1) Ramadan fasting among diabetics can provide medical benefits such as reduced body weight and BMI, improved glycemic control, and decreased blood pressure, but also carries risks. 2) The risk of hypoglycemia increases for type 1 diabetics and those with poor glycemic control, while the risk of hyperglycemia and ketoacidosis increases for type 2 diabetics. 3) Patients at very high risk of complications from fasting include those with history of severe diabetes issues, poor long-term control, pregnancy, or advanced kidney disease. Those at high or moderate risk include patients with complications or using certain medications.

1. DIABETES IN RAMADHAN

4. 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. Back Ground
References:
1. Al-Arouj M, Assaad-Khalil S, Buse J, et al. Recommendations for management of diabetes during Ramadan: update 2010. Diabetes Care. 2010; 33(8): 1895-902.
2. Karamat MA, Syed A, Hanif W. Review of diabetes management and guidelines during Ramadan. J R Soc Med. 2010; 103(4): 139-147.
3. Salti I, Bénard E, Detournay B, et al. A population-based study of diabetes and its characteristics during the fasting month of Ramadan in 13 countries: results of the
epidemiology of diabetes and Ramadan 1422/2001 (EPIDIAR) study. Diabetes Care. 2004; 27(10): 2306-2311.
4. Loke SC, Rahim KF, Kanesvaran R, et al. A prospective cohort study on the effect of various risk factors on hypoglycaemia in diabetics who fast during Ramadan. Med J
Malaysia. 2010; 65(1): 3-6.

7. PHYSIOLOGICAL CHANGES
DURING RAMADHAN

8. Non Fasting State

9. Low level
of insulin
↑ counter
regulatory
hormones
(glucagon,
cathecholamine)
Fasting
Hyperglycemia
Ketone
Fail to increase
appropiately
Hypoglycemia
Fasting State

10. MEDICAL BENEFIT OF FASTING
DURING RAMADHAN

11. o Reduction of
Body Mass Index
(BMI)
o With or without any
changes in TC & TG
levels
o Improvement of
HbA1c level
o Decrease in
daytime average
SBP/DBP in
hypertensive
patients
o Elimination of toxins
o Reducing insulin-like
growth factor 1 (IGF-1)
which allows the
regeneration of stem cells
in the bone marrow
o Reduction in high
sensitive C-reactive
protein (hs-CRP)
o Reduction in
plasminogen activator
inhibitor type-1 (PAI-1
Decrease in body
weight1 Increase in high-density
lipoprotein (HDL)2
Improvement in glycaemic
control3
Decrease in blood
pressure4,5
Improvement in
immunity6
Reduced cardiovascular
disease markers7
References:
1. Mafauzy M, Mohammed WB, Anum MY, et al. A study of the fasting diabetic patients during the month of Ramadan. Med J Malaysia. 1990; 45(1): 14-17.
2. Benaji B, Mounib N, Roky R, et al. Diabetes and Ramadan: review of the literature. Diabetes Res Clin Pract. 2006; 73(2): 117-125.
3. Chamakhi S, Ftouhi B, Rahmoune NB, et al. Influence of the fast of Ramadan on the balance glycaemic to diabetics. Medicographia. 1991; 13: 27-29.
4. Perk G, Ghanem J, Aamar S, et al. The effect of the fast of Ramadan on ambulatory blood pressure in treated hypertensives. J Hum Hypertens. 2001; 15(10): 723-725.
5. Akturk IF, Biyik I, Kocas C, et al. PP-014 The effect of Ramadan fasting on blood pressure levels of hypertensive patients with combination therapy. Int J Cardiol. 2012; 155(Suppl 1): S103.
6. Cheng CW, Adams GB, Perin L, et al. Prolonged fasting reduces IGF-1/PKA to promote hematopoietic-stem-cell-based regeneration and reverse immunosuppression. Cell Stem Cell. 2014; 14(6): 810-823.
7. Ibrahim O, Kamaruddin N, Wahab N, et al. Ramadan Fasting And Cardiac Biomarkers In Patients With Multiple Cardiovascular Disease Risk Factors. The Internet Journal of Cardiovascular Research. 2010; 7(2).
Medical Benefit

12. Changes in Average SBP and f
Hypertensive Patients
0
Abbreviation: BP: Blood pressure; SBP: Systolic blood pressure; DBP: Diastolic blood pressure
Reference:
1. Akturk IF, Biyik I, Kocas C, et al. PP-014 The effect of Ramadan fasting on blood pressure levels of hypertensive patients with
combination therapy. Int J Cardiol. 2012; 155(Suppl 1): S103.
Average 24-h Average awake Average asleep
Ramadan fasting in Islamic populations of the world may cause significant reductions
on daytime and twenty four hour average systolic and diastolic blood pressures in
hypertensive patients with combination therapy.
Blood Pressure

13. 0
Reference:
1. Mafauzy M, Mohammed WB, Anum MY, et al. A study of the fasting diabetic patients during the month of Ramadan. Med J
Malaysia. 1990; 45(1): 14-17.
0.7 kg decrease
of mean body
weight
It was observed that the body weight decreased from 60.5 ± 12.6 kg
before Ramadan to 59.8 ± 12.3 kg with a mean decrease in of 0.7 ± 1.3
kg, p=0.01.
Body Weight

14. 0
The significant fall in the serum fructosamine level implied that the overall glycaemic control
was significantly better during the fasting month than before.
2.3 mmol/l
decrease of mean
body weight
Before Ramadan During Ramadan
Reference:
1. Mafauzy M, Mohammed WB, Anum MY, et al. A study of the fasting diabetic patients during the month of Ramadan. Med J
Malaysia. 1990; 45(1): 14-17.
Glycemic Control

15. Changes In Total Cholesterol and
Triglycerides Levels
0
The total cholesterol and
triglycerides was maintained
until post-Ramadan. For
diabetic patients apo A-1/HDL
ratios level increased after
Ramadan and this parameter
as determined from this study,
would suggest a reduced CHD
risk with Ramadan fasting.
Pre-Ramadan
Post-Ramadan
HDL (mM) Apo A-1/HDL
ratio
Total cholesterol
(mM)
Triglycerides
(mM)
Reference:
1. Akanji AO, Mojiminiyi OA, Abdella N. Beneficial changes in serum apo A-1 and its ratio to apo B and HDL in stable
hyperlipidaemic subjects after Ramadan fasting in Kuwait. Eur J Clin Nutr. 2000; 54: 508-513.
CHD: Coronary heart
disease
HDL: High density
lipoprotein

16. RISK OF FASTING IN DIABETES
DURING RAMADHAN

18. Risk
References:
1. Salti I, Bénard E, Detournay B, et al A population-based study of diabetes and its characteristics during the fasting month of Ramadan in 13 countries: results of the
epidemiology of diabetes and Ramadan 1422/2001 (EPIDIAR) study. Diabetes Care. 2004; 27(10): 2306-2311.
2. Loke SC, Rahim KF, Kanesvaran R, et al. A prospective cohort study on the effect of various risk factors on hypoglycaemia in diabetics who fast during Ramadan. Med J
Malaysia. 2010; 65(1): 3-6.
3. Ministry of Health Malaysia. Practical guide to Insulin Therapy in Type 2 Diabetes Mellitus. 2010.

21. Risk Of Hypoglycaemia During Ramadan
0
Type 1
diabetes
Type 1
diabetes
Type 2
diabetes
Type 2
diabetes
Overall
population
Patient who fasted ≥15 days
P = 0.0174 P < 0.0001
P = 0.9896 P = 0.0034
Before Ramadan During Ramadan
Reference:
1. Salti I, Bénard E, Detournay B, et al A population-based study of diabetes and its characteristics during the fasting month of Ramadan in 13 countries:
results of the epidemiology of diabetes and Ramadan 1422/2001 (EPIDIAR) study. Diabetes Care. 2004; 27(10): 2306-2311..

22. Risk of Hyperglycaemia/Ketoacidosis
during Ramadan
0
Type 1
diabetes
Type 1 diabetes
Type 2
diabetes
Type 2 diabetes
Overall population
Patient who fasted ≥15 days
P = 0.1635 P < 0.0001
P = 0.6701
P = 0.0015
Before Ramadan During Ramadan
Among the overall
population, the number of
severe hyperglycaemic
episodes with or without
ketoacidosis per month
showed a significant
difference between
Ramadan and the preceding
year only for patients with
Type 2 diabetes.
Among patients who fasted
for at least 15 days, the
frequency of severe
hyperglycaemia complications
was slightly lower than in the
overall population. Type 2
diabetes reported higher
severe complications per
month than Type 1 diabetes.
Reference:
1. Salti I, Bénard E, Detournay B, et al A population-based study of diabetes and its characteristics during the fasting month of Ramadan in 13 countries: results of the
epidemiology of diabetes and Ramadan 1422/2001 (EPIDIAR) study. Diabetes Care. 2004; 27(10): 2306-2311..

23. PATIENT WHO AT RISK TO
DEVELOP COMPLICATIONS
DURING RAMADHAN

27. VERY HIGH RISK
• History of severe diabetes complication within 3 months prior to
fasting:
• Severe Hypoglycemia
• Ketoacidosis
• Hyperosmolar Hyperglycemic Coma
• Recurrent Hypoglycemia
• Hypoglycemia Unawareness
• Acute Illness
• Sustained Poor glycemic control ( HbA1c > 9% )
• Pregnancy
• Advance Renal Failure / Chronic Dialysis
Reference:
1. Al-Arouj M, Assaad-Khalil S, Buse J, et al. Recommendations for management of diabetes during Ramadan: update
2010. Diabetes Care. 2010; 33(8): 1895-902.
Patient At Risk

28. Patient At Risk
HIGH RISK
Moderate Hyperglycemia (Hba1c 7.5% - 9%)
Moderate Renal Failure
Advance Macrovascular Complication
Living Alone And Treated With Insulin And Sulponylureas
Patient With Co-Morbid Condition That Present Additioonal Risk Factor
Old Patient With Ill Health
Treatment With Drug That May Affect Mentation

29. Patient At Risk
MODERATE RISK
Well Controlled Diabetes Treated With Short Acting Insulin
Secretagogues
LOW RISK
Well Controlled Diabetes Treated With Life Style , Metformin, Arcabose,
TZD & Incretin Based Therapy In Otherwise Healthy Patients

30. Fasting In Special Population
Pregnancy
• Strongly advised against fasting during Ramadan1
• The management of pregnant patients during Ramadan is based on
an appropriate diet and intensive insulin therapy1
Children & Adolescent
Children and adolescents with good glycaemic control who do
regular self-monitoring can fast safely during Ramadan2
References:
1. Al-Arouj M, Assaad-Khalil S, Buse J, et al. Recommendations for management of diabetes during Ramadan: update 2010.
Diabetes Care. 2010; 33(8): 1895-902.
2. Azad K, Mohsin F, Zargar AH, et al. Fasting guidelines for diabetic children and adolescents. Indian J Endocrinol Metab. 2012;
16(4): 516-518.

31. Fasting In Special Population
Dialysis Patient
• Most stable patients on haemodialysis and peritoneal dialysis can fast,
provided that they strictly adhere to their medications and dialysis therapy in
addition to the dietary restrictions1,2
• These patients should be followed-up closely to detect any
complications and to ensure that adequate fluid and electrolyte balance are
maintained1,2
Elderly Patient
• Elderly patients are exempted from fasting. Many may wish to observe the
fast3
• Those with diabetes having any degree of cognitive dysfunction,
dehydration, or an increased risk of thrombosis are advised against fasting3

32. Glycaemic Control Among Pregnant Diabetic
Women On Insulin Fasting During Ramadan
0
Level of HbA1c Level of
Fructosamine
Reference:
1. Ismail MNA, Raji HO, Wahab NA et al. glycaemic Control among Pregnant Diabetic Women on Insulin who fasted during Ramadan. IJMA; 2011; 36(4): 254-259.
There was no statistically significant
difference between the T2DM and GDM
groups in terms of glycaemic control at one
week before Ramadan. However, serum level
of HbA1c tended to be higher in the GDM
group and serum fructosamine levels tended
to be lower in T2DM group. Compared to pre-
Ramadan measurements, serum
fructosamine levels in both groups (T2DM
and GDM) were lower after Ramadan.
T2DM: Type 2 diabetes mellitus;
GDM: Gestational diabetes mellitus
Therefore, the findings of this study indicate
that pregnant diabetic women on insulin were
able to fast during Ramadan and their
glycaemic control was improved during the
fasting period.
Onset Ramadan Middle Ramadan After Ramadan

33. Fasting During Ramadan In Children And
Adolescents With Diabetes
0
*Children with Type 1 diabetes mellitus who completed Ramadan fasting
Glycaemic control Weight Insulin dose
Pre-Ramadan Post-
Ramadan
Reference:
1. Zabeen B, Tayyeb S, Benarjee B, Baki A, Nahar J, Mohsin F, Nahar N, Azad K. Fasting during Ramadan in adolescents with diabetes. Indian
J Endocr Metab 2014;18:44-7.
Comparing pre-Ramadan to post-Ramadan:
•Glycemic control/A1c showed slight
improvements
•No weight changes
•Insulin dose was increased in those who
completed the Ramadan fasting
Conclusion
•It is safe for diabetic children over the age of 11 years to
fast
•A well-structured program of education for both children
and their families is needed
•Close follow-up during the month of Ramadan is needed

34. Long-term Ramadan Fasting on Glucose Regulation in
Elderly with T2DM
0
Reference:
1. Karatopak C, Yolbas S, Cakirca M, Cinar A, Zorlu M, Kiskac M et al. The effects of long term fasting in Ramadan on glucose regulation in
Type 2 Diabetes Mellitus. Eur Rev Med Phamaco Sci. 2013; 17: 2512-2516.
Pre-Ramadan Post-Ramadan
• No disruption of glucose
control when fasting during
Ramadan
• No weight changes
• No significant increase in
adverse events like
hypoglycaemia,
hyperglycaemia, and diabetic
coma.
p = 0.37 p = 0.047
p = 0.15 p = 0.73
HbA1c Fasting plasma glucose
Postprandial plasma glucose Weight

35. PREPARATION PRIOR TO
RAMADHAN

39. Pre Ramadhan Medical Review
• All patients with diabetes wishing to fast should
have a pre-Ramadan assessment ideally 6–8
weeks before the start of Ramadan.

40. Pre Ramadhan Medical Review

41. Pre Ramadhan Medical Review

42. Patient Education

43. LIFESTYLE AND DIET
MANAGEMENT DURING
RAMADHAN

44. Dietary Advice
0
Reference:
1. Ministry of Health (MOH) Malaysia. Practical Guide to Diabetes Management in Ramadan 2015.
Good “buka puasa” meal Food that should be limited during
“buka puasa”
A B

46. Adjustment Of Diet Protocol For
Ramadhan Fasting
Reference:
1. Persatuan Dietitian Malaysia. Medical Nutrition Therapy Guidelines for Type 2 Diabetes Mellitus. 2013. Second Edition.

47. Physical Activity
0
References:
1. Bravis V, Hui E, Salih S, et al. Ramadan Education and Awareness in Diabetes (READ) programme for Muslims with Type 2 diabetes who fast during
Ramadan. Diabet Med. 2010; 27(3): 327-331.
2. Karamat MA, Syed A, Hanif W. Review of diabetes management and guidelines during Ramadan. J R Soc Med. 2010; 103(4): 139-147.
3. Ibrahim MA. Managing diabetes during Ramadan. Diabetes voice. 2007; 52(2): 19-22.

48. SELF MONITORING OF BLOOD
GLUCOSE (SMBG) DURING
RAMADHAN

49. Timing And Frequency Of SMBG
Based On Treatment
Therapy Timing & Frequency Of SMBG
Oral Anti Diabetes (OADs) Monitor when symptomatic1
Insulin Diabetic patients who are in the moderate
to high risk categories are advised to
monitor their blood glucose 5 times per
day2
• Pre-Dawn meal
• 2-hour to 4 hour post pre-dawn
meal (sahur)
• Mid-day
• Pre-Iftar
• 2-hour to 4 hour post sunset meal
(iftar)/Bedtime
References:
1. Ministry of Health (MOH) Malaysia. Practical Guide to Diabetes Management in Ramadan 2015.
2. Hui E, Bravis V, Hassanein M, et al. Management of people with diabetes wanting to fast during Ramadan. BMJ. 2010; 340:c3053.

51. Timing of SMBG Could Reflect
Adequacy Of Insulin Dose
Time Of Glucose
Monitoring
Timing Insulin Type
Mid Day Pre Sahur Pre Mixed / Bolus /
Basal Insulin
Pre Iftar Pre Sahur Pre Mixed / Basal Insulin
2 Hour Post Iftar Or
Bed Time
Pre Iftar Pre Mixed / Basal Insulin
Pre Sahur Pre Iftar /
Pre Bed
Pre Mixed / Basal Insulin
2 Hour Post Sahur Pre Sahur Pre Mixed / Bolus Insulin

52. When to End the Fast during
Ramadan

53. Management Of Hypoglycaemia During Ramadan
Patients need to end their fast if they experience symptoms
of hypoglycaemia or have low blood glucose values*
Take simple carbohydrates
0
Reference:
1. Ministry of Health (MOH) Malaysia. Practical Guide to Diabetes Management in Ramadan 2015.
*Refer to Section 7: Self-monitoring of blood glucose during Ramadan: Ministry of Health (MOH) Malaysia. Practical Guide to Diabetes Management in Ramadan 2015.
1. Blood glucose < 3.3 mmol/l at anytime during the fast.
2. Blood glucose < 3.9 mmol/l in the first few hours of fasting
(especially if the patient is taking sulfonylureas, meglitinides, or
insulin).
3. Experience symptoms of hypoglycaemia (patients without SMBG).
4. Symptoms suggestive of severe dehydration such as syncope and
confusion.

54. ORAL ANTI-DIABETIC
THERAPY DURING
RAMADHAN

56. Oral Anti Diabetic Therapy During
Ramadhan
• Oral anti-diabetic (OAD) therapies should be individualised during
fasting1
• OAD therapies that act by increasing peripheral insulin sensitivity may
be preferred due to a low risk of hypoglycaemia2
• Insulin secretagogues have higher risk of hypoglycaemia than the
insulin sensitizers3
• Newer sulphonylureas can be safely used during Ramadan4
• Incretin based therapies such as dipeptidyl peptidase-4 inhibitors and
GLP-1 receptor analogues have low risk of hypoglycaemia and do not
require dose adjustments5

57. Adjustment Of Oral Diabetic Therapy During Ramadhan
Oral Anti Diabetic Drug Iftar Sahur
α-glucosidase inhibitors No changes No changes
Biguanides
(Metformin)
BD dose No changes No changes
TDS dose 2/3 of dose 1/3 of dose
Extended Release Full dose None
Dipeptidyl peptidase-4 inhibitors No changes No changes
Meglitinides No changes No changes
Sulphonylurea Glibenclamide,
Gliclazide
No changes Reduce / Omit
Switch dosing to
sunset meal
Gliclazide MR
Sodium glucose co-transporter
2 inhibitors
No changes Switch dosing to
sunset meal
Thiazolidinediones No changes None

58. INSULIN THERAPY
DURING RAMADHAN

59. Basal Insulin
Basal Insulin Only
Type 1 Diabetes Mellitus Type 2 Diabetes Mellitus
Not Applicable Taken at bedtime or any time after iftar
meals.
May require dose 15% - 30% if there
is risk of daytime hypoglycaemia.
● Insulin glargine can be given once daily any time after iftar.
● Insulin levemir and NPH insulin can be given either once daily at bedtime or
divided into twice daily during pre-dawn meal (sahur) and iftar.1
References:
1. Al-Arouj M, Assaad-Khalil S, Buse J, et al. Recommendations for management of diabetes during Ramadan: update. 2010. Diabetes Care. 2010; 33(8): 1895-
902.
2. Ministry of Health Malaysia. Practical guide to Insulin Therapy in Type 2 Diabetes Mellitus. 2010.
3. Pathan MF, Sahay RK, Zargar AH, South Asian Consensus Guideline: Use of insulin in diabetes during Ramadan. Indian J Endocrinol Metab. 2012; 16(4): 499-
502.
4. Hui E, Devendra D. Diabetes and fasting during Ramadan. Diabetes Metab Res Rev. 2010; 26(8): 606-610.

60. Pre Mixed Insulin
Pre Mixed Regime Type 1 DM Type 2 DM
Pre Mixed Insulin Once
Daily
Not Applicable Inject insulin dose at Iftar
meals
Pre Mixed Insulin Twice
Daily
• Reverses dose –
Morning dose given at
Iftar and evening dose
at sahur.
• Insulin dose at sahur
reduced by 20% - 50%
to prevent daytime
hypoglycemia.
• Reverses dose –
Morning dose given at
Iftar and evening dose
given at sahur.
• Insulin doses at sahur
reduced by 20% - 50%
to prevent daytime
hypoglycemia.
OR
• Change to short / rapid
acting insulin*
• * Late hypoglycemia may
occur

61. Basal Bolus Insulin
Insulin Regime T1 DM T2 DM
Basal Taken at bedtime or any time after iftar meals.
May require dose reduction 15% - 30% if there is
daytime hypoglycaemia.
Bolus
Sahur • Usual pre Ramadhan BF or Lunch dose.
• May require dose reduction 25% - 50% to
avoid day time hypoglycemia.
Iftar • Usual pre Ramadhan dinner dose.
• May require dose increment .
Lunch Omit
● Total insulin requirement for Type 1 diabetics who are on basal bolus
insulin regimen while fasting during Ramadan may require dose
reduction 15‒30% of their pre-Ramadan dose requirements.

62. Insulin Adjustment During
Ramadhan

63. SUMMARY

66. QUIZ

67. https://forms.gle/D9EAVSLsivmSKmE6A

68. THANK YOU