• Credits

  • Section Writer: Dr. Om J Lakhani
  • Section Editor: Dr. Om J Lakhani

• **Fasting regulations during Ramadan **

• Q. How long is the fast period during Ramandan ?

  • About 1 month

• Q. What are the restriction suggested ?

  • Avoid eating, oral medication, drinking, smoking, and sexual activity from dawn to sunset

• Q. Who is exempted?

  • Elderly
  • Children
  • Pregnant women
    • Pregnant women are told to fast for a similar period after delivery
  • Those who cannot fast are asked to donate to the poor for every day of missed fast

• Q. How long during the day the fast lasts?

  • Since Ramadan is based on the Lunar calendar, it starts 10-11 day earlier each time
  • Hence the fasting may last longer in Summer times

• Q. What is the landmark epidemiological study for Diabetes and Ramadan?

  • EPIDIAR study

• Q. Are patients with Diabetes exempt from fast?

  • Yes
  • Yet they fast for 15 days at least

• Q. What is Shawwal ?

  • 1 month following Eid

• **Physiology of the Ramadan fast **

• Q. What asspects of physiology are affected during the Ramadan  ?

  • Meal times change
  • Fluid homeostasis changes
  • Sleep and circadian rhythm changes
  • Changes in physical activity

• Q. What are the typical meal times in Ramadan?

  • 6:00 pm and 3:00 am

• Q. What is Suhoor?

  • Muslims wake up before dawn to eat before the fast begins
  • This is called Suhoor
  • Many go back to sleep and wake up later again

• Q. What is  Iftar?

  • Evening meal after sunset
  • The largest calorie intake is during Iftar

• Q. What is the impact of sleep on Diabetes in Ramadan?

  • Sleep disturbance is well known to increase insulin resistance
  • There is noticed sleep disturbance in Ramadan
  • Its effect on Insulin resistance is not known, but it is likely it increases Insulin resistance

• Q. What happens he Cortisol in Ramadan ?

  • The cortisol circadian rhythm is changed
  • It is lower during the morning and higher in the evening
  • Hence they feel lethargy during daytime

• Q. What happens to hunger?

  • During the initial days, the hunger is increased, while during the later days of fast, there is adaptation- particularly in females

• Q. What happens to the bodyweight during Ramadan?

  • There are conflicting reports
  • Current evidence suggests that body weight reduces or remains the same during Ramadan
  • Males typically lose weight, while women maintain weight

• Q. How long do liver glycogen stores last during fasting?

  • 12-13 hours

• Q. Is liver glycogen depleted in Ramadan?

  • Yes
  • This is because Fast may last for >12 hours
  • Hence they are prone to ketosis after glycogen depletion

• Q. When does ketosis typically occur?

  • If they have their first meal before dawn- it typically occurs in the afternoon
  • While if they skip that meal – then it occurs in the morning time

• Q. Does this lead to changes in Fasting plasma glucose in people with Diabetes?

  • Interestingly No !
  • There is little change in Glucose levels observed in CGMS in diabetics
  • There is a mild increase after Iftar noted

• Q. What happens to lipid profile during Ramadan?

  • During Ramadan, there is an observed reduction in LDL
  • There is a favorable lipid profile during Ramadan months

• Q. What happens to leptin levels during Ramadan?

  • Morning levels of leptin were higher, and nighttime levels were lower

• Q. What about adiponectin?

  • Studies have shown opposite results- some showing increase while other reduction of adiponectin

• Q. What is the potential risk for people with Diabetes during Ramadan?

  • Increase risk of
    • Hypoglycemia
    • Ketoacidosis
    • Hyperglycemia
    • Dehydration
    • Thrombosis

• Q. What is the risk of hypoglycemia?

  • 4-7 times increase risk of severe hypoglycemia in type 1 and type 2 diabetics
  • There are also 3-5 times increase risk of hyperglycemia
  • Also, response to hypoglycemia may be blunted due to autonomic dysfunction
  • However, CGMS has shown little difference

• Q. What is the result of dehydration in people with Diabetes?

  • Dehydration in people with Diabetes during Ramadan increases the risk of retinal vein occlusion, which is found to increase during Ramadan months

• **Risk stratification of Diabetes in Ramadan **

• Q. What is the IDF/ADA risk stratification for people with Diabetes in Ramadan?

  • Four groups according to ADA guidelines
    • Very high risk
    • High risk
    • Moderate risk
    • Low risk
  • These risk group are endorsed by Islamic religious leaders as well
  • IDF proposes 3 group- combines the last 2 groups

• Q. Who is in category 1 – very high risk?

  • Very high risk group includes
    • Severe hypoglycemia in last 3 months
    • Hyperglycemic hyperosmolar state in the last 3 months
    • Diabetic ketoacidosis in last 3 months
    • Pregnant with diabetes  / GDM on Insulin/ SU
    • Poorly controlled type 1 diabetes
    • Hypoglycemic unawareness
    • Severe macrovascular disease
    • Old age
    • Acute illness
    • CKD stage 4/5 or on dialysis
  • This group are EXEMPT FROM FAST

• Q. What are high-risk groups?

  • High risk group includes
    • Poorly controlled type 2
    • Type  2 on MDI/Premixed
    • Well-controlled type 1
    • GDM/Diabetes in pregnancy on metformin/diet control
    • Stable macrovascular disease
    • CKD stage 3
    • Those doing intense physical labor

• Q. Who are low and moderate risk?

  • Type 2 diabetics on oral medications / basal insulin alone

• Q. Who is exempt from fast?

  • Very high risk and high risk are exempt
  • Low and moderate risk can fast

• Q. Are type 1 diabetes patients exempt from fasting?

  • Type 1 diabetes fall in high or very high risk and are always exempt from fast
  • Young type 1 otherwise well may fast- however, they must be educated well
  • SMBG during fast is vital

• **Pre-Ramadan education **

• Q. What are the key components of Ramadan medical education?

  • Risk stratification
  • Blood glucose monitoring
  • Fluid and diet advise
  • Exercise advice
  • Medication adjustment
  • When to break the fast

• Q. When should the risk stratification be done?

  • It must be done 6-8 weeks before Ramadan

• Q. Is SBMG a violation of Ramadan rules?

  • No
  • This is a misconception
  • Blood glucose monitoring is allowed during Ramadan

• Q. Which particular time is blood glucose monitoring particularly required ?

  • After iftar (post-prandial)

• Q. Summarize the dietary advice during Ramadan?

  • Divide daily calories between suhoor and iftar, plus 1-2 snacks if necessary
  • Ensure meals are well balanced
    • 45-50% carbohydrate
    • 20-30% protein
    • <35% fat (preferably mono- and polyunsaturated)
  • Include low glycemic index, high fiber foods that release energy slowly before and after fasting E.g. granary bread, beans, rice
  • Include plenty of fruit, vegetables and salads
  • Minimise foods that are high in saturated fats E.g. ghee, samosas, pakoras
  • Avoid sugary desserts
  • Use small amounts of oil when cooking E.g. olive, rapeseed
  • Keep hydrated between sunset and sunrise by drinking water or other non-sweetened beverages
  • Avoid caffeinated and sweetened drinks

• Q. What about exercise?

  • Rigorous exercise is not encouraged
  • Regular light to moderate exercise during Ramadan is encouraged

• Q. When should the fast be broken?

  • It is broken if they develop hypoglycemia

• Q. What is the READ study?

  • Ramadan Education and awareness in Diabetes a UK study
  • The study showed that Pre-Ramadan education led to weight loss and lesser hypoglycemia

• Q. Give some other practical advice on nutrition during Ramadan?

  • Avoid excess calories in Iftaar
  • Avoid frequent snack between meals
  • Avoid early Suhoor, which can cause hypoglycemia before Iftar
  • Proper hydration
  • Avoid sweetened beverages
  • Control on desserts and sweets
  • Consumption of low GI index food
  • Avoid fried food
  • Divide calories equally between Suhoor and Iftar

• Q. Can Ramadan be an opportunity to lose weight for obese diabetics?

  • Yes

• Q. What are caloric targets for people with Diabetes during Ramadan?

  • 
  • Ref: Hassanein M, Al-Arouj M, Hamdy O, Bebakar WM, Jabbar A, Al-Madani A, Hanif W, Lessan N, Basit A, Tayeb K, Omar MA. Diabetes and Ramadan: practical guidelines. Diabetes research and clinical practice. 2017 Apr 1;126:303-16.

• Q. What should the percentage of caloric distribution?

  • Suhoor – 30-40%
  • Iftar- 40-50%
  • Snack – 10-20%

• Q. What should be the meal composition of Suhoor?

  • Good protein and fat content
  • More fiber content
  • All this will help to kill hunger and avoid hypoglycemia

• Q. Describe the ‘ramadan plate’?

  • 
    • Ref: Hassanein M, Al-Arouj M, Hamdy O, Bebakar WM, Jabbar A, Al-Madani A, Hanif W, Lessan N, Basit A, Tayeb K, Omar MA. Diabetes and Ramadan: practical guidelines. Diabetes research and clinical practice. 2017 Apr 1;126:303-16.

• MEDICAL MANAGEMENT OF DIABETES DURING RAMADAN

• Q. When should planning for ramadan management start

  • Pre-Ramadan assessment must be done 6-8 weeks before Ramadan. This includes
  • Medical evaluation and evaluation of Diabetes status
  • Risk categorization and advice for fast
  • Education
  • Dietary advice
  • Medication advise during Ramadan

• Q. Summarize the Pre-Ramadan flow chart ?

  • 
  • Ref: Hassanein M, Al-Arouj M, Hamdy O, Bebakar WM, Jabbar A, Al-Madani A, Hanif W, Lessan N, Basit A, Tayeb K, Omar MA. Diabetes and Ramadan: practical guidelines. Diabetes research and clinical practice. 2017 Apr 1;126:303-16.

• Q. How frequently to perform SMBG?

  • Low /moderate risk- 1-2 times a day
  • High / very high risk- avoid fast, if done, then check several times a day

• **Pharmacological management in patients with type 2 diabetes **

• Q. What are changes recommended for Metformin?

  • Metformin can be continued during fasting. Timing needs to be adjusted
    • Once a day – take during Iftaar
    • long-acting preparation- take during Iftar
    • Twice  a day – take at Suhoor and Iftar
    • Thrice a day – combine two doses and give at Iftar and one at Suhoor

• Q. What about Acarbose?

  • No dose adjustment required and can be continued

• Q. What about Thiazolidinones (TZD) ?

  • They can be continued during Ramadan
  • Can be taken at Suhoor or Iftar
  • May cause weight gain according to studies done in Ramadan

• Q. What about use of Repaglinide ?

  • Studies have shown no increased risk of hypoglycemia with repaglinide
  • Hence they are ideal medications to be used in Ramadan
  • They can be given twice – before Iftar and Suhoor and dose of drugs adjusted according to the meal content

• Q. How much risk of hypoglycemia is seen with Sulphonylureas (SU) during Ramadan?

  • 1/5th of patients on SU experience hypoglycemia during Ramadan

• Q. Which SU has a higher risk ?

  • Highest with glibenclamide
  • Then glimiperide
  • And last is gliclazide
  • Glibenclamide typically causes hypo in mid-afternoon during Ramadan

• Q. What is the guidance on Use of SU ?

  • Glibenclamide- avoid
  • Glimiperide , Gliclazide and glipizide may be used

• Q. What are the dosing recommendations for SU

  • Once a day- give during Iftar – may consider reducing the dose
  • Twice a day –give during Iftar and Suhoor – reduce the Suhoor dose

• Q. What is the recommendation for SGLT2 inhibitors ?

  • Remember there is additionally the risk of dehydration and ketosis in ramadan
  • One study for the use of Dapa in ramadan did not show any significant adverse effect
  • It can be used in ramadan but use with caution
  • If used given at Iftar and patient asked to take more fluid during the nighttime

• Q. What is the STEADFAST study?

  • Compared use of Vildaglitpin vs. gliclazide during Ramadan
  • There was no difference in the overall incidence of hypoglycemia; however, the number of patients who had at least one  hypoglycemia more with gliclazide
  • VECTOR trial showed a lower incidence of hypoglycemia in the vildagliptin group

• Q. Overall, what is the take on the use of DPP-IV is ramadan?

  • They are safe and effective with a low risk of hypoglycemia
  • They are ideal drugs during Ramadan
  • They do not require any modifications during Ramadan

• Q. What about GLP1 analogs?

  • Liraglutide is a safe and practical add on to Metformin amongst Ramadan patients
  • It does not require any dose modification

• **Insulin treatment during Ramadan **

• Q. What is preferred in Ramadan- analog insulin or Regular insulin?

  • A trial by Akram et al. showed lower Postprandial glucose after Iftar in the Lispro group.p vs. that of Regular human insulin
  • Hence analogs are preferred

• Q. Is Basal insulin glargine safe in Ramadan ?

  • Yes

• Q. What is a good strategy for Ramadan patients with premixed insulin?

  • Give insulin 50/50 at Iftar and insulin 30/70 at Suhoor
  • This is better than twice daily premixed 30/70

• Q. Give the guidelines for basal insulin use in Ramadan?

  • Once a day basal insulin- reduce dose by 15-30% and give it at Iftar
  • For twice a day basal insulin – give the morning dose with iftar and evening dose with Suhoor and reduce the suhoor dose by 50%

• Q. What about short-acting insulin?

  • Omit lunch-time dose
  • Give the usual dose at Iftar and adjust as required
  • Reduce amount by 25-50% at Suhoor

• Q. Describe the insulin dose adjustment?

  • 
  • Ref: Hassanein M, Al-Arouj M, Hamdy O, Bebakar WM, Jabbar A, Al-Madani A, Hanif W, Lessan N, Basit A, Tayeb K, Omar MA. Diabetes and Ramadan: practical guidelines. Diabetes research and clinical practice. 2017 Apr 1;126:303-16.

• Q. What about Premixed insulin?

  • Once a day – give the same dose but at Iftar
  • Twice a day- reduce the Suhoor dose by 25-50%
  • Thrice a day – switch to twice a day and adjust doses at Iftar and Suhoor

• Management of type 1 diabetes during Ramadan

• Q. Does the risk of Diabetic ketoacidosis (DKA) risk increase during Ramadan?

  • Yes

• Q. When should patients with type 1 diabetes they break their fast?

  • Blood glucose <70 mg/dl or >300mg/dl

• Q. What are the SMBG guidelines for a patient on MDI / Type 1 / High risk during Ramadan?

  • Check BG during the following time
    • Pre-suhoor
    • Morning
    • Midday
    • Mid-afternoon
    • Before Iftar
    • 2 hours post Iftar
  • Any time there is a feeling of hypoglycemic / unwell

• Q. What adjustments are advised for patients with type 1 diabetes who insist on fasting?

  • Basal-bolus would be ideal
  • Reduce the basal dose by 30%
  • Skip the afternoon short-acting
  • Reduce suhoor dose by 30%
  • Normal dose at Iftar

• Q. What about the use of insulin pumps?

  • They can be used during Ramadan
  • However, they will need appropriate adjustments
  • Reduce basal rate by 30% in last few hours of fast during the day and increase by 30% after Iftaar
  • Keep Insulin sensitivity factor and Insulin carb ratio the same

• **Pregnancy, Diabetes, and Ramadan **

• Q. What is the general recommendations for pregnant women with diabetes during Ramadan ?

  • Pregnant women should not fast
  • However, Muslim laws insist they must compensate at a later date
  • However, they will have to fast alone, which is more difficult
  • Hence many chose to fast during Ramadan despite against medical advice
  • If they have diabetes, they are Very high risk

• Q. What are the potential problems of fasting during pregnancy?

  • Lower birth weight
  • Learning disabilities in the fetus
  • A lower weight of the placenta
  • Poor growth
  • Long term adverse programming of the fetus

• **Post Ramadan **

• Q. What is done during the Post Ramadan period ?

  • Avoid over indulgence during Eid
  • Schedule a visit with Healthcare provider after Ramadan is over

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