these are new agents and very few
studies are currently available to draw firm con-
clusions. One of the concerns regarding injectable
GLP-1 analogues is nausea and this could be a
limiting factor during fasting.
The incidence of hypoglycaemia with Vilda-
gliptin, an oral DPP 4 inhibitor, was less when
compared to glimepride.29
A meta-analysis on the
randomized controlled trials with exenatide
showed that severe hypoglycaemia was rare. Mild
to moderate hypoglycaemia was 16% versus 7%
(exenatide versus placebo) and more common
with co-administration with sulfonylurea.30
Similarly pooled analysis of 5141 patients in
clinical trials for %2 years showed that sitagliptin
monotherapy or combination therapy (metformin,
pioglitazone, sulfonylurea, or sulfonylurea and
metformin) was well-tolerated and hypoglycae-
mia occurred in the setting of combination therapy
with sulfonylurea only.30
Insulin
The general advice for long-acting insulin
(glargine and detemir) is to reduce the dose by
20%. The rationale is to try and reduce the risk of
hypoglycaemia. Long-acting insulin should be
administered with the evening meal at dusk.
Short-acting insulin analogues are also useful dur-
ing fasting as they can work immediately follow-
ing meals.20
Bruttomesso et al. showed that
positive metabolic effect of rapid-acting insulin
analogues may last for up to 6 hours following
ingestion of food.31
For premix insulins, the morn-
ing insulin dose should be taken at dusk and half
of the evening dose should be taken at dawn.20
During fasting human soluble insulins may re-
main in the system for 8–12 hours and, with their
late long-lasting peak starting 2 hours after admin-
istration, can potentially lead to late postprandial
hypoglycaemia. It is recommended that the newer
insulin analogue preparations may be more useful
in managing diabetes during Ramadan.32
Table 1 illustrates general guidelines for the
change in the diabetes regime before and during
Ramadan. Although the insulin regimes are not
extensive, they should be tailor-made to the indi-
vidual patient depending on diet and lifestyle,
close monitoring of blood sugars and baseline
glycaemic control.
Advice on breaking the fast
Although fasting is one of the pillars of Islam,
when fasting may affect health adversely Islam
provides an exemption from fasting.
‘Fasting is for a fixed number of days, but if any of
you is ill, or on a journey, the prescribed number
(missed) should be made up .’ (Al-Qur’an, 2:184)
There is resistance among Muslims about
breaking the fast even if there are serious health
concerns. All patients should understand that they
will need to break the fast if blood glucose is
<3.3 mmol/L or exceeds 16.7 mmol/L.5
They
should be advised to break the fast if blood glucose
is <3.9mmol/L in the morning if the patient is
taking sulfonylurea or insulin.5
Conclusion
Culture and religion have a great impact on the
management of chronic disease like diabetes. For a
growing Muslim population in the Western world,
fasting during Ramadan is a central pillar of faith.
We need to engage with reality that many patients
will continue to fast during Ramadan despite

medical advice. Indeed the EPIDIAR study
showed 43% of patients with type 1 and 79% with
type 2 diabetes fasted for at least for 15 days.
Hence, it is important that healthcare professionals
are well-informed regarding the effects of
Ramadan on diabetes and are able to offer advice,
guidance and change of medications as required
during pre-Ramadan counselling to enable
patients to fast safely should they wish to do so.
The aim of this review was to examine the cur-
rent evidence and guidelines for fasting and man-
agement of diabetes during Ramadan. Although
studies in literature have suggested safe manage-
ment of patients with type 2 diabetes on a number
of combination therapies, there have been no ran-
domized controlled studies. Most of the previous
studies have been carried out in the Middle East or
South East Asia where time zone fluctuations
between summer and winter are minimal. On the
other hand, in European countries this is a major
factor as fasting may last for up to 19 hours during
summer months and can be as short as 10 hours
during winter,
The general advice regarding type 1 diabetes is
similar to other groups (Al-Arouj and others), i.e.
patients with type 1 diabetes should be strongly
advised to not fast. The EPIDIAR study suggested
that despite this advice being available about half
of patients with type 1 diabetes continued to fast.
An important part of the management is to educate
the patient, alter their therapy with clear guidance
as when to break fast. This could be achieved by
pre-Ramadan counselling that will give an oppor-
tunity to educate patients about fasting and dia-
betes, at the same time adjusting their medication
as required, and also educate and encourage smok-
ing cessation. This would be in keeping with
the whole spirit of fasting and the patients who
manage to abstain from smoking during the whole
day could be motivated to give up smoking on a
long-term basis. We know from previous studies
that only half of the patients do get any kind of
Table 1
A rough guide of optimization of anti-diabetic medications during Ramadan
Before Ramadan During Ramadan
Diet controlled No change needed
Biguanides
Metformin 500 mg TDS Metformin 1000 mg (sunset – Iftar), 500 mg (dawn – Sehr)
Metformin SR 1000 mg OD Metformin 1000 mg (sunset – Iftar)
Thiazolidinediones No change required
TZD+Biguanide combination
Avandamet BD Avandamet –1 tablet (sunset – Iftar), Half tablet (dawn – Sehr)
Sulphonylureas
Gliclazide 80 mg BD Gliclazide 80 mg (sunset – Iftar), 40 mg (dawn – Sehr)
Glimepiride 4 mg OD Glimepiride 4 mg (sunset – Iftar)
Prandial regulators
Repaglinide 4 mg BD No change(taken with Iftar and Sehr)
Incretin mimetics: DPP 4 inhibitors No change; if taken with SU, will need dose reduction
Vildagliptin 50 mg BD
Sitagliptin 100 mg OD
Saxagliptin 5 mg OD
GLP 1 Analogues No change (may need dose reduction if severe nausea, or if
used in combination with SU)
Liraglutide 1.2 mg OD
Exenetide 10 mcg BD
Insulin
Once daily Glargine 20 units Glargine 16 units (20% decrease in dose) with Iftar
Pre-mixed insulin – Novomix 30–30 and
20 units
10 units (dawn – Sehr) and 30 units (sunset – Iftar)
Novorapid/Humalog 10 units tds with
each meal
Omit afternoon dose; twice daily with Iftar and Sehr meals

counselling or advice regarding fasting. One way
of improving awareness and education regarding
fasting would be to incorporate in diabetes educa-
tion a programme like BME DESMOND, enabling
patients to seek such advice before fasting. Second,
this article aims to educate healthcare profession-
als in having a better understanding of Islam and
attitudes of Muslims towards fasting and at the
same time offering clear guidelines regarding
management. One of the difficulties for a review
like this is a paucity of good randomized trials as a
whole and especially from Western countries as a
long duration of fasting during summer months
has an impact on diabetes. Studies are needed
to examine the effect of education on patients,
especially as a part of structured education pro-
grammes like DESMOND and Expert Patient. The
incidence of diabetes complications like hypogly-
caemia and diabetic ketoacidosis need to be
studied in prospective trials. The use of guidance
and dose adjustment through pre-Ramadan coun-
selling also needs to be looked into through a
multicentre trial. The newer agents for manage-
ment of diabetes like incretin-based therapies may
have a role, as they do not cause hypoglycaemia
hence not requiring dose adjustments. However,
these agents are new and have no published
studies so far on their effect during Ramadan.
Recently Diabetes UK and South Asian Health
Foundation published research priorities of dia-
betes in South Asians and Ramadan was identified
as an important area for further research. This
hopefully is a step in the right direction to address
gaps in our knowledge in diabetes management
during Ramadan.
References
1 See http://en.wikipedia.org/wiki/Muslim_population
2 Hanif MW, Valsamakis G, Dixon A, et al. Detection of
impaired glucose tolerance and undiagnosed type 2
diabetes in UK South Asians: an effective screening
strategy. Diabetes Obes Metab 2008;10:755–62
3 Holt T, Kumar S. ABC of Diabetes. London: BMJ
Publishing; 2003
4 Fazel M. Medical implications of controlled fasting. J R
Soc Med 1998;91:453
5 Al-Arouj M, Bouguerra R, Buse J, et al. Recommendations
for management of diabetes during Ramadan. Diabetes
Care 2005;28:2305–11
6 Qureshi B. Diabetes in Ramadan. J R Soc Med 2002;95:489–
90
7 Chowdhury TA, Lasker SS. Controlling the Asian diabetic.
Care of the Elderly Fasting and Feasting, September 2006
8 Takruri HR. Effect of fasting in Ramadan on body weight.
Saudi Med J 1989;10:491–4
9 Ziaee V, Razaei M, Ahmadinejad Z, et al. The changes of
metabolic profile and weight during Ramadan fasting.
Singapore Med J 2006;47:409–14
10 Dikensoy E, Balat O, Cebesoy B, Ozkur A, Cicek H, Can G.
The effect of Ramadan fasting on maternal serum lipids,
cortisol levels and fetal development. Arch Gynecol Obstet
2009;279:119–23
11 Mafauzy M, Mohammed WB, Anum MY, Zulkifli A,
Ruhani AH. A study of the fasting diabetic patients
during the month of Ramadan. Med J Malaysia 1990;45:14–
7
12 Ibrahim Salti, Eric Bénard, Bruno Detournay, et al.
EPIDIAR Study Group. A population-based study of
diabetes and its characteristics during the fasting month of
Ramadan in 13 countries: results of the epidemiology of
diabetes and Ramadan 1422/2001 (EPIDIAR) Study.
Diabetes Care 2004;27:2306–11
13 Yarahmadi Sh, Larijani B, Bastanhagh MH, et al. Metabolic
and clinical effects of Ramadan fasting in patients with
type II diabetes. J Coll Physicians Surg Pak 2003;13:329–32
14 Akanji AO, Mojiminiyi OA, Abdella N. Beneficial changes
in serum apo A-1 and its ratio to apo B and HDL in stable
hyperlipidaemic subjects after Ramadan fasting in
Kuwait. Eur J Clin Nutr 2000;54:508–13
15 Alghadyan AA. Retinal vein occlusion in Saudi Arabia:
possible role of dehydration. Ann Ophthalmol 1993;25:
394–8
16 International Consensus Meeting. Morocco; 1995
17 White M, Bush J, Kai J, Bhopal R, Rankin J. Quitting
smoking and experience of smoking cessation
interventions among UK Bangladeshi and Pakistani
adults: the views of community members and health
professionals. J Epidemiol Community Health 2006; 60:
405–11
18 See http://www.communitiesinaction.org/Ramadan
19 Sarween N, Bilkhu H, Bain S. Diabetic control during
Ramadan. Diabetic Medicine 2006;23 (Suppl. 2):P386
20 Greenstein A, Malik R. Why are South Asians at greater risk
of developing diabetes? Care of the Elderly Fasting and
Feasting, September 2006
21 Mucha GT, Merkel S, Thomas W, Bantle JP. Fasting and
insulin glargine in individuals with type 1 diabetes.
22 Kassem HS, Zantout MS, Azar ST. Insulin therapy during
Ramadan fast for Type 1 diabetes patients. J Endocrinol
Invest 2005;28:802–5
23 Kadiri A, Al-Nakhi A, El-Ghazali S, et al. Treatment of
type 1 diabetes with insulin lispro during Ramadan.
Diabetes Metab 2001;27:482–6
24 Sari R, Balci MK, Akbas SH, Avci B. The effects of diet,
sulfonylurea, and Repaglinide therapy on clinical and
metabolic parameters in type 2 diabetic patients during
Ramadan. Endocr Res 2004;30:169–77
25 Belkhadir J, el Ghomari H, Klöcker N, et al. Muslims with
non-insulin dependent diabetes fasting during Ramadan:
treatment with glibenclamide. BMJ 1993;307:292–5
26 Glimepiride in Ramadan (GLIRA) Study Group.. The
efficacy and safety of glimepiride in the management of
type 2 diabetes in Muslim patients during Ramadan.
27 Mafauzy M. Repaglinide versus glibenclamide treatment
of type 2 patients during Ramadan fasting. Diabetes Res
Clin Pract 2002;58:45–53
28 Cesur M, Corapcioglu D, Gursoy A, et al. A comparison of
glycemic effects of glimepiride, repaglinide, and insulin
glargine in type 2 diabetes mellitus during Ramadan
fasting. Diabetes Res Clin Pract 2007;75:141–7

29 Ferrannini E, Fonseca V, Zinman B, et al. Fifty-two-week
efficacy and safety of vildagliptin vs. glimepiride in
patients with type 2 diabetes mellitus inadequately
controlled on metformin monotherapy. Diabetes Obes
Metab 2009;11:157–66
30 Chia CW, Egan JM. Incretin-based therapies in type 2
diabetes mellitus. J Clin Endocrinol Metab 2008;93:
3703–16
31 Bruttomesso D, Pianta A, Mari A, et al. Restoration of
early rise in plasma insulin levels improves the glucose
tolerance of type 2 diabetic patients. Diabetes 1999;48:99–
105
32 Akram J, De Verga V. Insulin lispro (Lys(B28), Pro(B29) in
the treatment of diabetes during the fasting month of
Ramadan. Ramadan Study Group. Diabet Med
1999;16:861–6

C11 review of diabetes management and guidelines during ramadan 2010

Recommended

Recommended

More Related Content

What's hot

What's hot (19)

Viewers also liked

Viewers also liked (20)

Similar to C11 review of diabetes management and guidelines during ramadan 2010

Similar to C11 review of diabetes management and guidelines during ramadan 2010 (20)

More from Diabetes for all

More from Diabetes for all (20)

Recently uploaded

Recently uploaded (20)

C11 review of diabetes management and guidelines during ramadan 2010