This document provides guidelines for managing diabetes during Ramadan fasting. It was created by the International Diabetes Federation and Diabetes and Ramadan International Alliance. The guidelines cover epidemiology of diabetes and Ramadan fasting, physiology changes during fasting, risk stratification for fasting, diabetes education, and medication adjustments. The goal is to enhance healthcare provider knowledge to safely support patients with diabetes who choose to fast during Ramadan.
This document summarizes findings from the Australian Longitudinal Study on Women's Health regarding adherence to various health guidelines. It examines guidelines for smoking, alcohol use, overweight/obesity, nutrition, physical activity, and pregnancy/early motherhood. The study analyzed data from three cohorts of Australian women born between 1921-1926, 1946-1951, and 1973-1978 to assess adherence levels and changes over time. Key findings included low adherence rates for smoking, alcohol, nutrition, and physical activity guidelines across cohorts.
The document provides guidelines for diabetes care in Massachusetts that were updated in 2007. It includes sections on diagnosing and classifying diabetes, preventing type 2 diabetes, diabetes medications and treatment approaches, cardiovascular risk reduction, hypertension, nephropathy, retinopathy, neuropathy, self-management education, nutrition, physical activity, tobacco use, and inpatient glucose control. The guidelines are intended to improve diabetes care by highlighting essential components of management and offering accompanying tools for primary care providers.
This document provides a summary of a systematic literature review that examined the effectiveness of nutrition interventions for the prevention and treatment of chronic diseases in primary care settings. The review included studies on conditions such as overweight/obesity, diabetes, cardiovascular disease, and other conditions. It found that nutrition counselling and education led to beneficial outcomes for many conditions. However, it noted that the specific components and delivery methods of nutrition interventions varied widely between studies. The review concluded that nutrition services provided by dietitians can be effective in primary care, but more research is still needed, especially on the organizational aspects and implementation of such services.
This document provides guidance from NICE on local measures to promote walking and cycling for travel or recreation. It makes several recommendations:
1. It recommends high-level support from the health sector to promote walking and cycling, including ensuring these activities are considered in health strategies and chronic disease pathways.
2. It recommends ensuring all relevant local policies and plans, such as transport, environment and planning policies, support and encourage walking and cycling.
3. It recommends local authorities and partners develop coordinated, cross-sector programmes to promote walking and cycling for both transport and recreation. These should be long-term and address the needs of all groups.
This document provides information from the U.S. Department of Health and Human Services about physical activity and its impact on heart health. It discusses how physical inactivity greatly increases the risk of heart disease, and that regular physical activity can help reduce this risk. The document provides tips on starting a physical activity routine and maintaining it over time for long-term heart health benefits. It also discusses different types of physical activities and intensity levels.
This document contains a compilation of practice tests for the nursing board exam. It includes 5 parts that cover the following topics:
1. Foundation of Professional Nursing Practice
2. Community Health Nursing and Care of the Mother and Child
3. Care of Clients with Physiologic and Psychosocial Alterations
4. Additional topics like Medical-Surgical Nursing, Psychiatric Nursing, and Fundamentals of Nursing
5. Each part contains multiple choice tests and answer keys to help students prepare.
Este documento resume la crioglobulinemia, incluyendo su clasificación, epidemiología, etiología, patogenia, manifestaciones clínicas, diagnóstico y tratamiento. La crioglobulinemia se clasifica en tres tipos y se asocia comúnmente con infecciones como la hepatitis C. Los síntomas incluyen púrpura, artralgias y fatiga. El diagnóstico requiere la detección e identificación de crioglobulinas en la sangre, y el tratamiento depende de la gravedad de los síntomas y la en
This document summarizes findings from the Australian Longitudinal Study on Women's Health regarding adherence to various health guidelines. It examines guidelines for smoking, alcohol use, overweight/obesity, nutrition, physical activity, and pregnancy/early motherhood. The study analyzed data from three cohorts of Australian women born between 1921-1926, 1946-1951, and 1973-1978 to assess adherence levels and changes over time. Key findings included low adherence rates for smoking, alcohol, nutrition, and physical activity guidelines across cohorts.
The document provides guidelines for diabetes care in Massachusetts that were updated in 2007. It includes sections on diagnosing and classifying diabetes, preventing type 2 diabetes, diabetes medications and treatment approaches, cardiovascular risk reduction, hypertension, nephropathy, retinopathy, neuropathy, self-management education, nutrition, physical activity, tobacco use, and inpatient glucose control. The guidelines are intended to improve diabetes care by highlighting essential components of management and offering accompanying tools for primary care providers.
This document provides a summary of a systematic literature review that examined the effectiveness of nutrition interventions for the prevention and treatment of chronic diseases in primary care settings. The review included studies on conditions such as overweight/obesity, diabetes, cardiovascular disease, and other conditions. It found that nutrition counselling and education led to beneficial outcomes for many conditions. However, it noted that the specific components and delivery methods of nutrition interventions varied widely between studies. The review concluded that nutrition services provided by dietitians can be effective in primary care, but more research is still needed, especially on the organizational aspects and implementation of such services.
This document provides guidance from NICE on local measures to promote walking and cycling for travel or recreation. It makes several recommendations:
1. It recommends high-level support from the health sector to promote walking and cycling, including ensuring these activities are considered in health strategies and chronic disease pathways.
2. It recommends ensuring all relevant local policies and plans, such as transport, environment and planning policies, support and encourage walking and cycling.
3. It recommends local authorities and partners develop coordinated, cross-sector programmes to promote walking and cycling for both transport and recreation. These should be long-term and address the needs of all groups.
This document provides information from the U.S. Department of Health and Human Services about physical activity and its impact on heart health. It discusses how physical inactivity greatly increases the risk of heart disease, and that regular physical activity can help reduce this risk. The document provides tips on starting a physical activity routine and maintaining it over time for long-term heart health benefits. It also discusses different types of physical activities and intensity levels.
This document contains a compilation of practice tests for the nursing board exam. It includes 5 parts that cover the following topics:
1. Foundation of Professional Nursing Practice
2. Community Health Nursing and Care of the Mother and Child
3. Care of Clients with Physiologic and Psychosocial Alterations
4. Additional topics like Medical-Surgical Nursing, Psychiatric Nursing, and Fundamentals of Nursing
5. Each part contains multiple choice tests and answer keys to help students prepare.
Este documento resume la crioglobulinemia, incluyendo su clasificación, epidemiología, etiología, patogenia, manifestaciones clínicas, diagnóstico y tratamiento. La crioglobulinemia se clasifica en tres tipos y se asocia comúnmente con infecciones como la hepatitis C. Los síntomas incluyen púrpura, artralgias y fatiga. El diagnóstico requiere la detección e identificación de crioglobulinas en la sangre, y el tratamiento depende de la gravedad de los síntomas y la en
La agammaglobulinemia ligada al cromosoma X es una inmunodeficiencia congénita causada por mutaciones en el gen BTK que provoca la ausencia de linfocitos B y anticuerpos. Los pacientes sufren infecciones recurrentes graves. El tratamiento consiste en reemplazar los anticuerpos faltantes mediante inyecciones mensuales de inmunoglobulinas.
Cryoglobulinemia is a condition where proteins in the blood called cryoglobulins precipitate or clump together at low temperatures. There are three main types of cryoglobulins:
Type I consists of a single monoclonal immunoglobulin. Type II contains monoclonal rheumatoid factors along with polyclonal immunoglobulins. Type III contains only polyclonal immunoglobulins.
The most common cause of cryoglobulinemia is hepatitis C virus infection, which is associated with type II cryoglobulinemia. Other causes include other infections, autoimmune diseases like Sjögren's syndrome, hematological cancers, and essential/idiopathic cryoglobulinemia.
La agammaglobulinemia ligada al cromosoma X o enfermedad de Bruton es una enfermedad hereditaria de carácter recesivo ligado al sexo, que se caracteriza por una afectación profunda de la inmunidad humoral con una inmunidad celular normal.
La clínica de la enfermedad suele consistir en infecciones de repetición, sobre todo del tracto respiratorio tanto alto como bajo y en frecuentes diarreas bien de origen vírico, bacteriano o por protozoos. La sintomatología comienza generalmente a partir del sexto o séptimo mes de vida, cuando los anticuerpos recibidos de la madre están ya en unos niveles muy bajos. El tratamiento es fundamentalmente profiláctico y consiste en la administración intravenosa de inmunoglobulina humana, con lo que se consigue reducir el número y la gravedad de las infecciones que afectan a estos pacientes.
La agammaglobulinemia ligada al X o de Bruton constituye el prototipo de deficiencia primaria de célula B. Los niños varones afectados presentan infecciones recurrentes y manifestaciones autoinmunes a partir de los 6 meses de edad. La utilización de modernas técnicas de biología molecular ha permitido la identificación del gen responsable de la enfermedad en el locus Xq22. La naturaleza genética de la misma ha posibilitado además, la detección de madres portadoras y la realización de un diagnóstico prenatal. Actualmente se continúa en la profundización de los aspectos moleculares, con el objetivo de manipular el material genético de los pacientes con fines terapéuticos, lo que resultará en una cura definitiva de la enfermedad.
El documento presenta un resumen de 3 oraciones sobre agammaglobulinemia:
1) Describe el primer caso clínico de agammaglobulinemia reportado en 1952, en el que un niño sufría infecciones neumocócicas recurrentes y no presentaba anticuerpos en respuesta a vacunas.
2) Explica que en 1993 se descubrió que los pacientes con agammaglobulinemia ligada al X presentaban un gen alterado que codifica la proteína tirosin-quinasa BtK.
3) Señala que la agam
This document discusses nutrition support for various inborn errors of protein metabolism, including amino acid disorders and organic acid disorders. Key points include:
- Treatment involves restricting intake of specific amino acids or proteins to reduce toxic metabolite buildup, while providing adequate nutrition for growth. Formula supplementation provides most protein/nutrients.
- Requirements for disorders like PKU, MSUD, and others vary by age but involve restricting intake of certain amino acids while meeting protein and calorie needs. Blood amino acid levels must be carefully monitored.
- Organic acid disorders also involve restricting intake of specific amino acids derived from lysine or tryptophan to control toxic metabolite levels while meeting nutritional needs. Early treatment is
- Alpha-fetoprotein (AFP) is a glycoprotein normally produced during gestation and elevated in patients with hepatocellular carcinoma (HCC).
- Elevated AFP can also occur in pregnancy, other cancers like gastric cancer, and chronic liver diseases without HCC such as hepatitis.
- While an AFP over 500 mcg/L strongly indicates HCC, tumors are often diagnosed at lower AFP levels in screening patients, and AFP may be normal in up to 40% of small HCCs.
This document provides a summary of health indicators in OECD countries. It begins with an introduction that describes the document as the 2013 edition of Health at a Glance, which presents recent comparable data on key health indicators across 34 OECD countries. The data is drawn from contributions of national health agencies and aims to monitor health status, determinants, health workforce, health care activities, and quality of care.
This 2013 edition of Health at a Glance – OECD Indicators presents the most recent comparable
data on key indicators of health and health systems across the 34 OECD member countries. Where
possible, it also reports comparable data for Brazil, China, India, Indonesia, the Russian Federation,
and South Africa, as key emerging countries
C13 nice diabetes type 1and type 2 in children and young adult 2015Diabetes for all
This document provides guidance from NICE on the diagnosis and management of diabetes in children and young people. It covers:
- Key priorities for implementation, including education and information, insulin therapy, dietary management, blood glucose and HbA1c targets, psychological support, and kidney disease screening.
- Recommendations on diagnosis, management of type 1 diabetes, management of type 2 diabetes, treatment of diabetic ketoacidosis, and service provision.
- Research recommendations on topics like peer-led education, optimal blood glucose monitoring, metformin preparations, and intravenous insulin dosing.
- Information on how the guideline was developed and related NICE guidance.
This document summarizes a systematic review of studies reporting on the global and regional incidence of preeclampsia and eclampsia between 2002-2010. The review identified 129 studies meeting inclusion criteria, from which 74 reports with data from over 39 million births across 40 countries were analyzed. Crude and model-based estimates were calculated. The overall estimates from the model were 4.6% of deliveries for preeclampsia and 1.4% for eclampsia, with significant regional variations. However, many countries lacked data, highlighting the need for improved data collection to better inform health policies.
The document reviews the association between COVID-19 and diabetes. It summarizes the general characteristics of COVID-19, including its incubation period, modes of transmission, clinical presentation, and diagnosis. It then discusses the relationship between diabetes and viral infections in general, and explores some potential pathophysiological mechanisms linking COVID-19 and diabetes. The review suggests chronic inflammation, immune dysfunction, and direct pancreatic damage as possible underlying factors. It notes that more research is needed to fully understand this relationship and its clinical implications.
This thesis examines the impact of climate change on Sámi youth wellbeing and cultural continuity in Kautokeino, Norway. Interviews were conducted with Sámi adolescents, community members, and leaders. The results suggest that climate change is negatively impacting traditional Sámi culture and reindeer herding. It is causing difficulties for teaching traditional knowledge to younger generations and changing seasonal patterns that Sámi culture depends on. Climate change is also increasing stress levels and risks to mental health among Sámi youth. Adaptation strategies are needed to address these challenges and ensure the intergenerational transmission of Sámi culture and language.
Nutrition for the ageing brain: Towards evidence for an optimal dietNutricia
This article reviews the latest research on nutrition and cognitive aging. It discusses normal and pathological cognitive decline in aging. Several key mechanisms of brain aging are explored, including oxidative stress, neuroinflammation, and autophagy. The review examines the potential for specific nutrients and dietary patterns to prevent cognitive decline through these mechanisms. While some studies link nutrients like polyphenols, flavonoids, vitamins and omega-3 fatty acids to cognitive benefits, the research is inconsistent and more work is needed to determine optimal doses and relationships between diet and brain health in older adults.
This review article summarizes research on the impact of coffee consumption on health. It finds that coffee contains several bioactive compounds like caffeine, chlorogenic acids, and diterpenes. While caffeine can increase blood pressure short-term, coffee drinking appears to reduce the risk of cardiovascular diseases like heart disease and stroke. Coffee is also associated with a reduced risk of type 2 diabetes and liver disease. The effects of coffee on cancer risk depend on the specific cancer type, but coffee drinking may lower overall cancer risk and mortality. However, the clinical evidence comes mostly from observational studies rather than randomized trials.
The document discusses malignant hyperthermia, a rare genetic condition triggered by certain anesthetic agents. It can cause a severe hypermetabolic state and muscle rigidity. If not rapidly treated, it can result in death from complications like cardiac arrest or brain damage. The document outlines strategies for preventing and treating malignant hyperthermia in the operating room, including having emergency supplies and medication available, monitoring patients closely, and educating staff on treatment protocols.
C13 nice type 2 diabetes in adults management 2015Diabetes for all
This document provides guidelines for managing type 2 diabetes in adults. It focuses on patient education, dietary advice, managing cardiovascular risk factors like blood pressure, managing blood glucose levels, and treating long-term complications. The guidelines were updated in 2015 and replace several previous NICE guidelines on type 2 diabetes. Proper management of type 2 diabetes is complex and requires lifestyle changes, medical therapy, and involvement of multiple areas of healthcare to help control blood glucose and reduce health risks.
This document provides guidelines for the management of cardiovascular diseases during pregnancy from the European Society of Cardiology (ESC). It was developed by an international task force and endorsed by several societies. The guidelines cover epidemiology, physiological adaptations during pregnancy, pre-pregnancy counseling, cardiovascular diagnosis and testing considerations in pregnancy, genetic testing, fetal assessment, interventions in mothers, timing and mode of delivery, postpartum care, breastfeeding, and infective endocarditis management. The goal is to provide recommendations to optimize outcomes for both maternal and fetal health in women with heart disease who are pregnant or wish to become pregnant.
2018 esc guidelines for the management of cardiovascular disease during pregn...Vinh Pham Nguyen
This document provides guidelines for the management of cardiovascular diseases during pregnancy published by the European Society of Cardiology (ESC) in 2018. It was developed by an international task force and provides recommendations on risk assessment, diagnosis, treatment and management for a variety of heart conditions that may occur during pregnancy. The guidelines reflect recent advances and aim to improve outcomes for both mothers and infants.
Foodborne disease and food control in the gulf states reviewchoi khoiron
The document discusses foodborne disease and food control challenges in Gulf States, including Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and the United Arab Emirates. It notes that these states have transitioned rapidly from subsistence communities to modern states through oil revenues. Fresh water scarcity is a major issue as rainfall does not meet demands, forcing reliance on desalination. Food imports satisfy expanding populations, especially foreign workers who comprise over half of residents. Gastrointestinal diseases can enter through workers or refugees, while some illnesses are endemic. Government agencies work to oversee restaurants and food safety but surveillance systems need improvement. As long as resources continue, food control will likely progress over time in these Gulf States.
This review discusses microRNA-based therapeutic strategies for breast cancer. It begins by describing various microRNAs (miRNAs) that are involved in breast cancer development and progression, including oncogenic miRNAs that promote cell motility, proliferation, and other processes, as well as tumor suppressor miRNAs that inhibit metastasis, proliferation, and induce apoptosis. The review then discusses different therapeutic approaches to regulate miRNAs, including nucleic acid-based methods to replace or inhibit miRNAs, and drug-based strategies that interact with miRNAs. The review focuses on miR-21 and miR-34 as particularly promising targets for RNA-based therapy in non-invasive and invasive breast cancer, respectively. It concludes by highlighting relevant commercialized therapeutic strategies and approaches using nanotechnology
Changing Diets, Changing Minds: How Food Affects Mental Wellbeing and BehaviourGeoAnitia
This document discusses the relationship between diet and mental well-being. It acknowledges the high cost of mental illness and explores the role that food plays in affecting mental health. The report examines the science behind how nutrients physically impact brain structure and function, such as how proteins, fats, carbohydrates and micronutrients are used by the brain. It analyzes how nutrition at different life stages, from prenatal to older age, can influence brain development and mental well-being. The report provides an overview of this emerging area and argues that diet is an important consideration for mental health.
La agammaglobulinemia ligada al cromosoma X es una inmunodeficiencia congénita causada por mutaciones en el gen BTK que provoca la ausencia de linfocitos B y anticuerpos. Los pacientes sufren infecciones recurrentes graves. El tratamiento consiste en reemplazar los anticuerpos faltantes mediante inyecciones mensuales de inmunoglobulinas.
Cryoglobulinemia is a condition where proteins in the blood called cryoglobulins precipitate or clump together at low temperatures. There are three main types of cryoglobulins:
Type I consists of a single monoclonal immunoglobulin. Type II contains monoclonal rheumatoid factors along with polyclonal immunoglobulins. Type III contains only polyclonal immunoglobulins.
The most common cause of cryoglobulinemia is hepatitis C virus infection, which is associated with type II cryoglobulinemia. Other causes include other infections, autoimmune diseases like Sjögren's syndrome, hematological cancers, and essential/idiopathic cryoglobulinemia.
La agammaglobulinemia ligada al cromosoma X o enfermedad de Bruton es una enfermedad hereditaria de carácter recesivo ligado al sexo, que se caracteriza por una afectación profunda de la inmunidad humoral con una inmunidad celular normal.
La clínica de la enfermedad suele consistir en infecciones de repetición, sobre todo del tracto respiratorio tanto alto como bajo y en frecuentes diarreas bien de origen vírico, bacteriano o por protozoos. La sintomatología comienza generalmente a partir del sexto o séptimo mes de vida, cuando los anticuerpos recibidos de la madre están ya en unos niveles muy bajos. El tratamiento es fundamentalmente profiláctico y consiste en la administración intravenosa de inmunoglobulina humana, con lo que se consigue reducir el número y la gravedad de las infecciones que afectan a estos pacientes.
La agammaglobulinemia ligada al X o de Bruton constituye el prototipo de deficiencia primaria de célula B. Los niños varones afectados presentan infecciones recurrentes y manifestaciones autoinmunes a partir de los 6 meses de edad. La utilización de modernas técnicas de biología molecular ha permitido la identificación del gen responsable de la enfermedad en el locus Xq22. La naturaleza genética de la misma ha posibilitado además, la detección de madres portadoras y la realización de un diagnóstico prenatal. Actualmente se continúa en la profundización de los aspectos moleculares, con el objetivo de manipular el material genético de los pacientes con fines terapéuticos, lo que resultará en una cura definitiva de la enfermedad.
El documento presenta un resumen de 3 oraciones sobre agammaglobulinemia:
1) Describe el primer caso clínico de agammaglobulinemia reportado en 1952, en el que un niño sufría infecciones neumocócicas recurrentes y no presentaba anticuerpos en respuesta a vacunas.
2) Explica que en 1993 se descubrió que los pacientes con agammaglobulinemia ligada al X presentaban un gen alterado que codifica la proteína tirosin-quinasa BtK.
3) Señala que la agam
This document discusses nutrition support for various inborn errors of protein metabolism, including amino acid disorders and organic acid disorders. Key points include:
- Treatment involves restricting intake of specific amino acids or proteins to reduce toxic metabolite buildup, while providing adequate nutrition for growth. Formula supplementation provides most protein/nutrients.
- Requirements for disorders like PKU, MSUD, and others vary by age but involve restricting intake of certain amino acids while meeting protein and calorie needs. Blood amino acid levels must be carefully monitored.
- Organic acid disorders also involve restricting intake of specific amino acids derived from lysine or tryptophan to control toxic metabolite levels while meeting nutritional needs. Early treatment is
- Alpha-fetoprotein (AFP) is a glycoprotein normally produced during gestation and elevated in patients with hepatocellular carcinoma (HCC).
- Elevated AFP can also occur in pregnancy, other cancers like gastric cancer, and chronic liver diseases without HCC such as hepatitis.
- While an AFP over 500 mcg/L strongly indicates HCC, tumors are often diagnosed at lower AFP levels in screening patients, and AFP may be normal in up to 40% of small HCCs.
This document provides a summary of health indicators in OECD countries. It begins with an introduction that describes the document as the 2013 edition of Health at a Glance, which presents recent comparable data on key health indicators across 34 OECD countries. The data is drawn from contributions of national health agencies and aims to monitor health status, determinants, health workforce, health care activities, and quality of care.
This 2013 edition of Health at a Glance – OECD Indicators presents the most recent comparable
data on key indicators of health and health systems across the 34 OECD member countries. Where
possible, it also reports comparable data for Brazil, China, India, Indonesia, the Russian Federation,
and South Africa, as key emerging countries
C13 nice diabetes type 1and type 2 in children and young adult 2015Diabetes for all
This document provides guidance from NICE on the diagnosis and management of diabetes in children and young people. It covers:
- Key priorities for implementation, including education and information, insulin therapy, dietary management, blood glucose and HbA1c targets, psychological support, and kidney disease screening.
- Recommendations on diagnosis, management of type 1 diabetes, management of type 2 diabetes, treatment of diabetic ketoacidosis, and service provision.
- Research recommendations on topics like peer-led education, optimal blood glucose monitoring, metformin preparations, and intravenous insulin dosing.
- Information on how the guideline was developed and related NICE guidance.
This document summarizes a systematic review of studies reporting on the global and regional incidence of preeclampsia and eclampsia between 2002-2010. The review identified 129 studies meeting inclusion criteria, from which 74 reports with data from over 39 million births across 40 countries were analyzed. Crude and model-based estimates were calculated. The overall estimates from the model were 4.6% of deliveries for preeclampsia and 1.4% for eclampsia, with significant regional variations. However, many countries lacked data, highlighting the need for improved data collection to better inform health policies.
The document reviews the association between COVID-19 and diabetes. It summarizes the general characteristics of COVID-19, including its incubation period, modes of transmission, clinical presentation, and diagnosis. It then discusses the relationship between diabetes and viral infections in general, and explores some potential pathophysiological mechanisms linking COVID-19 and diabetes. The review suggests chronic inflammation, immune dysfunction, and direct pancreatic damage as possible underlying factors. It notes that more research is needed to fully understand this relationship and its clinical implications.
This thesis examines the impact of climate change on Sámi youth wellbeing and cultural continuity in Kautokeino, Norway. Interviews were conducted with Sámi adolescents, community members, and leaders. The results suggest that climate change is negatively impacting traditional Sámi culture and reindeer herding. It is causing difficulties for teaching traditional knowledge to younger generations and changing seasonal patterns that Sámi culture depends on. Climate change is also increasing stress levels and risks to mental health among Sámi youth. Adaptation strategies are needed to address these challenges and ensure the intergenerational transmission of Sámi culture and language.
Nutrition for the ageing brain: Towards evidence for an optimal dietNutricia
This article reviews the latest research on nutrition and cognitive aging. It discusses normal and pathological cognitive decline in aging. Several key mechanisms of brain aging are explored, including oxidative stress, neuroinflammation, and autophagy. The review examines the potential for specific nutrients and dietary patterns to prevent cognitive decline through these mechanisms. While some studies link nutrients like polyphenols, flavonoids, vitamins and omega-3 fatty acids to cognitive benefits, the research is inconsistent and more work is needed to determine optimal doses and relationships between diet and brain health in older adults.
This review article summarizes research on the impact of coffee consumption on health. It finds that coffee contains several bioactive compounds like caffeine, chlorogenic acids, and diterpenes. While caffeine can increase blood pressure short-term, coffee drinking appears to reduce the risk of cardiovascular diseases like heart disease and stroke. Coffee is also associated with a reduced risk of type 2 diabetes and liver disease. The effects of coffee on cancer risk depend on the specific cancer type, but coffee drinking may lower overall cancer risk and mortality. However, the clinical evidence comes mostly from observational studies rather than randomized trials.
The document discusses malignant hyperthermia, a rare genetic condition triggered by certain anesthetic agents. It can cause a severe hypermetabolic state and muscle rigidity. If not rapidly treated, it can result in death from complications like cardiac arrest or brain damage. The document outlines strategies for preventing and treating malignant hyperthermia in the operating room, including having emergency supplies and medication available, monitoring patients closely, and educating staff on treatment protocols.
C13 nice type 2 diabetes in adults management 2015Diabetes for all
This document provides guidelines for managing type 2 diabetes in adults. It focuses on patient education, dietary advice, managing cardiovascular risk factors like blood pressure, managing blood glucose levels, and treating long-term complications. The guidelines were updated in 2015 and replace several previous NICE guidelines on type 2 diabetes. Proper management of type 2 diabetes is complex and requires lifestyle changes, medical therapy, and involvement of multiple areas of healthcare to help control blood glucose and reduce health risks.
This document provides guidelines for the management of cardiovascular diseases during pregnancy from the European Society of Cardiology (ESC). It was developed by an international task force and endorsed by several societies. The guidelines cover epidemiology, physiological adaptations during pregnancy, pre-pregnancy counseling, cardiovascular diagnosis and testing considerations in pregnancy, genetic testing, fetal assessment, interventions in mothers, timing and mode of delivery, postpartum care, breastfeeding, and infective endocarditis management. The goal is to provide recommendations to optimize outcomes for both maternal and fetal health in women with heart disease who are pregnant or wish to become pregnant.
2018 esc guidelines for the management of cardiovascular disease during pregn...Vinh Pham Nguyen
This document provides guidelines for the management of cardiovascular diseases during pregnancy published by the European Society of Cardiology (ESC) in 2018. It was developed by an international task force and provides recommendations on risk assessment, diagnosis, treatment and management for a variety of heart conditions that may occur during pregnancy. The guidelines reflect recent advances and aim to improve outcomes for both mothers and infants.
Foodborne disease and food control in the gulf states reviewchoi khoiron
The document discusses foodborne disease and food control challenges in Gulf States, including Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and the United Arab Emirates. It notes that these states have transitioned rapidly from subsistence communities to modern states through oil revenues. Fresh water scarcity is a major issue as rainfall does not meet demands, forcing reliance on desalination. Food imports satisfy expanding populations, especially foreign workers who comprise over half of residents. Gastrointestinal diseases can enter through workers or refugees, while some illnesses are endemic. Government agencies work to oversee restaurants and food safety but surveillance systems need improvement. As long as resources continue, food control will likely progress over time in these Gulf States.
This review discusses microRNA-based therapeutic strategies for breast cancer. It begins by describing various microRNAs (miRNAs) that are involved in breast cancer development and progression, including oncogenic miRNAs that promote cell motility, proliferation, and other processes, as well as tumor suppressor miRNAs that inhibit metastasis, proliferation, and induce apoptosis. The review then discusses different therapeutic approaches to regulate miRNAs, including nucleic acid-based methods to replace or inhibit miRNAs, and drug-based strategies that interact with miRNAs. The review focuses on miR-21 and miR-34 as particularly promising targets for RNA-based therapy in non-invasive and invasive breast cancer, respectively. It concludes by highlighting relevant commercialized therapeutic strategies and approaches using nanotechnology
Changing Diets, Changing Minds: How Food Affects Mental Wellbeing and BehaviourGeoAnitia
This document discusses the relationship between diet and mental well-being. It acknowledges the high cost of mental illness and explores the role that food plays in affecting mental health. The report examines the science behind how nutrients physically impact brain structure and function, such as how proteins, fats, carbohydrates and micronutrients are used by the brain. It analyzes how nutrition at different life stages, from prenatal to older age, can influence brain development and mental well-being. The report provides an overview of this emerging area and argues that diet is an important consideration for mental health.
Innovation and Diversification Policies for Natural RLaticiaGrissomzz
Innovation and Diversification Policies
for Natural Resource Rich Countries
Mueid Al Raee
UNU MERIT, UM MGSoG
Supervisors
Professor Jo Ritzen
Dr. Denis de Crombrugghe
2
3
Contents
1. Introduction .................................................................................................................... 7
Appendix 1-A ................................................................................................................... 16
2. Productivity and Innovation Policy .............................................................................. 19
2.1. Introduction ........................................................................................................... 20
2.2. Innovation policies and the path towards successful innovation ............................ 24
2.3. Identification Strategy ........................................................................................... 29
2.4. Data ...................................................................................................................... 32
2.5. Results ................................................................................................................... 36
2.5.1. Global ............................................................................................................. 36
2.5.2. Arabian Gulf countries - A special case? ........................................................ 42
2.6. Conclusions and Discussion ................................................................................... 45
Appendix 2-A ................................................................................................................... 49
Appendix 2-B ................................................................................................................... 50
3. Policy and Economy in the GCC .................................................................................. 53
3.1. Introduction ........................................................................................................... 55
3.2. Perspectives on innovation .................................................................................... 59
3.2.1. General ........................................................................................................... 59
3.2.2. The literature on GCC countries .................................................................... 61
3.3. The Case of GCC – Policies and Enablers ............................................................ 68
3.3.1. Section Summary ............................................................................................ 68
3.3.2. Development of education systems ................................................................. 71
3.3.3. Literacy, primary education, secondary education, reforms and performance 72
3.3.4. Tertiary education and vocational education ......................... ...
This document provides guidelines for HIV prevention, diagnosis, treatment, and care for key populations. It summarizes the methodology used to develop the guidelines, which included establishing expert groups, reviewing evidence, and developing recommendations. The guidelines cover a comprehensive package of interventions for key populations, including health sector interventions like prevention, testing, treatment, and management of coinfections. It also addresses critical enablers of effective responses like reducing stigma and discrimination, and supportive laws and policies. The target audience is those involved in HIV responses for key populations.
Consolidated guidelines on HIV prevention, diagnosis, treatment and care for ...clac.cab
This document provides guidelines for HIV prevention, diagnosis, treatment, and care for key populations. It summarizes the methodology used to develop the guidelines, which included establishing expert groups, reviewing evidence, and developing recommendations. The guidelines cover a comprehensive package of interventions for key populations, including health sector interventions like prevention, testing, treatment, and management of coinfections. It also addresses critical enablers of effective responses like addressing legal barriers and reducing stigma and discrimination. The target audience is those involved in HIV responses for key populations.
This document is a medical manual for the Royal Adelaide Hospital Intensive Care Unit from 2012. It provides information on administration, clinical procedures, drugs and infusions for ICU staff. The manual aims to standardize patient management through protocols and guidelines derived from evidence and experience. It contains sections on staffing, admission/discharge policies, documentation, consent, ward rounds, clinical duties, procedures, cardiovascular and respiratory drugs, sedation, and more. The director notes that while aiming for accuracy, errors may exist and staff should notify the duty consultant of any issues.
This document provides the 2005 Dietary Guidelines for Americans. It is intended to advise policymakers, nutrition educators, and health professionals on recommendations for healthy eating based on the latest scientific evidence. The guidelines emphasize choosing a nutritious diet within calorie needs, achieving and maintaining a healthy weight, being physically active, eating from key food groups, and following food safety practices. They are designed to help Americans live longer, healthier lives.
This review article summarizes the 2011 evidence-based practice guideline published by the American Society of Hematology for the diagnosis and treatment of immune thrombocytopenia (ITP). The guideline was created using a rigorous evidence-based approach and provides treatment recommendations using the GRADE system where evidence exists. It identifies a lack of evidence in several key areas of ITP therapy, such as comparative studies of front-line therapies and management of bleeding. The guideline covers diagnosis and treatment of ITP in both children and adults, including recommendations for initial treatment, management of non-responders, treatment of specific secondary forms of ITP, and treatment during pregnancy.
Two types of acute diarrhoeal emergencies are cholera, which causes acute watery diarrhoea, and Shigella dysentery, which causes acute bloody diarrhoea. Both are transmitted through contaminated water, food, hands, and vomit or stool of sick individuals. The first steps in managing a diarrhoeal outbreak are determining if there are an unusual number of similar cases, identifying whether patients have cholera or Shigella by their symptoms, and being prepared for a potential increase in cases.
The document provides guidelines for diabetic eye care developed by the International Council of Ophthalmology (ICO). It aims to improve eye care quality worldwide by addressing screening and management of diabetic retinopathy for different resource settings. The guidelines describe classifying and screening for diabetic retinopathy, detailed eye exams, treating retinopathy and macular edema, and managing special circumstances. It includes tables outlining follow-up schedules and treatment recommendations based on retinopathy severity and resource level.
This document discusses special considerations for managing chronic myeloid leukemia (CML) during pregnancy and in the pediatric population. For pregnancy:
- Tyrosine kinase inhibitors (TKIs) used to treat CML are teratogenic and known to cause fetal toxicities. TKI therapy during pregnancy has been associated with higher rates of miscarriage and fetal abnormalities.
- If a patient wants to conceive, discontinuing TKI therapy may be considered if a deep molecular response has been maintained for at least 2 years. Close monitoring would be needed if CML recurs during pregnancy.
- For pediatric CML management, no evidence-based recommendations exist since CML is relatively rare in children. Specialized care at a cancer center is
This document discusses several minor blood group systems beyond ABO and Rh, including I/i, Lewis, P, MN, and SsU. It provides details on the antigens and antibodies in each system, including frequencies, clinical significance, and serological characteristics. The key points are:
- Over 500 antigens beyond ABO have been identified on red blood cells.
- The I/i, Lewis, P, MN, and SsU systems involve antigens that are inherited based on allelic genes and their interactions.
- Antibodies in these systems are usually naturally occurring and clinically insignificant, though some like anti-S, anti-s, and anti-U can cause hemolytic disease of the new
This document provides a focused update to the 2013 ACCF/AHA guidelines for the management of heart failure. It was developed by a writing group comprised of experts from the ACC, AHA, HFSA, and other organizations. The update provides new recommendations on the use of biomarkers for diagnosis and prognosis of heart failure as well as for treatment of stages A through D. It also includes new recommendations on treating anemia, hypertension, and sleep disordered breathing in heart failure patients. The update was reviewed and approved by several committees and is intended to provide guidance for clinicians on best practices in heart failure management.
These guidelines provide recommendations for managing dyslipidemia and preventing cardiovascular disease. They were developed by a writing committee and task force of experts based on reviews of current literature. The guidelines note that medical decisions should be made using clinical judgment and local resources, as rapid changes in the field may lead to periodic revisions. The document aims to assist healthcare professionals while not replacing their independent judgment.
This document provides an overview of the process and methods used to develop recommendations for the testing, management, and treatment of hepatitis C virus (HCV) infection. A panel of HCV experts from various medical fields develops the guidance using an evidence-based approach. Recommendations are rated based on the strength of evidence. The guidance is intended to be a living document that is regularly updated as new treatments and information become available. Strict processes are in place to manage conflicts of interest among panel members.
This document provides information on drugs that are contraindicated (Pregnancy Category X) for use during pregnancy. It lists the generic and brand names of drugs across several therapeutic categories including cardiovascular, dermatological, gastrointestinal, infections/infestations, musculoskeletal, neoplasms, nutrition, OB/GYN, pain/pyrexia, respiratory, and urogenital systems. For some drugs, it specifies the trimester or stage of pregnancy during which they should be avoided. The document also explains the pregnancy categories (A, B, C, D, X) used to qualify contraindications and precautions for drug use during pregnancy.
Muslims believe that death comes by divine decree and marks the beginning of an eternal journey in the afterlife. Some terminally ill Muslim patients receive care in intensive care units that prolong their lives through significant medical intervention when they may instead suffer without meaningful benefit. There is limited information available about Islamic beliefs regarding end of life issues for Muslims living in non-Muslim countries. Withdrawal of futile treatment is permitted in Islamic law for terminally ill patients to allow death to take its natural course. "Do not resuscitate" orders are also permitted in certain situations according to Islamic rulings if three physicians agree treatment would be non-beneficial. However, hydration and pain management should continue until death.
This document reviews recent guidelines for treating painful diabetic neuropathy (DPN) and compares their recommendations. It finds that the main drug classes recommended as first-line treatment are anticonvulsants like pregabalin and gabapentin, antidepressants like tricyclic antidepressants and duloxetine, and opioids. Pregabalin and duloxetine are the only drugs approved to treat neuropathic pain in diabetes. The guidelines differ in their methodologies, with some based more quantitatively on clinical trial evidence while others incorporate additional factors. Patient characteristics may also influence which treatment is most appropriate.
This document provides guidance from NICE on the assessment and treatment of acute stroke. It outlines recommendations for promptly admitting patients to specialist stroke units, performing brain imaging, providing thrombolysis or mechanical clot retrieval if appropriate, administering antiplatelets or anticoagulants, managing blood pressure and blood sugar, assessing swallowing function and providing nutrition, and carrying out carotid imaging and endarterectomy if indicated. The pathway is designed to optimize stroke care from initial presentation through the acute and subacute phases of recovery.
1) A randomized clinical trial of 576 adults with acute sore throat found that a single dose of oral dexamethasone did not increase the proportion of patients with complete resolution of symptoms at 24 hours compared to placebo.
2) However, at 48 hours significantly more patients in the dexamethasone group experienced complete resolution of symptoms than those in the placebo group.
3) The study found no other significant differences between the dexamethasone and placebo groups in secondary outcomes such as duration of symptoms, health care use, time off work, or medication use.
This document provides guidelines for managing diabetes during Ramadan fasting. It was created by the International Diabetes Federation and Diabetes and Ramadan International Alliance. The guidelines cover epidemiology of diabetes during Ramadan, physiology of fasting and how it impacts diabetes, risk stratification of patients, education recommendations, and medication adjustments for various diabetes medications and high-risk patient groups, such as those with type 1 diabetes. The goal is to enhance healthcare professionals' knowledge to best support patients during Ramadan fasting.
May-Hegglin anomaly is part of a spectrum of disorders called MYH9-related disease. Mutations in the MYH9 gene cause macrothrombocytopenia (low platelet count with large platelets) and basophilic inclusions in white blood cells. A diagnosis can be facilitated by platelet electron microscopy and MYH9 gene sequencing. While each disorder in the spectrum has some unique characteristics, they are all characterized by macrothrombocytopenia and are now considered manifestations of MYH9-related disease.
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
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NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Cell Therapy Expansion and Challenges in Autoimmune DiseaseHealth Advances
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
Despite these headwinds, industry leaders and investors remain confident that cell therapies are poised to address significant unmet need in patients suffering from autoimmune disorders. However, the extent of this impact on the treatment landscape remains to be seen, as the industry rapidly approaches an inflection point.
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Here is the updated list of Top Best Ayurvedic medicine for Gas and Indigestion and those are Gas-O-Go Syp for Dyspepsia | Lavizyme Syrup for Acidity | Yumzyme Hepatoprotective Capsules etc
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
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Vestibulocochlear Nerve by Dr. Rabia Inam Gandapore.pptx
Diabetes and Ramadan
1. Invited review
Diabetes and Ramadan: Practical guidelines
Mohamed Hassanein a,*, Monira Al-Arouj b
, Osama Hamdy c
,
Wan Mohamad Wan Bebakard
, Abdul Jabbar e
, Abdulrazzaq Al-Madani f
, Wasim Hanif g
,
Nader Lessan h
, Abdul Basit i
, Khaled Tayeb j
, MAK Omar k
, Khalifa Abdallah l
,
Abdulaziz Al Twaim m
, Mehmet Akif Buyukbese n
, Adel A. El-Sayed o
,
Abdullah Ben-Nakhi b
, On behalf of the International Diabetes Federation (IDF),
in collaboration with the Diabetes and Ramadan (DAR) International Alliance
a
Dubai Hospital, Dubai Health Authority, Dubai, United Arab Emirates
b
Dasman Diabetes Institute, Kuwait City, Kuwait
c
Joslin Diabetes Center, Boston, MA, USA
d
School of Medical Sciences, Universiti Sains Malaysia, Hospital Universiti Sains Malaysia, Kota Bharu, Malaysia
e
Aga Khan University, Karachi, Pakistan
f
President of Emirates Diabetes Society, Dubai, United Arab Emirates
g
University Hospital Birmingham, Birmingham, UK
h
Imperial College London Diabetes Centre, Abu Dhabi, United Arab Emirates
i
Baqai Institute of Diabetology & Endocrinology, Baqai Medical University, Karachi, Pakistan
j
Diabetes Center, Al-Noor Hospital, Makkah, Saudi Arabia
k
Nelson R Mandela School of Medicine, University of KwaZulu Natal, Durban, South Africa
l
Alexandria University, Alexandria, Egypt
m
King Abdulaziz Medical City, National Guard Hospital, Western Region, Saudi Arabia
n
NCR International Hospital, Gaziantep, Turkey
o
Chair of Diabetes Unit, Department of Internal Medicine, Sohag Faculty of Medicine, Sohag University, Egypt
A R T I C L E I N F O
Article history:
Received 1 March 2017
Accepted 6 March 2017
Available online 12 March 2017
Keywords:
Diabetes
Dosing
Fasting
Guidelines
Ramadan
A B S T R A C T
Ramadan fasting is one of the five pillars of Islam and is compulsory for all healthy Mus-
lims from puberty onwards. Exemptions exist for people with serious medical conditions,
including many with diabetes, but a large number will participate, often against medical
advice. Ensuring the optimal care of these patients during Ramadan is crucial. The Interna-
tional Diabetes Federation (IDF) and Diabetes and Ramadan (DAR) International Alliance
have come together to deliver comprehensive guidelines on this subject. The key areas cov-
ered include epidemiology, the physiology of fasting, risk stratification, nutrition advice
and medication adjustment. The IDF-DAR Practical Guidelines should enhance knowledge
surrounding the issue of diabetes and Ramadan fasting, thereby empowering healthcare
professionals to give the most up-to-date advice and the best possible support to their
patients during Ramadan.
Ó 2017 The Authors. Published by Elsevier Ireland Ltd. This is an open access article under the
CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
http://dx.doi.org/10.1016/j.diabres.2017.03.003
0168-8227/Ó 2017 The Authors. Published by Elsevier Ireland Ltd.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
* Corresponding author.
E-mail address: mhassanein148@hotmail.com (M. Hassanein).
d i a b e t e s r e s e a r c h a n d c l i n i c a l p r a c t i c e 1 2 6 ( 2 0 1 7 ) 3 0 3 – 3 1 6
Contents available at ScienceDirect
Diabetes Research
and Clinical Practice
journal homepage: www.elsevier.com/locate/diabres
2. Contents
1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 304
2. Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305
3. Physiology of Ramadan fasting and diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305
4. Risk stratification of individuals with diabetes during Ramadan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 306
5. Pre-Ramadan education. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 306
6. Diabetes management during Ramadan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 308
6.1. Pharmacological management of people with T2DM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309
6.1.1. Metformin and a-glucosidase inhibitors (acarbose) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309
6.1.2. Thiazolidinediones (TZD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309
6.1.3. Short-acting insulin secretagogues (meglitinides) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309
6.1.4. Sulphonylureas (SU) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 310
6.1.5. Sodium-glucose co-transporter-2 (SGLT2) inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 310
6.1.6. Dipeptidyl peptidase-4 (DPP-4) inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311
6.1.7. Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 312
6.1.8. Insulin treatment for T2DM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 312
6.2. Pharmacological management of high risk populations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313
6.2.1. Adults with T1DM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313
6.2.2. Young adults/adolescents with T1DM. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313
6.2.3. Pregnant women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313
7. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313
Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 314
Author contributions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 314
Conflict of interest statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 314
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 314
Appendix A. Supplementary material . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 314
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 314
1. Introduction
Fasting during Ramadan is one of the five pillars of Islam and
is obligatory for all healthy adult Muslims. Within the Muslim
community, there is an intense desire to participate in fast-
ing, even among those who are eligible for exemption. The
timing of Ramadan is based on the lunar calendar (355 days
per year), which means that the start of Ramadan varies from
year to year. In some parts of the world, daylight can last up to
20 h in the peak of summer. Climate conditions also vary
according to the date of Ramadan, with people fasting in very
dry and hot weather some years.
Some regions with a high Muslim population, including
the Middle East, Africa and South East Asia, are expected to
see the number of patients with diabetes more than double
in the next 25 years [1]. The Epidemiology of Diabetes and
Ramadan (EPIDIAR) study performed in 2001 found that
42.8% and 78.7% of patients with Type 1 or Type 2 diabetes
mellitus (T1DM/T2DM), respectively, fasted for at least 15 days
during Ramadan [2]. More recently, the CREED study reported
that 94.2% of T2DM patients fasted for at least 15 days and
63.6% fasted every day [3].
For fasting Muslims, the onset of Ramadan heralds a sud-
den shift in meal times and sleep patterns. This has impor-
tant implications for physiology, with ensuing changes in
the rhythm and magnitude of fluctuations in several homeo-
static and endocrine processes. Sleeping patterns are often
altered during Ramadan and several circadian rhythm
changes have been noted, including changes in body temper-
ature and cortisol levels [4–7]. When fasting, insulin resis-
tance/deficiency can lead to excessive glycogen breakdown
and increased gluconeogenesis in patients with diabetes, as
well as ketogenesis in patients with T1DM. As a result, the
risks facing patients with diabetes, including hypoglycaemia,
hyperglycaemia, diabetic ketoacidosis, dehydration and
thrombosis, are heightened during Ramadan [8].
Ramadan fasting, therefore, represents a challenge to both
patients and healthcare professionals (HCPs). Existing recom-
mendations on the management of people with diabetes who
fast during Ramadan are mostly based on expert opinion
rather than evidence gained from clinical studies. With so
many Muslims with diabetes choosing to fast and with the
numbers predicted to rise sharply over the coming years,
there is an immediate requirement for evidence-based practi-
cal management guidelines. The International Diabetes
Federation (IDF) and the Diabetes and Ramadan (DAR)
International Alliance have come together to deliver compre-
hensive guidance on this subject. The IDF-DAR Practical Guide-
lines provide HCPs with relevant background information and
practical recommendations, allowing them to deliver the best
possible care and support to patients with diabetes during
Ramadan, while minimising the risk of complications.
304 d i a b e t e s r e s e a r c h a n d c l i n i c a l p r a c t i c e 1 2 6 ( 2 0 1 7 ) 3 0 3 –3 1 6
3. 2. Methods
The IDF and DAR International Alliance invited recognised
experts in the field to develop joint practical guidelines for
the management of diabetes during Ramadan. This panel
met on several occasions, and extensive literature searches
for studies related to diabetes and Ramadan fasting were con-
ducted. Relevant publications were identified and results
from pertinent clinical studies (see supplementary informa-
tion for details) were used to develop the recommendations
outlined in this article. Where evidence was missing, expert
opinion was agreed upon. The full version of these IDF-DAR
Practical Guidelines are available for free download on the web-
sites of the IDF (http://www.idf.org/guidelines/diabetes-in-
ramadan) and the DAR International Alliance (http://
www.daralliance.org/daralliance/).
3. Physiology of Ramadan fasting and
diabetes
As a result of daylight fasting, the time between meals during
Ramadan is much longer than at other times of the year, and
sleep patterns often change. The physiological impact of such
changes is most marked when Ramadan falls during the
longer summer days in countries at higher latitudes.
Typically, sleep is broken before dawn to enable Muslims to
eat before fasting begins (suhoor) [5]. Many will return to
sleep afterwards and wake for a second time to start the
day, and some may sleep in the afternoon. Following the
evening meal (iftar), many Muslims stay awake late into the
night. Although the physiological relevance of these sleep
changes is unknown, there is evidence to suggest that glucose
intolerance and insulin resistance may be linked to sleep
Fig. 1 – Mean continuous glucose monitoring profiles before and during Ramadan in healthy subjects (A) and patients with
diabetes (B) [14].
d i a b e t e s r e s e a r c h a n d c l i n i c a l p r a c t i c e 1 2 6 ( 2 0 1 7 ) 3 0 3 –3 1 6 305
4. deprivation [9–11]. Shifts in cortisol circadian rhythm have
been observed during Ramadan fasting [7], which may be
partly responsible for the feeling of lethargy felt by some Mus-
lims during Ramadan. Hunger rating increases progressively
during fasting hours and can be intense by iftar time [12].
Interestingly, as Ramadan progresses, this tends to be less
severe in women compared with men [12].
Fasting can result in excessive glycogenolysis and gluco-
neogenesis in individuals with T1DM or T2DM, and increased
ketogenesis in those with T1DM [13]. As a consequence, indi-
viduals with diabetes are at increased risk of hypoglycaemia,
hyperglycaemia and diabetic ketoacidosis (DKA) [8]. A contin-
uous glucose monitoring (CGM) study before and during
Ramadan found a remarkable stability of blood glucose dur-
ing fasting hours in healthy subjects, followed by a minimal
rise in blood glucose at iftar (Fig. 1A) [14]. However, major
intra- and inter-individual variability in CGM profiles were
observed in patients with diabetes. A rapid rise in glucose
level after iftar was seen (Fig. 1B), most probably due to the
carbohydrate-rich foods typically taken at this meal [14].
Ramadan fasting can be associated with favourable physi-
ological changes among healthy individuals, such as
decreased body weight and beneficial changes in lipid profile
[15]. The picture is not so clear for individuals with diabetes
and the risks posed by the pathophysiology that disrupts nor-
mal glucose homeostatic mechanisms need further studies.
4. Risk stratification of individuals with
diabetes during Ramadan
The principal risks for people with diabetes who participate in
Ramadan are hypoglycaemia, hyperglycaemia, DKA, dehydra-
tion and thrombosis. The EPIDIAR study recorded higher rates
of severe hypoglycaemia in people with T1DM or T2DM dur-
ing Ramadan compared with before Ramadan (4.7-fold and
7.5-fold increases, respectively) [2]. Hyperglycaemia incidence
increased 5-fold among patients with T2DM [2]. A study in
Pakistan, carried out by Ahmedani et al., found that of the
388 patients with diabetes who chose to fast, symptomatic
hypoglycaemia was reported by 35.3% and 23.2% of patients
with T1DM and T2DM, respectively, and symptomatic hyper-
glycaemia by 33.3% and 15.4%, respectively [16]. Lower figures
were observed in the CREED study, where only 8.8% of
patients with T2DM reported a hypoglycaemic event; a major-
ity of these episodes, however, required further assistance or
breaking of the fast [3]. In another study, the rate and duration
of hospital admission for DKA during Ramadan and the fol-
lowing month (Shawal) were higher than the average monthly
rate over the preceding six months. Many of those with DKA
during Ramadan had experienced DKA in the previous few
months [17].
Taking all these risks into account, it is easy to see why
religious regulations, as well as medical recommendations,
allow exemption from fasting for some people with diabetes
[8,18,19]. However, for many such individuals, fasting is a dee-
ply spiritual experience and they will insist on taking part,
perhaps unaware of the risks they are taking. HCPs caring
for these patients must be conscious of the potential dangers
and should quantify and stratify the risks for every patient
individually in order to provide the best possible care. Safety
of fasting is paramount and various elements should be con-
sidered when quantifying the risk for such patients, such as
type of diabetes, type of medication, presence of comorbidi-
ties and personal circumstances [18]. These factors will vary
for each patient, emphasising the need for an individualised
approach.
The 2005 American Diabetes Association (ADA) recom-
mendations for management of diabetes during Ramadan,
and its 2010 update, categorised people with diabetes into
four risk groups (very high risk, high risk, moderate risk and
low risk) [8,18]. The CREED study reported that 62.6% of physi-
cians referred to guidelines for the management of fasting
and, of these, the majority were using the ADA recommenda-
tions [3]. Surprisingly, the numbers of days fasted by the high-
est and the lowest risk groups only varied by 3 days,
indicating that either these risk categories are not efficiently
applied by HCPs or people with diabetes are ignoring medical
recommendations. A recent survey of nearly 200 physicians,
mainly from the Middle East and North Africa, revealed that
not all high risk categories were identified by those providing
care to patients with diabetes during Ramadan [20].
The IDF-DAR Practical Guidelines propose three categories of
risk, based on the most recent available information from
science and clinical practice during Ramadan fasting (Table 1).
These risk categories take into account a more practical
approach while recognising the need to consider the everyday
practice of many people with diabetes. Importantly, these rec-
ommendations have been approved by the Mofty of Egypt, the
highest religious regulatory authority in Egypt. Religious opin-
ion on fasting for each of the three categories is included in
the risk stratification table (Table 1). All patients are
instructed to follow medical advice and should not fast if
the probability of harm is high. It should be noted that this
opinion may not reflect the religious rulings in all countries,
therefore further regional discussions are needed. These rec-
ommendations also include some essential conditions that
need to be fulfilled by those who are considered high risk
but choose to fast against medical/religious advice.
Patients who are in the two highest categories of IDF-DAR
risk should not fast; however, as previously mentioned, many
of these patients will choose to do so. These patients need to
be aware of the risks associated with fasting, and of tech-
niques to decrease this risk. Those patients stratified to the
moderate/low risk category may be able to fast if both HCP
and patient agree, but appropriate advice and support must
be provided to ensure safety. Once a patient has been made
aware of the risks, they should be offered an individualised
management plan and be advised on the measures they can
take to minimise these risks, as listed in Table 1.
5. Pre-Ramadan education
Ramadan-focused diabetes education is centred around
empowering patients with the knowledge to make informed
decisions regarding how to manage their condition during
Ramadan. The key components are risk quantification, blood
glucose monitoring, nutritional advice, exercise advice, med-
ication adjustments and knowing when to break the fast to
306 d i a b e t e s r e s e a r c h a n d c l i n i c a l p r a c t i c e 1 2 6 ( 2 0 1 7 ) 3 0 3 –3 1 6
5. Table 1 – IDF-DAR risk categories and recommendations for patients with diabetes who fast during Ramadan.
Risk category and religious opinion
on fastinga
Patient characteristics Comments
Category 1: very high risk One or more of the following:
Severe hypoglycaemia within the 3 months prior to Ramadanb
Unexplained DKA within the 3 months prior to Ramadan
Hyperosmolar hyperglycaemic coma within the 3 months prior to
Ramadan
History of recurrent hypoglycaemia
History of hypoglycaemia unawareness
Poorly controlled T1DM
Acute illness
Pregnancy in pre-existing diabetes, or GDM treated with insulin or SUs
Chronic dialysis or CKD stage 4 5
Advanced macrovascular complications
Old age with ill health
If patients insist on fasting, then they should:
Receive structured education
Be followed by a qualified diabetes team
Check their blood glucose regularly (SMBG)
Adjust medication dose as per recommendations
Be prepared to break the fast in case of hypo- or
hyperglycaemia
Be prepared to stop the fast in case of frequent hypo- or
hyperglycaemia or worsening of other related medical
conditions
Listen to medical advice
MUST NOT fast
Category 2: high risk One or more of the following:
T2DM with sustained poor glycaemic controlc
Well-controlled T1DM
Well-controlled T2DM on MDI or mixed insulin
Pregnant T2DM or GDM controlled by diet only or metformin
CKD stage 3
Stable macrovascular complications
Patients with comorbid conditions that present additional risk factors
People with diabetes performing intense physical labour
Treatment with drugs that may affect cognitive function
Listen to medical advice
Should NOT fast
Category 3: moderate/low risk Well-controlled T2DM treated with one or more of the following:
o Lifestyle therapy
o Metformin
o Acarbose
o Thiazolidinediones
o Second-generation SUs
o Incretin-based therapy (DPP-4 inhibitors or GLP-1 RAs)
o SGLT2 inhibitors
o Basal insulin
Patients who fast should:
Receive structured education
Check their blood glucose regularly (SMBG)
Adjust medication dose as per recommendations
Listen to medical advice
Decision to use licence not to fast
based on discretion of medical
opinion and ability of the individual
to tolerate fast
CKD, chronic kidney disease; DAR, Diabetes and Ramadan International Alliance; DKA, diabetic ketoacidosis; DPP-4, dipeptidyl peptidase-4; GDM, gestational diabetes mellitus; GLP-1 RA, glucagon-
like peptide-1 receptor agonist; IDF, International Diabetes Federation; MDI, multiple dose insulin; SGLT2, sodium-glucose co-transporter-2; SMBG, self-monitoring of blood glucose; SU; sulpho-
nylurea; T1DM, Type 1 diabetes mellitus; T2DM, Type 2 diabetes mellitus.
a
In all categories, people with diabetes should follow medical opinion if the advice is not to fast due to high probability of harm.
b
Hypoglycaemia that is not due to accidental error in insulin dose.
c
The level of glycaemic control is to be agreed upon between doctor and patient according to a multitude of factors.
diabetesresearchandclinicalpractice126(2017)303–316307
6. minimise acute complications. Ramadan-focused diabetes
education has been shown to be effective in reducing the inci-
dence of hypoglycaemic events. The Ramadan Education and
Awareness in Diabetes (READ) study demonstrated a signifi-
cant decrease in the number of hypoglycaemic events in a
group of patients with T2DM that received diabetes education
(from nine events pre-Ramadan to just five during Ramadan)
compared with an increase (from nine to 36 events) in a con-
trol group that did not receive the educational advice
(p 0.001) [21]. The impact of an educational programme on
the occurrence of diabetes complications during Ramadan
was also assessed in the Ramadan Diabetes Prospective study,
which revealed a downward trend in symptomatic hypogly-
caemic episodes from week 1 to week 4, with only one patient
experiencing a severe hypoglycaemic event [22]. Self-
monitoring of blood glucose (SMBG) is essential for high risk
patients that choose to fast and it should be emphasised that
testing does not invalidate religious fast. SMBG should be per-
formed multiple times during the day and, most importantly,
whenever symptoms of hypoglycaemia or acute illness occur
(Fig. 2). Patients should break the fast if blood glucose is
70 mg/dL (3.9 mmol/L) or 300 mg/dL (16.7 mmol/L) and
should not fast if they feel unwell [23]. Low risk patients also
need to perform SMBG at the following times: pre-suhoor,
midday, pre-iftar and whenever symptoms of hypoglycaemia
or acute illness occur [23].
During Ramadan, there is a dramatic change in eating pat-
terns compared with other months of the year. Dietary rec-
ommendations should be individualised and tailored to
patients’ lifestyle requirements, age, comorbidities and other
medical needs [24]. This makes dietary advice critically
important in the pre-Ramadan assessment. Accordingly, the
DAR International Alliance has developed the Ramadan
Nutrition Plan (RNP), a web-based tool designed to help HCPs
in delivering patient-specific medical nutrition therapy (MNT)
during Ramadan fasting (http://www.daralliance.org/daral-
liance/). Cultural and regional differences can make it chal-
lenging for HCPs to deliver individualised patient-applicable
dietary advice. To assist in this regard, the RNP includes meal
plans for different countries and in different languages. Meal
plans are categorised in several daily caloric targets (Fig. S1
supplementary information). This may aid HCPs and patients
to plan daily meals with the aim of maintaining body weight
if they are lean, or reducing body weight if they are over-
weight or obese. The RNP has been adopted for use in many
countries and it may allow patients with limited access to
HCPs to construct a healthy eating plan for Ramadan. More
details on RNP, the importance of MNT, avoidance of weight
gain and construction of a balanced dietary plan during
Ramadan are provided in the full version of the IDF-DAR Prac-
tical Guidelines.
6. Diabetes management during Ramadan
All patients with diabetes wishing to fast should have a pre-
Ramadan assessment with their HCP, ideally 6–8 weeks before
the start of Ramadan. This allows enough time to review the
patient’s medical history, stratify the risk of fasting and
develop a Ramadan management plan. The physician must
assess the patient’s glycaemic control, risk of hypoglycaemia
Fig. 2 – Recommended timings to check blood glucose levels during Ramadan fasting.
308 d i a b e t e s r e s e a r c h a n d c l i n i c a l p r a c t i c e 1 2 6 ( 2 0 1 7 ) 3 0 3 –3 1 6
7. and self-management capabilities, and ultimately advise the
patient on whether to fast or to seek exemption. A proposed
patient assessment flowchart can be found in Fig. 3.
6.1. Pharmacological management of people with T2DM
A cornerstone of a Ramadan individualised management plan
is therapeutic modification. The type of medication the
patient is taking for diabetes management influences the
potential risks that fasting may cause and needs careful
attention within the plan. The following sections review the
available evidence for the use of medication during Ramadan
in patients with T2DM and use it to generate evidence-based
recommendations regarding treatment and any dose adjust-
ments that may be required. A summary of the recommenda-
tions for non-insulin therapies and insulin can be found in
Figs. 4 and 5, respectively. Details of all studies reviewed in
this section can be found in supplementary information
(Table S1).
6.1.1. Metformin and a-glucosidase inhibitors (acarbose)
Severe hypoglycaemia in non-fasting patients receiving met-
formin and/or acarbose is rare. There are no randomised con-
trolled trials (RCTs) on these agents, however, metformin
and/or acarbose use in patients with T2DM during Ramadan
is considered safe. No dose modification is needed but tim-
ings should be changed depending on the frequency of dose
(Fig. 4).
6.1.2. Thiazolidinediones (TZD)
Clinical data on pioglitazone use during Ramadan is limited
to one study [25]. This study found that compared with pla-
cebo, pioglitazone significantly improved glycaemic control
during the early, mid- and post-Ramadan periods. There
was no difference in the number of hypoglycaemic events
between the two treatment groups, but a significant increase
in weight of 3.02 kg (p = 0.001) was observed in the pioglita-
zone group compared with a non-significant loss in weight
(À0.46 kg) in the placebo group [25]. No adjustment to TZD
medication is needed during Ramadan and doses can be
taken with iftar or suhoor (Fig. 4).
6.1.3. Short-acting insulin secretagogues (meglitinides)
Meglitinides such as repaglinide are usually taken before
meals. In two small observational studies, no hypoglycaemic
events were reported in patients treated with repaglinide dur-
ing Ramadan [26,27]. A third study demonstrated no differ-
ence in hypoglycaemia when compared with insulin
glargine or glimepiride, a sulphonylurea (SU) therapy [28].
Similarly, in two randomised parallel-group trials, a low
incidence of hypoglycaemic events was associated with
repaglinide treatment during Ramadan, occurring in similar
Fig. 3 – Ramadan patient assessment flowchart. HCP, healthcare professional; SMBG, self-monitoring of blood glucose.
d i a b e t e s r e s e a r c h a n d c l i n i c a l p r a c t i c e 1 2 6 ( 2 0 1 7 ) 3 0 3 –3 1 6 309
8. proportions of patients treated with glibenclamide and glime-
piride [29,30]. The short duration of action and low risk of
hypoglycaemia of these agents make them appealing for
use in Ramadan. The daily dose (based on a three-meal dos-
ing) may be reduced or redistributed to two doses (taken
before iftar and suhoor) during Ramadan, according to meal
size (Fig. 4).
6.1.4. Sulphonylureas (SU)
SUs are associated with a higher risk of hypoglycaemia com-
pared with other oral anti-diabetic drugs (OADs), which has
raised some concerns about their use during Ramadan. How-
ever, this risk varies across medications within this class due
to differing receptor interactions, binding affinities and dura-
tions of action.
In a multinational observational study of 1378 patients
with T2DM treated with SUs, approximately one-fifth of
patients experienced a symptomatic hypoglycaemic event
during Ramadan. When this was broken down by drug, the
highest incidence was associated with glibenclamide
(25.6%), followed by glimepiride (16.8%), and gliclazide
(14.0%) [31]. Glibenclamide similarly showed the highest inci-
dence of hypoglycaemic events in other studies when com-
pared with second-generation SUs [32,33] and lowering the
dose of glibenclamide did not seem to reduce the incidence
of hypoglycaemia [34]. In some studies, the proportion of
patients on gliclazide who experienced symptomatic hypo-
glycaemic events has been found to be similar to the dipep-
tidyl peptidase-4 (DPP-4) inhibitors, sitagliptin (6.6% vs. 6.7%,
respectively) or vildagliptin (6.0% vs. 8.7%, respectively), and
lower than sitagliptin in one study (1.8% vs. 3.8%, respec-
tively) [33,35,36]. The recorded incidence of hypoglycaemia
during Ramadan has also been low for glimepiride [29,37].
Data on glipizide are too sparse to provide specific advice on
its use in Ramadan.
These studies demonstrate that many patients with T2DM
may continue to use second-generation SUs and fast safely
during Ramadan. Glibenclamide should be used with caution
during Ramadan. The use of these drugs should be individu-
alised following clinician guidance, and medication adjust-
ments are outlined in Fig. 4.
6.1.5. Sodium-glucose co-transporter-2 (SGLT2) inhibitors
SGLT2 inhibitors have demonstrated effective improvements
in glycaemic control and weight loss, and are associated with
a low risk of hypoglycaemia. Because of this, these drugs
could be a safe treatment option for patients with T2DM dur-
ing Ramadan. However, certain safety concerns have been
raised, such as an increase in dehydration or postural
hypotension as well as the risk of ketoacidosis [38,39]. Cur-
rently, only one study has published data on the use of SGLT2
inhibitors during Ramadan. Patients with T2DM were ran-
domised to receive either dapagliflozin or to continue with
SU therapy. Significantly fewer patients in the dapagliflozin
group reported hypoglycaemia than in the SU arm (6.9% vs.
28.8%, respectively; p = 0.002). Incidences of postural hypoten-
sion were greater in the dapagliflozin group but did not reach
significance [40], and no increased risk of dehydration was
TZDs
No dose
modificaƟons
Dose can be taken
with iŌar or suhoor
DPP-4
inhibitors
No dose
modificaƟons
SGLT2 inhibitors
No dose modificaƟons
Dose should be taken with iŌar
Extra clear fluids should be ingested during non-fasƟng periods
Should not be used in the elderly, paƟents with renal impairment, hypotensive individuals or those taking diureƟcs
GLP-1 RAs
Once appropriate
dose ƟtraƟon has
been achieved no
further dose
modificaƟons are
needed
Meƞormin
Daily dose remains unchanged
Immediate release: OD – Take at iŌar; BID – Take at iŌar and suhoor; TID – Morning dose at suhoor, combine aŌernoon and evening
dose at iŌar
Prolonged release: Take at iŌar
SU
Switch to newer SU (gliclazide, glimepiride) where possible, glibenclamide should be avoided
OD – Take at iŌar.* Dose may be reduced in paƟents with good glycaemic control
BID – IŌar dose remains unchanged.** Suhoor dose may be reduced in paƟents with good glycaemic control
Acarbose
No dose
modificaƟons
Short-acƟng insulin secretagogues
TID dosing may be reduced/
redistributed to two doses taken
with iŌar and suhoor
Fig. 4 – Non-insulin dose modifications for patients with T2DM. *
SU combination therapy OD – take at iftar and consider
reducing the dose by 50%; **
SU combination therapy BID – omit morning dose and take normal dose at iftar. BID, twice daily;
DPP-4, dipeptidyl peptidase-4; GLP-1 RAs, glucagon-like protein-1 receptor agonists; OD, once daily; SGLT2, Sodium-glucose
co-transporter 2; SU, sulphonylurea; TID, three times a day; TZD, thiazolidinedione; T2DM, Type 2 diabetes mellitus.
310 d i a b e t e s r e s e a r c h a n d c l i n i c a l p r a c t i c e 1 2 6 ( 2 0 1 7 ) 3 0 3 –3 1 6
9. evident with dapagliflozin treatment [41]. A recent survey of
physicians’ views on the use of SGLT2 inhibitors during
Ramadan for the treatment of patients with T2DM reported
that the majority (70.6%) considered them suitable and safe
for some patients [20]. Patients deemed more at risk of com-
plications, such as the elderly, patients with renal impair-
ment, hypotensive individuals or those taking diuretics,
should not be treated with SGLT2 inhibitors. Most physicians
agreed that SGLT2 inhibitors should be taken with iftar, and
the importance of taking on extra fluids during the evening
after a fast was highlighted [20]. Due to the low risk of hypo-
glycaemia with SGLT2 inhibitors, no dose adjustment is
required (Fig. 4).
6.1.6. Dipeptidyl peptidase-4 (DPP-4) inhibitors
Four RCTs have examined the effects of switching from SU
therapy to either vildagliptin or sitagliptin prior to Ramadan
compared with continuing on SUs [31,33,36,42]. The largest
of these studies compared the incidence of self-reported
hypoglycaemic events in 1066 patients with T2DM treated
with sitagliptin or SUs during Ramadan. Overall, the risk of
hypoglycaemia was significantly lower in patients on the
sitagliptin-based regimen compared with those continuing
with SU treatment (relative risk ratio [95%CI] = 0.51 [0.34,
0.75]; p 0.001) [33]. The risk of hypoglycaemia between sita-
gliptin and gliclazide were equal. A similar risk ratio (0.52
[0.29, 0.94]; p = 0.028) was recorded in a second RCT compar-
ing sitagliptin with SU treatment [35]. Neither of these two
studies investigated glycaemic control. In the multinational
STEADFAST study, patients with T2DM were randomised to
receive either vildagliptin or gliclazide during Ramadan. No
significant difference in the reporting of any hypoglycaemic
event was observed between the two groups. However, the
proportion of patients experiencing at least one confirmed
hypoglycaemic event during Ramadan was lower on vildaglip-
tin compared with gliclazide (3.0% vs. 7.0%, p = 0.039) [36].
Good glycaemic control was demonstrated in both arms of
study.
A number of observational studies have examined the effi-
cacy and safety of DPP-4 inhibitor treatment during Ramadan
[32,43–46]. In the VECTOR study, no self-reported hypogly-
caemic events were reported in the vildagliptin group com-
pared with 35 events in 15 patients (41.7%) in the gliclazide
arm (including one severe event). In addition, the change in
glycated haemoglobin (HbA1c) from baseline to post-
Ramadan was significantly greater in the vildagliptin group
compared with the gliclazide group (p = 0.026) [45]. The VERDI
study compared the incidence of hypoglycaemic events dur-
ing Ramadan in patients who received vildagliptin or SU/glin-
ide and found no significant difference in the number of
patients experiencing at least one hypoglycaemic event [44].
However, the proportion of patients experiencing a severe
Insulin therapy
Switch to insulin analogues where possible
• Long- or intermediate-acƟng basal insulin:
• OD – NPH*/detemir/glargine/degludec. Take at iŌar. Reduce dose by 15–30%
• BID – NPH/detemir/glargine. Take usual morning dose at iŌar. Reduce evening dose by 50% and take at suhoor
• Rapid- or short-acƟng prandial/bolus insulin:
• Take normal dose at iŌar. Omit lunch-Ɵme dose. Reduce suhoor dose by 25–50%
• Premixed insulin:
• OD – Take normal dose at iŌar
• BID – Take usual morning dose at iŌar. Reduce evening dose by 25–50% and take at suhoor
• TID – Omit aŌernoon dose. Adjust iŌar and suhoor doses
Dose ƟtraƟon should be performed every three days and dose adjustments made according to BG levels
• Insulin pump:
• Basal rate – Reduce dose by 20–40% in the last 3–4 h of fasƟng. Increase dose by 0–30% early aŌer iŌar
• Bolus rate – Normal carbohydrate counƟng and insulin sensiƟvity principles apply
FasƟng/Pre-iŌar/Pre-suhoor BG
Pre-iŌar** Post-iŌar**/Post-suhoor***
Basal insulin Short-acƟng insulin Premixed insulin
70 mg/dL (3.9 mmol/L) or symptoms Reduce by 4 units Reduce by 4 units Reduce by 4 units
70–90 mg/dL (3.9–5.0 mmol/L) Reduce by 2 units Reduce by 2 units Reduce by 2 units
90–126 mg/dL (5.0–7.0 mmol/L) No change required No change required No change required
126–200 mg/dL (7.0–11.1 mmol/L) Increase by 2 units Increase by 2 units Increase by 2 units
200 mg/dL (11.1 mmol/L) Increase by 4 units Increase by 4 units Increase by 4 units
Fig. 5 – Insulin dose modifications for patients with diabetes. *
Alternatively, reduced NPH dose can be taken at suhoor or at
night; **
adjust the insulin dose taken before suhoor; ***
adjust the insulin dose taken before iftar. BG, blood glucose; BID, twice
daily; NPH, neutral protamine Hagedorn; OD, once daily; TID, three times a day.
d i a b e t e s r e s e a r c h a n d c l i n i c a l p r a c t i c e 1 2 6 ( 2 0 1 7 ) 3 0 3 –3 1 6 311
10. hypoglycaemic event and/or an unscheduled medical visit
due to hypoglycaemia was significantly lower in the vildaglip-
tin group (p = 0.029) [44]. The VIRTUE study, conducted in the
Middle East and Asia, is the largest of the observational stud-
ies to date and enrolled 1300 patients with T2DM. Like the
smaller studies, significantly fewer patients treated with a
DPP-4 inhibitor (vildagliptin) experienced at least one hypo-
glycaemic event during Ramadan compared with those on
SUs (5.4% vs. 19.8%, p 0.001). Patients on vildagliptin also
demonstrated significantly greater reductions in HbA1c and
body weight from baseline compared with those on SUs (both
p 0.001) [32].
The results of the studies described above indicate that vil-
dagliptin is effective in improving glycaemic control and that
both vildagliptin and sitagliptin are associated with low rates
of hypoglycaemia during fasting, making them attractive
treatment options during Ramadan. These drugs do not
require any treatment modifications during Ramadan
(Fig. 4). Other more recently-approved DPP-4 inhibitors (alo-
gliptin, saxagliptin and linagliptin) have yet to be studied dur-
ing Ramadan.
6.1.7. Glucagon-like peptide-1 receptor agonists (GLP-1 RAs)
A number of studies on the use of GLP-1 RAs during Ramadan
have been published recently. The TREAT4 Ramadan trial
examined the safety and efficacy of liraglutide compared with
SU treatment in T2DM patients during Ramadan [47]. More
patients in the liraglutide group achieved the composite end-
point of HbA1c 7%, no weight gain and no severe hypogly-
caemia 12 weeks post-Ramadan compared with the SU
group (26.7% vs. 10.3%, respectively), but this did not reach
statistical significance. The incidence of self-reported hypo-
glycaemic events was lower in the liraglutide group [47]. In
the open-label LIRA-Ramadan study conducted in several
countries in Africa and Asia, patients with T2DM were ran-
domised to switch to liraglutide or continue on SU treatment
[48]. Significantly more patients in the liraglutide group
reached the composite endpoint (HbA1c 7.0%, no weight
gain, no hypoglycaemia) than in the SU group at the end of
Ramadan (51.3% vs. 17.7%; p 0.0001). Patients in the liraglu-
tide arm also demonstrated better weight control and fewer
confirmed hypoglycaemic episodes compared with the SU
group [48]. Adding liraglutide to pre-existing anti-diabetic reg-
imens (including SU and insulin) during Ramadan resulted in
16.2% of patients developing symptoms of hypoglycaemia,
but no severe events were recorded [49]. A small observational
study in patients with T2DM treated with exenatide reported
no significant differences in weight or hypoglycaemic epi-
sodes [50]. Data relating to the use of newer GLP-1 RAs (lixise-
natide, dulaglutide and albiglutide) during Ramadan are
lacking.
These studies demonstrate that liraglutide is safe as an
add-on treatment to pre-existing anti-diabetic regimens and
can be effective in reducing weight and HbA1c levels during
Ramadan. Data on exenatide is limited to one study but, like
liraglutide, the risk of hypoglycaemia during Ramadan is low.
As long as GLP-1 RAs have been appropriately dose-titrated
prior to Ramadan (6 weeks before), no further treatment mod-
ifications are required (Fig. 4).
6.1.8. Insulin treatment for T2DM
Insulin use during prolonged fasting carries an increased risk
of hypoglycaemia, particularly for those with T1DM but also
for those with T2DM. The use of insulin analogues (basal,
prandial and premix) is recommended over regular human
insulin due to a number of advantages, including lower rates
of hypoglycaemia [51]. Although a number of small ran-
domised trials and observational studies have been con-
ducted to assess some insulin regimens during Ramadan
(Table S1), large RCT data in this area are lacking.
A multinational study reported a significant increase in
mild hypoglycaemic events during Ramadan compared with
the pre-Ramadan period in patients treated with insulin glar-
gine plus glimepiride (p 0.001) [52]. Two smaller observa-
tional studies found insulin glargine to be safe to use during
Ramadan, with no significant increases in hypoglycaemia
when compared with non-fasting individuals or when com-
pared with those taking OADs [26,28].
A comparison of rapid-acting analogue insulin lispro and
short-acting soluble human insulin, taken before iftar,
revealed that the postprandial rise in blood sugar levels after
iftar and the rate of hypoglycaemia were both significantly
lower in the lispro group (p 0.01 and p 0.002, respectively)
[53].
A comparison of insulin lispro Mix25 (25% short-acting lis-
pro/75% intermediate-acting lispro protamine) with human
insulin 30/70 (30% short-acting soluble human insulin/70%
intermediate-acting neutral protamine Hagedorn [NPH]) dur-
ing Ramadan found that overall glycaemia was significantly
lower for patients on insulin lispro Mix25 (p = 0.004), with
the greatest between-treatment difference evident before
and after iftar [54]. Similarly, in another study insulin lispro
Mix50 (50% lispro/50% lispro protamine) in the evening and
regular human insulin with NPH (30:70) in the morning
improved glycaemic control without increasing the incidence
of hypoglycaemic events compared with regular human insu-
lin with NPH (30:70) given twice daily [55].
A new regimen in which 40% of the daily insulin dose was
given as insulin detemir at suhoor and 60% was given as
NovoMix70, a biphasic insulin aspart, before iftar has been
assessed and was found to be non-inferior to standard care
with a significantly lower hypoglycaemic event rate [56].
Another study found that compared with pre-Ramadan base-
line levels, biphasic insulin aspart reduced all glycaemic
indices following Ramadan without an increase in body
weight or risk of hypoglycaemia [57].
Insulin treatment must be appropriately individualised,
and the recommended medication adjustments and SMBG-
guided dose titrations can be found in Fig. 5.
If a patient is taking NPH or premixed insulin at suhoor, it
is important to check blood glucose at noon before up-
titration of the pre-suhoor dose. If noon blood glucose is
110 mg/dL and pre-iftar blood glucose is not at target, long-
acting insulin analogues are preferred. It is important to note
that many patients may be on multiple therapies for diabetes
management. The adjustment of each drug is stated above.
For those on insulin and SU, a decision on the need to reduce
doses of both agents, or to start with insulin only, is required
based on individual assessment.
312 d i a b e t e s r e s e a r c h a n d c l i n i c a l p r a c t i c e 1 2 6 ( 2 0 1 7 ) 3 0 3 –3 1 6
11. 6.2. Pharmacological management of high risk
populations
6.2.1. Adults with T1DM
People with T1DM who fast can develop serious health prob-
lems [18]. Indeed, religious leaders, in unification with many
diabetes experts, do not recommend fasting in individuals
with T1DM, and such patients are categorised as very high
risk. In general, patients with T1DM who have any of the fol-
lowing conditions must not fast [8,58]:
History of recurrent hypoglycaemia.
Hypoglycaemia unawareness.
Poor diabetes control.
Brittle diabetes.
Non-compliance with medical treatment.
Patients who are ‘unwilling’ or ‘unable’ to monitor and
manage their blood glucose levels.
Those who insist on fasting must be aware of all the
potential risks associated with fasting and must have close
medical supervision [58]. A Ramadan study using CGM found
that some patients experienced significant periods of hypo-
glycaemia while fasting, without being aware of the problem
[59]. Patients are advised to test their blood glucose levels reg-
ularly throughout the fasting period (Fig. 2). Most importantly,
glucose levels should be checked at any time when symptoms
of hypoglycaemia are recognised [23]. All patients should
comprehend the dangers of low and high blood glucose levels,
know when to break the fast, and must not fast if they are
unwell [8]. In a non-Ramadan study, patients with T1DM tak-
ing the long-acting insulin, glargine, could fast safely for 18 h
with only mild hypoglycaemic episodes reported [60]. A lim-
ited number of studies have shown that some patients with
T1DM can tolerate Ramadan fasting (Table S2 in supplemen-
tary information). Two small observational studies reported
that patients taking ultralente or insulin lispro could fast
without experiencing severe hypoglycaemic episodes [61,62].
More recent studies in patients using insulin pumps reported
no cases of severe hypoglycaemia, although some episodes of
hypoglycaemia required the fast to be broken and adjust-
ments to the basal rate were needed [63,64]. If patients with
T1DM insist on fasting, then the recommended adjustments
to insulin medication and/or dosing regimen during Ramadan
are outlined in Fig. 5.
6.2.2. Young adults/adolescents with T1DM
Once a child reaches puberty he/she is expected to fast during
Ramadan. There have been a number of studies, albeit with a
limited number of patients, that have investigated fasting in
adolescents with T1DM. No severe hypoglycaemic episodes
have been observed, but significant periods of hypoglycaemia
during fasting hours have gone unnoticed by the patient
[59,65–68] (Table S2 in supplementary information). The gen-
eral consensus is that fasting should be avoided due to the
observation of unrecognised hypoglycaemia. However, those
patients who insist on fasting need to have good hypogly-
caemia awareness, good glycaemic control pre-Ramadan,
have the knowledge and willingness to test their blood
glucose levels, be able to adjust medication as needed and
be carefully supervised by an expert physician. As with
adults, adolescents with T1DM who fast (and their parents)
must be aware of all potential risks associated with Ramadan
fasting. Frequent SMBG, knowing when to break the fast, and
avoiding fasting on ‘sick days’ are all essential to avoid com-
plications [69]. Children and adolescents on a conventional
twice a day regimen should take their usual morning dose
before iftar and short-acting insulin at suhoor. Adolescents
on multiple daily injections should take long/intermediate-
acting insulin at iftar but reduce the dose by 30–40%, and take
a normal dose of short-acting insulin at iftar but reduce
suhoor dose by 25–50%. For those using insulin pumps, the
changes to dose are the same as those for adults (Fig. 5).
6.2.3. Pregnant women
All pregnant women have the option not to fast if they are
worried about either their health or that of their foetus. Many
do decide to participate as they feel guilty if they do not
[70,71]. In fact, evidence from some countries indicates that
70–90% of pregnant women observe the fast [72], although
surveys suggest that they may not manage the full month
[70,73,74]. Some studies in healthy pregnant women, without
diabetes, have shown no harmful effects of fasting on baby or
mother [73,75–77], although other studies have reported some
negative outcomes [72,78,79].
Pregnant women with hyperglycaemia (gestational dia-
betes mellitus [GDM] or pre-existing diabetes) are stratified
as very high risk and are advised against fasting during preg-
nancy [8,18]. However, fasting in Ramadan is a personal deci-
sion, and a practical approach would be to explain the
potential effects on mother and foetus, thereby empowering
women with knowledge and education regarding self-
management skills for good pregnancy outcomes. Women
with GDM who are well-controlled pre-Ramadan on diet or
metformin are at low risk of hypoglycaemia, however they
must ensure that they are achieving post-prandial glucose
targets, which is a difficult task after a prolonged fast.
Patients on SU therapy and/or insulin should be strongly
advised against fasting due to the higher risk of hypogly-
caemia. Modifications to diet and insulin regimens such as
those outlined for patients with T1DM will be required in con-
junction with frequent SMBG, focused education and strict
medical supervision by an expert team [8].
7. Conclusions
With so many Muslims with diabetes choosing to fast during
Ramadan, potentially in some, against medical advice, there
is an immediate need for practical management guidelines
that enable HCPs to offer the most up-to-date information,
advise patients if fasting should not be undertaken, and sup-
port those that do fast. A pre-Ramadan assessment is vital for
any patient with diabetes who intends to fast in order to eval-
uate the risks, educate the patient in self-management of the
condition during Ramadan and to produce a patient-specific
treatment plan describing any medication adjustments
needed. Ramadan-focused education and a better knowledge
of nutrition during Ramadan are essential elements for safer
d i a b e t e s r e s e a r c h a n d c l i n i c a l p r a c t i c e 1 2 6 ( 2 0 1 7 ) 3 0 3 –3 1 6 313
12. fasting during Ramadan. The IDF-DAR Practical Guidelines pro-
pose three categories of risk, with patients stratified to the
very high or high risk groups being advised not to fast. With
the correct advice and support from HCPs, many people with
T2DM may be able to fast safely during Ramadan. Patients
taking metformin, SUs or insulin will need to make adjust-
ments to dose and/or timings to reduce the risk of complica-
tions. Newer anti-glycaemic medications, including incretin-
based therapies, are associated with a lower risk of hypogly-
caemia and may be preferable for use during Ramadan.
Patients classified as very high or high risk, including those
with T1DM and pregnant women with diabetes, need close
medical supervision if they insist on Ramadan fasting.
The implementation of these guidelines will require the
involvement of religious leaders in community alongside
HCPs, to ensure that patients receive advice combining reli-
gious and medical directives. The IDF-DAR Practical Guidelines
have been approved by the Mofty of Egypt but religious opin-
ions in other countries may differ, therefore further regional
discussions are warranted.
Funding
The preparation of this manuscript was funded through an
unrestricted educational grant provided by Sanofi Middle East
(Dubai, UAE).
Author contributions
MH, M A-A and A B-N contributed in writing and editing the
manuscript. All other authors contributed in writing the
manuscript. All authors have approved the final article.
Conflict of interest statement
MH has received honoraria from and sat on advisory boards
for MSD and Sanofi. M A-A and A B-N have sat on advisory
boards for MSD, AstraZeneca, Sanofi and Servier. OH has
received research grants from Metagenics and provided con-
sultation for Novo Nordisk, AstraZeneca and Metagenics.
WMWB has received research grants from Sanofi, Novo Nor-
disk and MSD. WH has received travel grants, research grants
and consultancy fees from Novo Nordisk, Eli Lilly, Sanofi,
MSD, Jansen, AstraZeneca and BI. MAKO has sat on advisory
boards and/or gave lectures sponsored by Novo Nordisk, Eli
Lily, Sanofi, Medtronic, Servier, MSD, BI, Pfizer, AstraZeneca,
Abbott and Johnson Johnson. KA has received honoraria
as a speaker and/or sat on advisory boards for Novo Nordisk,
Eli Lilly, Takeda, MSD, Novartis, AstraZeneca, Pfizer, BI, Sanofi,
Amgen and Abbott. AJ, NL, AB, AAT, AA-M and AAE-S have
declared no conflicts of interest. KT and MAB have not
declared any conflicts of interest.
Acknowledgements
Special thanks for editorial advice must go to Pablo Aschner
(Javeriana University and San Ignacio University Hospital,
Columbia), Chairman of the IDF Clinical Guidelines Taskforce
and to Stephen Colagiuri (The Boden Institute, University of
Sydney, Sydney, NSW, Australia) for his support in developing
these guidelines. We thank Fatheya Alawadi, Muhammad
Yakoob Ahmedani, Inass Shaltout, Ines Slim, Bachar Afandi,
Musarrat Riaz, Barakatun Nisak Mohamed Yusof, Line Kleine-
breil, Wafa H Reda, Mesbah Sayed Kamel, Mohamed Sandid,
Sulaf Ibrahim Abdelaziz, Henda Jamoussi, Wan Mohamad
Izani and Sudzila Nordin for their invaluable contributions
to and support of the IDF-DAR Practical Guidelines. Medical
writing and editorial assistance was provided by Joanna
Chapman PhD (Aspire Scientific Limited; Bollington, UK) and
was funded through an unrestricted educational grant pro-
vided by Sanofi Middle East (Dubai, UAE).
Appendix A. Supplementary material
Supplementary data associated with this article can be found,
in the online version, at http://dx.doi.org/10.1016/j.diabres.
2017.03.003.
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316 d i a b e t e s r e s e a r c h a n d c l i n i c a l p r a c t i c e 1 2 6 ( 2 0 1 7 ) 3 0 3 –3 1 6