1) The document provides guidelines for healthcare professionals on managing diabetes patients who wish to fast during Ramadan. Fasting is an important religious practice in Islam that occurs during the month of Ramadan.
2) For diabetes patients, fasting can increase the risk of hypoglycemia, hyperglycemia, dehydration and other issues. The guidelines help clinicians evaluate a patient's risk level, provide advice on medication adjustments, blood glucose monitoring and other self-management techniques to minimize health risks from fasting.
3) Key recommendations include individualizing care plans based on a patient's diabetes type, medications, medical history and social circumstances. Patients at very high risk of health complications should not fast, while others may fast
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Case presentation
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This Presentation Prepared from IDF-DAR,BMJ,ADA & Other guidelines.It will cover to solve problems faced by the physicians during management of DM in the Holy Month of Ramadan specially monitoring of blood glucose,Drug doses,dietary and exercise advice etc.
THE NUTRITION THERAPY IN DIABETIC PATIENTS: A REVIEWPARUL UNIVERSITY
Diabetes Mellitus is one of the leading metabolic disorders in the world with many complications. The
management of Diabetes Mellitus can prevent many chronic diseases like stroke, myocardial infarction, diabetic
nephropathy, neuropathy and obesity. An appropriate dietary changes and lifestyle changes have proven to be
effective in the preventing and management of this disorder.Medical nutrition therapy (MNT) is an essential
component of diabetes management that comprises counseling and recommendations for dietary intake and nutrition
goals by a registered dietician (RD) or a nutrition expert to optimize metabolic control and maximize treatment
outcomes. The designing of the diet according to the nutrional needs of an individual and regular monitoring by a
dietician can provide effective results in the management. The counseling with the patient provides the detailed
information about the diet and the modifications in the diet can be made according to the age, weight, glucose level
and physical activity. The desired goal of the blood pressure, blood glucose, triglycerides can be achieved by
following the diet plan.
Operation “Blue Star” is the only event in the history of Independent India where the state went into war with its own people. Even after about 40 years it is not clear if it was culmination of states anger over people of the region, a political game of power or start of dictatorial chapter in the democratic setup.
The people of Punjab felt alienated from main stream due to denial of their just demands during a long democratic struggle since independence. As it happen all over the word, it led to militant struggle with great loss of lives of military, police and civilian personnel. Killing of Indira Gandhi and massacre of innocent Sikhs in Delhi and other India cities was also associated with this movement.
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2024.06.01 Introducing a competency framework for languag learning materials ...Sandy Millin
http://sandymillin.wordpress.com/iateflwebinar2024
Published classroom materials form the basis of syllabuses, drive teacher professional development, and have a potentially huge influence on learners, teachers and education systems. All teachers also create their own materials, whether a few sentences on a blackboard, a highly-structured fully-realised online course, or anything in between. Despite this, the knowledge and skills needed to create effective language learning materials are rarely part of teacher training, and are mostly learnt by trial and error.
Knowledge and skills frameworks, generally called competency frameworks, for ELT teachers, trainers and managers have existed for a few years now. However, until I created one for my MA dissertation, there wasn’t one drawing together what we need to know and do to be able to effectively produce language learning materials.
This webinar will introduce you to my framework, highlighting the key competencies I identified from my research. It will also show how anybody involved in language teaching (any language, not just English!), teacher training, managing schools or developing language learning materials can benefit from using the framework.
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The Roman Empire, a vast and enduring power, stands as one of history's most remarkable civilizations, leaving an indelible imprint on the world. It emerged from the Roman Republic, transitioning into an imperial powerhouse under the leadership of Augustus Caesar in 27 BCE. This transformation marked the beginning of an era defined by unprecedented territorial expansion, architectural marvels, and profound cultural influence.
The empire's roots lie in the city of Rome, founded, according to legend, by Romulus in 753 BCE. Over centuries, Rome evolved from a small settlement to a formidable republic, characterized by a complex political system with elected officials and checks on power. However, internal strife, class conflicts, and military ambitions paved the way for the end of the Republic. Julius Caesar’s dictatorship and subsequent assassination in 44 BCE created a power vacuum, leading to a civil war. Octavian, later Augustus, emerged victorious, heralding the Roman Empire’s birth.
Under Augustus, the empire experienced the Pax Romana, a 200-year period of relative peace and stability. Augustus reformed the military, established efficient administrative systems, and initiated grand construction projects. The empire's borders expanded, encompassing territories from Britain to Egypt and from Spain to the Euphrates. Roman legions, renowned for their discipline and engineering prowess, secured and maintained these vast territories, building roads, fortifications, and cities that facilitated control and integration.
The Roman Empire’s society was hierarchical, with a rigid class system. At the top were the patricians, wealthy elites who held significant political power. Below them were the plebeians, free citizens with limited political influence, and the vast numbers of slaves who formed the backbone of the economy. The family unit was central, governed by the paterfamilias, the male head who held absolute authority.
Culturally, the Romans were eclectic, absorbing and adapting elements from the civilizations they encountered, particularly the Greeks. Roman art, literature, and philosophy reflected this synthesis, creating a rich cultural tapestry. Latin, the Roman language, became the lingua franca of the Western world, influencing numerous modern languages.
Roman architecture and engineering achievements were monumental. They perfected the arch, vault, and dome, constructing enduring structures like the Colosseum, Pantheon, and aqueducts. These engineering marvels not only showcased Roman ingenuity but also served practical purposes, from public entertainment to water supply.
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We all have good and bad thoughts from time to time and situation to situation. We are bombarded daily with spiraling thoughts(both negative and positive) creating all-consuming feel , making us difficult to manage with associated suffering. Good thoughts are like our Mob Signal (Positive thought) amidst noise(negative thought) in the atmosphere. Negative thoughts like noise outweigh positive thoughts. These thoughts often create unwanted confusion, trouble, stress and frustration in our mind as well as chaos in our physical world. Negative thoughts are also known as “distorted thinking”.
2. IDF-DAR Practical Guidelines
Diabetes, Culture and Religion; Fasting
• Fasting is an important part of many religions across the globe
• The duration of fast per day, the number of days and the type of fast
varies greatly across religions
• Healthcare professionals (HCP) treating people with diabetes need to
understand the impact of the religious/cultural practices of their
patients on their diabetes
• Consequently, this can improve the skills of HCP and the safetyof
people with diabetes wishing to fast.
3. IDF-DAR Practical Guidelines
Ramadan and diabetes
Fasting involves
refrain from
intake of
Food Liquids Oral Medications
Religious fasting is not intended
to create excessive hardship and ill
individuals are exempt from fasting
However, many Muslims with diabetes
choose to fast during Ramadan for religious,
cultural or social reasons
patients with
diabetes
worldwide may
fast during
Ramadan1
Muslims
with
diabetes
worldwide1
1. http://www.daralliance.org/daralliance/wp-content/uploads/IDF-DAR-Practical-Guidelines_15-April-2016_low.pdf
>116 million
>148 million
1 of the 5
pillars of
Islam
Fasting for a month
from dawn to sunset
Depending on the season and
geographical location, the
duration of fast will vary from
12–20 hours
4. • Female 42 years of age. Works as a teacher
• Weight 70 kg; BMI 27 kg/m2 BP 130/74
• Diagnosed with diabetes 6 years ago
• Mild background retinopathy. Renal function is normal
• Rx: Metformin and Sulphonylurea
• She attends your clinic before Ramadan and her latest HbA1c is 8.1%.
• She experienced symptoms of hypoglycaemia twice during busy days at
work
• She always fasted Ramadan and she’s keen to fast and she asks for
your advice
Case Scenario
5. IDF-DAR Practical Guidelines
To Fast or not to Fast?
Level of risk grade?
How to Assess?
How to minimize her risk if
she fasts Ramadan?
6. IDF-DAR Practical Guidelines
The majority of Muslims with T2DM fasted
every day during Ramadan 1,2
T2DM, type 2 diabetes
1. Babineaux SM, Toaima D, Boye KS, et al. 2015
2. Hassanein et al, IDF 2017 Posterpresentation
.
<15 days ≥15 days
≥15 days
(<every day)
Every day
5.9%
94.2%
32.4%
67.6%
CREED Study1
Ramadan Prospective Study2
7. IDF-DAR Practical Guidelines
Blood glucose levels rise rapidly after iftar in
patients with diabetes
CGM, continuous glucose monitoring Lessan N, Hannoun Z, Hasan H, et al. 2015.
6.0
8.0
12.0
10.0
4.0
2.0
Time (hours)
Mean
interstitial
glucose
(mmol/L)
0
Fasting
Non-fasting
05:00
04:00
03:00
02:00
01:00
00:00
23:00
22:00
21:00
20:00
19:00
18:00
17:00
16:00
15:00
14:00
13:00
12:00
11:00
10:00
09:00
08:00
07:00
06:00
Iftar
Mean CGM profiles from patients with diabetes before andduring
Ramadan
• In the CGM study
there was no
difference in number
of glycaemic events
during Ramadan
compared with pre-
Ramadan
• Major inter- and
intra-individual
variability in CGM
profiles were
observed
• Rapid rise in blood
glucose after iftar
was recorded
8. Key risks associated with Ramadan fasting in
patients with diabetes1
Summer fasting periods can last up to 20 hours per day and are often
undertaken in hot and humid conditions which can exacerbate the risks
RISKS
Diabetic
ketoacidosis
Dehydration
and thrombosis
Hypoglycaemia
<70 mg/dL
(3.9 mmol/L)
Hyperglycaemia
>300 mg/dL
(16.7 mmol/L)
IDF-DAR Practical Guidelines
1. Al-Arouj M, Bouguerra R, Buse J, et al. 2005.
9. IDF-DAR Practical Guidelines
T2D Confirmed Hypoglycemia
10
CREED Study
BR - T2DM
(n=3250)
DR-T2DM
(n=3250)
Patients reporting
hypoglycemia
175 (5.4) 285 (8.8)
Abdul Jabbar et al, diabetes research and clinical practice 132 (2017) 19–26
10. IDF-DAR Practical Guidelines
HCPs and religious leaders must deliver the same
message regarding which patients should not fast
HCPs
Religious
leaders
• Not all patients will consult HCPs prior to fasting
• Some patients prefer to discuss fasting with their
local imam rather than their physician1,2
• Disparity has existed between medical and
religious advice on diabetes and Ramadan fasting
UNIFICATION
Hassanein M et al. Diabetes and Ramadan: Practical guidelines. Diabetes Res Clin Pract (2017),
http://dx.doi. org/10.1016/j.diabres.2017.03.003
1. Gaborit B, Dutour O, Ronsin O, et al. 2011.
HCP, healthcare professional 2. Hui E, Reddy M, Bravis V, et al. 2012.
11. IDF-DAR Practical Guidelines
IDF-DAR Practical Guidelines include the religious
opinion from the Mofty of Egypt
In all categories
people with diabetes
should follow
medical opinion if
the advice is not to
fast due to high
probability of harm
It should be noted
that some countries
may have different
religious views
Category 1: very high risk
Listen to medicaladvice
MUST NOT fast
Category 3: moderate/low risk
Listen to medical advice
Decision to use licence not tofast
based on discretion of medical
opinion and ability of the
individual to tolerate fast
Category 2: high risk
Listen to medicaladvice
Should NOT fast
Hassanein M et al. Diabetes and Ramadan: Practical guidelines. Diabetes Res Clin Pract (2017),
http://dx.doi. org/10.1016/j.diabres.2017.03.003
12. IDF-DAR Practical Guidelines
Both diabetes and patient characteristics
influence the risk of Ramadan fasting
• Safety of fasting is paramount and various elements should be considered
when quantifying the risk for such patients
• Risk quantification must be carried out on an individual basis for each
patient looking to fast
• The care given must be personalised according to the patient’s specific
circumstances
Factors for risk quantification1
Type of
diabetes
Patient
medications
Previous
Ramadan
experience
Individual
social and
work
circumstances
Presence of
complications
and/or
comorbidities
Individual
hypoglycaemic
risk
Hassanein M et al. Diabetes and Ramadan: Practical guidelines. Diabetes Res Clin Pract (2017),
http://dx.doi. org/10.1016/j.diabres.2017.03.003
1. Al-Arouj M. 2015.
.
13. IDF-DAR Practical Guidelines
Pre-Ramadan diabetes education should focus on
six key areas
When to
break the
fast
Risk
quantification
Blood
glucose
monitoring
Fluids and
dietary
advice
Exercise
advice
Medication
adjustments
Key
components of a
Ramadan-focused
educational
programme
Hassanein M et al. Diabetes and Ramadan: Practical guidelines. Diabetes Res Clin Pract (2017),
http://dx.doi. org/10.1016/j.diabres.2017.03.003
14. IDF-DAR Practical Guidelines
Impact of Day-time Hypoglycemia
% of patients who broke the fast due to hypoglycemia
65%
31%
Breaking the fast
Patients
Not breaking the fast
4%
Missing
Abdul Jabbar et al, diabetes research and clinical practice 132 (2017) 19–26
15. IDF-DAR Practical Guidelines
Individualisation of treatment is key to the
management of diabetes during Ramadan
• Despite the risks, many people with diabetes will fast during this month
• Most patients with T2DM can do so safely as long as medical advice is
sought and followed prior to and during fasting
SMBG, self-monitoring of bloodglucose;
T2DM, type 2 diabetes
Before
Pre-Ramadan
assessment
• Categorise risk
• Create individualised
management plan
• Provide advice on
self-management
During
Individualised
managementplan
• Nutritional plan
• Medication
adjustments
• SMBG
After
Post-Ramadan
follow-up
• Discuss medication
and regimen
readjustments
Hassanein M et al. Diabetes and Ramadan: Practical guidelines. Diabetes Res Clin Pract (2017),
http://dx.doi. org/10.1016/j.diabres.2017.03.003
16. IDF-DAR Practical Guidelines
Impact of Patient Education on Hypoglycaemic Events
5
0
10
15
20
25
40
35
30
Education No education
9 9
5
36
Pre-Ramadan
HE
X4 increase
17. Patients are advised to monitor their blood
glucose several times during the day1
Levels should be checked at
any time when symptoms of
hypoglycaemia are recognised
Recommended timings to check blood glucose levels during Ramadan fasting
Midday/Noon
Morning
Suhoor/dawn
Afternoon
Iftar/sunset
Morning Evening
12 Midnight 00:00
Midnight
2
1
4
5
6
12 Midday 12:00
3
pm
am
DAY
7
NIGHT
1. Pre-dawn meal (suhoor)
2. Morning
3. Midday
4. Mid-afternoon
5. Pre-sunset meal (iftar)
6. 2-hours after iftar
7. At any time when there are symptoms
of hypoglycaemia/hyperglycaemia or feeling unwell
IDF-DAR PracticalGuidelines
1. Hassanein M, Belhadj M, Abdallah K, et al. 2014.
18. IDF-DAR Practical Guidelines
The 10 principles of the RNP
Divide an adequate amount of calories
between suhoor, iftar and if necessary,
1–2 snacks
1
Meals should be balanced, with 45–
50% carbohydrate, 20–30%protein
and <35% fat
2
Design meals using the “Ramadan
plate” method
3
Avoid sugar-heavy desserts
4
Low-GI, high-fibre carbohydrates
are preferable
5
Hydration should be maintained
between meals by drinking waterand
non-sweetened beverages
6
Take suhoor as late as possible
7
Adequate protein and fat should be
consumed at suhoor to inducesatiety
8
Iftar should begin with water to
rehydrate, and 1–2 dates to raise
blood glucose
9
Low calorie snacks such as fruit,nuts,
or vegetables may be consumed
between meals
10
GI, glycaemic index; RNP, Ramadan Nutrition Plan
Hassanein M et al. Diabetes and Ramadan: Practical guidelines. Diabetes Res Clin Pract (2017),
http://dx.doi. org/10.1016/j.diabres.2017.03.003
19. IDF-DAR Practical Guidelines
All patients should break their fast if:
•Blood glucose <70 mg/dL (3.9 mmoI/L)
‒Re-check within 1 h if blood glucose 70–90 mg/dL (3.9–5.0 mmoI/L)
• Blood glucose >300 mg/dL (16.7 mmoI/L)**
•Symptoms of hypoglycaemia or acute illness occur
Frequency of SMBG:
1–2 times a day
Structured education for all patients, to include:
1.Risk quantification
2.The role of SMBG
3.When to break the fast
4.When to exercise
5.Fluids and meal planning
6.Medication adjustments during fasting
Advise not to fast
Moderate/low risk group
Allow to fast*
Very high risk group High risk group
Frequency of SMBG:
several times a day
To stratify risk and develop
an individualised management plan
1.Detailed history
2.Patient’s experience duringprevious
Ramadan
3.Patient’s ability to self-manage diabetes
ASSESS
All patients should schedule a visit with HCP 6–8 weeks before
Ramadan
Hassanein M et al. Diabetes and Ramadan: Practical guidelines. Diabetes Res Clin Pract (2017),
http://dx.doi. org/10.1016/j.diabres.2017.03.003
20. IDF-DAR Practical Guidelines
TZDs
No dose
modifications
Dose can be
taken with iftar or
suhoor
DPP-4
inhibitors
No dose
modification
s
GLP-1 RAs
Once appropriate
dose titration has
been achieved no
further dose
modifications are
needed
Metformin
Daily dose remains unchanged
Immediate release: OD – Take at iftar; BID – Take at iftar and suhoor; TID – Morning dose at suhoor, combine afternoon
and evening dose at iftar
Prolonged release: Take at iftar
SU
Switch to newer SU (gliclazide, glimepiride) where possible, glibenclamide should be avoided
OD – Take at iftar.* Dose may be reduced in patients with good glycaemic control
BID – Iftar dose remains unchanged.** Suhoor dose may be reduced in patients with good glycaemiccontrol
SGLT2 inhibitors
No dose modifications
Dose should be taken with iftar
Extra clear fluids should be ingested during non-fastingperiods
Should not be used in the elderly, patients with renal impairment, hypotensive individuals or those taking diuretics
Acarbose
No dose
modification
s
Short-acting insulin
secretagogues
TID dosing may be reduced/
redistributed to two doses taken
with iftar and suhoor
Hassanein M et al. Diabetes and Ramadan: Practical guidelines. Diabetes Res Clin Pract (2017),
http://dx.doi. org/10.1016/j.diabres.2017.03.003
21. IDF-DAR Practical Guidelines
TZDs
No dose
modifications
Dose can be
taken with iftar or
suhoor
DPP-4
inhibitors
No dose
modification
s
GLP-1 RAs
Once appropriate
dose titration has
been achieved no
further dose
modifications are
needed
Metformin
Daily dose remains unchanged
Immediate release: OD – Take at iftar; BID – Take at iftar and suhoor; TID – Morning dose at suhoor, combine afternoon
and evening dose at iftar
Prolonged release: Take at iftar
SU
Switch to newer SU (gliclazide, glimepiride) where possible, glibenclamide should be avoided
OD – Take at iftar.* Dose may be reduced in patients with good glycaemic control
BID – Iftar dose remains unchanged.** Suhoor dose may be reduced in patients with good glycaemiccontrol
SGLT2 inhibitors
No dose modifications
Dose should be taken with iftar
Extra clear fluids should be ingested during non-fastingperiods
Should not be used in the elderly, patients with renal impairment, hypotensive individuals or those taking diuretics
Acarbose
No dose
modification
s
Short-acting insulin
secretagogues
TID dosing may be reduced/
redistributed to two doses taken
with iftar and suhoor
Hassanein M et al. Diabetes and Ramadan: Practical guidelines. Diabetes Res Clin Pract (2017),
http://dx.doi. org/10.1016/j.diabres.2017.03.003
22. IDF-DAR Practical Guidelines
Insulin therapy
Switch to insulin analogues where possible
• Long- or intermediate-acting basal insulin:
• OD – NPH*/detemir/glargine/degludec. Take preferably at iftar. Reduce dose by 15–30%
• BID – NPH/determir/glargine. Take usual morning dose at iftar. Reduce evening dose by 50% and
take at suhoor
• Rapid- or short-acting prandial/bolus insulin:
• Take normal dose at iftar. Omit lunch-time dose. Reduce suhoor dose by25–50%
• Premixed insulin:
• OD – Take normal dose at iftar
• BID – Take usual morning dose at iftar. Reduce evening dose by 25–50% and take atsuhoor
• TID – Omit afternoon dose. Adjust iftar and suhoordoses
Dose titration 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 fasting. Increase dose by 0–30% earlyafter
iftar
• Bolus rate – Normal carbohydrate counting and insulin sensitivity principlesapply
Pre-iftar** Post-iftar**/P ost-suhoor***
Fasting/Pre-iftar/Pre-suhoor BG
Basal insulin Short-acting 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 (3.9–5.0mmol/L) Reduce by 2 units Reduce by 2 units Reduce by 2 units
90–126 mg/dL (5.0–7.0mmol/L) No change required No change required No change required
126–200 mg/dL(7.0–16.7
mmol/L)
Increase by 2 units Increase by 2 units Increase by 2 units
> 200 mg/dL (16.7 mmol/L) Increase by 4 units Increase by 4 units Increase by 4 units
Hassanein M et al. Diabetes and Ramadan: Practical guidelines. Diabetes Res Clin Pract (2017),
http://dx.doi. org/10.1016/j.diabres.2017.03.003
23. IDF-DAR Practical Guidelines
Summary
• The rising prevalence of diabetes in the Muslim population, combined with
the high numbers that participate in fasting, creates a pressing need for
effective guidance for the management of diabetes during Ramadan
• The IDF-DAR Practical Guidelines have been designed to provide HCPs
with background and practical information in order to optimise care for
patients with diabetes who plan to fast during Ramadan
• Individualised Ramadan-specific treatment regimens should be provided
for each patient, which are sensitive to regional and cultural factors
• Education, communication and accessibility are all critical to the success
of the guidance provided in these guidelines
• More research is required to increase understanding and safetyof
Diabetes and Ramadan
DAR, Diabetes and Ramadan International Alliance;
HCP, healthcare professional; IDF, International DiabetesFederation