What is Diabetes?
Diabetes mellitus or (high blood sugar) is a widespread andrapidly increasing condition where glucose levels (normal fuel for day to dayenergy) cross its upper limit (126 mg/dl in fasting state) of normal. This highglucose level ends up damaging most of the body tissues mainly blood vessels inheart, kidneys, eyes, feet. This leadsto very high morbidity (handicaps) and mortality (death) among populations if nottaken care.
What is Ramdan
Ramdan is a lunar-based month in the Muslim calendar whichis generally between 29 and 30 days duration. Its beginning and end is linkedto the sighting of the new moon following month of Shaban. According to Muslimcalendar Eid al-Fitr also sometimes referred to as ‘Sweet Eid’ in Asia marks the end of the fasting month ofRamadhan observed by millions of Muslims across the world.
What alteration in lifestyle is expected in Ramdan?
During Ramadhan, Muslims must fast (not taking any food or even water) from dawn (Sehri or Suhur) to sunset (Iftiari or Iftar) whih may be 8-20 hours depending up the region and season. Accordingly there is a sudden and major change in the daily meals.
These changes include meal timing, total calories, food types and consistency, exercise changes etc. Food, fluids and oral medications can be consumed freely during the night, but forbidden during the daytime (between Sehri and Iftiari). During the month of Ramadhan, people usually change from 3 major meals (breakfast, lunch, dinner/supper) to two:Iftar around 7:00 to 8 pm and Sahur will be around 3 to 4:00 am with free access to foods during night hours.
Are there any exemptions?
Although the Ramdan fast (ROZA) is obligatory for allhealthy Muslims, patients with one or more of the following are advised not tofast: Physiological conditions: Pregnancy and lactation (feeding baby).Co-existing major medical conditions such as: acute peptic ulcer, people proneto urinary stones formation with frequent urinary tract infections, cancers ,overt cardiovascular diseases (recent MI, unstable angina), severe psychiatricconditions, pulmonary tuberculosis and uncontrolled infections, severebronchial asthma, hepatic dysfunction (liver enzymes >2 x ULN). Besides someconditions related to diabetes are also considered to prohibitions:
1. Multiple insulin injections per day (as type 1 DM)
2. Recent hyperosmolar state or DKA
3. Poorly controlled diabetes (Mean Random BG > 300)
4. Hypoglycemia unawareness
5. Nephropathy with serum creatinine more than 1.5 mg/dL
6. Severe retinopathy
7. Autonomic neuropathy: gastroparesis, postural hypotension
8. Major macrovascular complications: coronary and cerebrovascular
What are the issues of Diabetes and Ramdhan?
As already mentioned 30-40% diabetic subjects still insist on fasting athough exempted from observing fast (EPIDIAR study). As diabetes management is not exactly compatible with the tradition of fasting during the month of Ramadhan where Muslims restrain from food, water and even medication from dawn to sunset, it is the onus on the physician to clearly explain risks.
Therefore, it is needless to say Roza is to be planned well before the arrival of Ramadhan and the patient and his physician should discuss the pros and cons after a fresh evaluation. Besides it is incumbent on the physicians to be educated about the issues during Ramdan fasting among diabetics in order to address them successfully.
What should be your approach once a diabetic individual likes to fast?
After initial evaluation of control and complication status, one needs to categorize the subjects in terms of their risks involved in fasting (low, moderate or high risk) as per the practice guidelines by The International Diabetes Federation.
Patients should be stratified into their risk of hypoglycemia and/or the presence of complications prior to the beginning of fasting. Patients at high risk of hypoglycemia and with multiple diabetic complications should be advised against prolonged fasting.
Structured diabetes education is an essential tool for the management of diabetes during the fasting period and after breaking the fast during Ramadhan. In a retrospective analysis subjects who diabetes education had less weight gain and fewer episodes of hypoglycemia compared with a group that did not receive education prior to Ramadhan.
What is the role of medical nutrition therapy ?
Since the diabetic individual observing Ramadhan fast caneat through out night hours till predawn (Sehri) lower component of complexcarbohydrate at the night meal and higher complex carbohydrate at predawn seemsbeneficial as shown by studies using diet popularly known as MaPi diet. Dietdevised by Mario Pianesi is rich in complex carbohydrates, whole grains,vegetables and legumes, and fermented products, and low in unrefined sea saltand green tea, without fat or protein from animal sources (including milk anddairy products) and no added sugars and go well with ADA and European nutritionrecommendations.
There is growing evidence of the beneficial effects of dates (usual practice in breaking fast) in improving glycemic and lipid control in patients with diabetes and a possible reduction in cardiovascular risk factors.
According to ADA Working group recommendation 2010 consumption of 100 g of dates provides 50–100% of the recommended dietary fiber intake. In addition, dates have high fructose content with a 1:1 ratio of fructose and glucose. Since fructose is a more powerful sweetener than glucose, it is less rapidly absorbed than sugar, which results in a relatively low glycemic index (GI). The GI of most common dates range between 35 and 55, with an average of 42.
What changes are required in exercise pattern?
Physical activity can be tailored according to theconvenience and risk of hypoglycemia. Evening exercise after Iftiari or morningexercise after Sehri can be advised with avoidance of strenous exercise beforeIftiari to avoid hypoglycemia. Taraweeh (long prayers) should be considered asa part of the daily exercise program. So patients are to be advised to monitorBG concentration, to eat starchy foods with Iftar, which are digested slowly,and to drink plenty of water before prayers to avoid dehydration.
How do you modify drug regimens during Ramdan fast?
There are many and ever increasing choices for patients withDiabetes opting to observe ROZA (Table 1). All these agents have simplified thediabetes care but the options need to be weighed against risks duly discussedfully with the patients. Patients on agents such as metformin, α-glucosidaseinhibitors, TZDs, and DPP4 inhibitors do not need major dose adjustments asthese appear to be safe.
Thus the agents likemetformin, pioglitazone, Gliptins (sitagliptin, Saxagliptin, Linagliptin andVildagliptin) and alpha glycosidase inhibitors (Voglibose or Acarbose) are thefirst line choices provided diabetes is uncomplicated and is not so severe(high level of glucose). These agents can be given at any time (Iftiar orSehri) and do not cause hypoglycemia (low glucose).
There is increasing knowledge on the efficacy and safety ofDPP4 inhibitors as monotherapy or in combination with metformin therapy. Theuse of DPP4-inibitors appears to be safe and with low rates of hypoglycemia.The use of GLP-1 RA may also be of benefit in obese patients in improvingglycaemic control and in reducing appetite during Ramadhan. There is littledata on the safety and efficacy of SGLT-2 inhibitors during the fasting periodof Ramadhan
Insulin secretors such as Sulfonylureas and Glinides having increased risk ofhypoglycemia need dose adjustment of stopping before the start of the fast,depending on the degree of glycemic control, kidney function, and presence ofdiabetic complications. Patients with type 1 and type 2 diabetes treated withinsulin should be educated on the appropriate use of insulin administration andthe need for glucose monitoring during the fasting period. Most patientsrequire a modification of the basal insulin dosage and on the use of premealinsulin to cover meals after breaking of the fast.
How does pre Ramdan regimen guide in current managementplan?
The regimen (type of drug), control (HbA1C level and glucoselevel) and complications status (nephropathy, gatroperesis etc. ) is pivotal informatting the treatment plan. These are as :
Diet controlled patients
1. Risk of fasting is quite low
2. Risk for occurrence of post prandial hyperglycemia
3. Distribute the calorie to >2 smaller meal during non-fasting hours
Type 2 Diabetes on Metformin
• May safely fast
• 2/3 total daily dose immediately before sunset meal 1/3 before pre-dawn.
Type 2 Diabeteson Thiozolidinediones (TZDs) /DPP-4i /GLP-1 RA/SGLT2i/AGI
1. No dose change required
2. Low risk of hypoglycemia
Type 2 Diabetes within Sulphonylureas
Glimepiride and Gliclazide MR are the second line agents buttheir requirement of doses should be less than half maximal. Importantprecaution is that these agents can be used at the time of Iftiar (eveningmeal) and patients have to be warned about hypoglycemia. A blood glucose levelof <70 mg/dl at around 3-4 pm (10 hours fast) should be prompted to breakthe fast.
Type 1 Diabetes or Type 2 Diabetes on insulin
Among insulin users (mainly type 1 diabetics), majority of subjects are advised to refrain from the fast especially, if there is prevalent poor glucose control or history of frequent hypoglycemia, as has been exempted in the Holy Quran (SuraBakra Verse 83:85).
However, as already said still large number of subjects insists in fasting and deserves particular attention and advice. If the total insulin dose is approximately 30 units a day, it is advisable to divide the insulin in to two doses (premixed insulin generally) and administer two third before Iftiar and 1/3rd before Sehri (10-20% reduction).
Commonly used are analogues of the insulin: ultra-shortacting analogues such as Lispro (Humalog), Aspart (Novorapid), etc. that have a very short duration of action and hence low chances of hypoglycemia (low sugar). These agents also don’t require any waiting before the meal and therefore, are called “shot and eat” agents.
Hence they are quietappropriate for fasting diabetics. Patients on peaklessinsulins such as Glargine (Glaritus, Basalog, Lantus), detmir (Levimer) orDegludec (Tresiba) in combination with the above analogues or oral agents, have to shift basalinsulin with Iftiari. Subjects on insulin pump may require 20% reduction in basal rate with individualizations of blouses.
Guidelines to monitor?
The self monitoring of blood glucose (SMBG) is the key and patients have to be on close care of their treating physicians. They have to be advised clearly to end fast prematurely in case of hypoglycemia which generally happens around afternoon to evening.
Contrary to the widespread belief among some Muslim communities that injection or pricking the finger for glucose testing breaks the fast, which may lead to patients skipping insulin injections or glucose testing during Ramadhan. Patients and care givers whether given by the subcutaneous, intramuscular, or intravenous route and finger prick does not void the fast instead increases safety by detecting any hypoglycemia at earliest.
This becomes more important in view of the data from retrospective surveys that despite education 77% of patients did not perform blood glucose monitoring as they believed that skin pricking during fasting would make the fast void. The low rates SMBG may result in a higher risk of hypoglycemia especially in sulphonylurea or insulin-treated patients with diabetes.
What are advances in Diabetes management during Ramdan fast?
Life of Diabetics in general is improving owing to newer developments and it holds true for those fasting in holy month of Ramadhan. Although modes of insulin administration and types of analogues are constantly improving patient convenience, physicians have to be geared.
In near future the Newer molecules like Semaglutide/ Lixenatide (once a week) etc. may be popular in Ramadhan as these do not cause low glucose and need to be given weekly. The use of insulin pump therapy has been shown to be effective in improving glycemic control and in reducing the risk of hypoglycemia in patients with type 1 diabetes during Ramadhan.
The use of an insulin pump helps to provide a continuous basal rate of insulin during the fasting period and to rapidly cover for meals intake after the breaking of the fast. In one study, patients on insulin pumps monitored by continuous glucose-monitoring (CGM) device didn’t show any significant increase in the risk of hypoglycemia when comparing the periods before, during, and after the end of fasting.
However, the insulin infusion rate needs to be adjusted, with a reduction in the basal insulin rate during the day and greater postprandial boluses after the breaking of the fast.The use of CGM devices have evolved during the past decade from being a research tool to serving as a device useful for clinical care in patients with type 1 and type 2 diabetes.
CGM devices provide information about the current glucose concentration, direction, and rate of change in glucose concentration. Since it provides glucose values every 5–10 min 24 h a day, CGM may have an advantage over glucometer testing with respect to reducing the incidence of severe hypoglycemia during fasting. However, no randomized controlled studies, however, have studied the impact of CGM in patients with diabetes during Ramadhan
To conclude that while respecting the faith and belief adiabetic individual desiring to observe Ramdan fast, the pros and cons have tobe discussed well before hand to ensure safety. Uncomplicated andwell-controlled diabetics on diet, metformin, glitazone, or gliptin classes ofdrugs can be allowed to fast comfortably.
Those who are uncontrolled have complications, are on sulphonylureas, or multiple insulin doses are at risk of hypoglycemia (low glucose) or hyperglycemic emergency and hence need close, individualized, care and monitoring.
Misconceptions and local habits should be addressed and dealt with in any educational intervention and therapeutic planning with patients with diabetes. Efforts are still needed for controlled prospective studies in the field of efficacy and safety of the different interventions during the fasting of Ramadhan I Diabetics.
Care during after Eid days
The end of Ramadhan is followed by a 2-3 day festival ofEidul-Fitr (Sweet Eid) which is marked with festivities, sharing of food, andsweet beverages. This may pose risks of hyperglycemia during this time, as manyindividuals overindulge in eating and drinking. Subjects should change back to its pre Ramdan regimen if glycaemic control was satisfactory.
Dr. Mohd Ashraf Ganie is Professor Department ofEndocrinology SKIMS Srinagar. He is former Additional Professor Endocrinologyand Metabolism, AIIMS New Delhi.
Fasting during the holy month of Ramadhan forms one of the five pillars of the Muslim faith. Almost every adult Muslim has an intense desire to fast despite some common health issues like diabetes, where fasting could prove harmful for the person. In the current year, month of Ramadhan falls in the months of May & June and days are expected to be longer and hotter.
Is fasting associated with any risk?
Restriction on eating during long, hot and humid days andunrestricted over eating during night can result in dehydration (deficiency ofwater inside body) and low blood glucose level during daytime and high bloodglucose during feasting time. There also is an increased risk of clotting ofblood in the vessels (because of dehydration and high blood glucose). Keepingthese complications and balance of religious sentiments in mind, experts haverecommended some guidelines for the physicians, patients and their caregivers.
Who can fast safely?
According to these guidelines, following group of patientscan safely fast during Ramadhan:
1. Well-controlleddiabetes treated with one or more of the following modalities: diabetescontrolled with diet and exercise only (lifestyle therapy)
2. Diabeteswell controlled on medications like metformin; gliptins like sitagliptin,vildagliptin, saxagliptin and teneligliptin; alpha glucosidase inhibitors likeacarbose and voglibose; thiazolidinediones like pioglitazone; second-generationsulfonylureas (like glipizide, glimpiride and gliclazide); incretin-basedtherapy (like GLP-1 receptor agonists); gliflozins like canagliflozin,dapagliflozin, empagliflozin etc.
3. Diabetescontrolled on insulin dose of insulin given once daily in the form of basalinsulin
To carry on fasting safely, this group of patients should0follow the advice from the treating physician regarding diet, exercise,medications and monitor blood glucose frequently.
Who should not fast?
Because of high risk of fatal complications during fasting,a patient with diabetes with one or more of the following is advised not tofast:
1. Type 1 diabetes( diabetes of young children needing multiple insulin injections daily
2. Poor blood sugar control in the previous three months (HbA1c of more than 8.5%)
3. History of hospitalization for ketoacidosis during 3 months before Ramadhan
4. Advanced heart, liver and kidney disease
5. Cognitive dysfunction (problems in judgment and understanding) and epilepsy
6. Repeated episodes of low blood glucose
7. Severe hypoglycemia(low blood glucose needing assistance of another person to treat) in last 3 months before Ramadhan
8. Patient getting low blood glucose without symptoms( unawareness)
9. Pregnant women with diabetes
10. Acute illness including diabetic foot or foot ulcer
11. People with diabetes taking intense physical labor
Diet composition during Ramadhan
Generally, people tend to overeat during Ramadhan and dietis typically rich in carbohydrate and fat, both these factors are responsiblefor excessive rise in blood glucose and its consequences. Because of fear ofblood glucose falling during daytime, people tend to overeat during suhur aswell.
A healthy diet during Ramadhan consists of a balanced dietwith distribution into 2-3 servings (rather than two big servings) duringnon-fasting hours. Pre dawn meal (suhur) should mainly comprise foods rich incomplex carbohydrates like whole grain cereals, vegetables such as beans andlentils and fruits. Eating dates traditionally marks the end of a fast but arevery rich in sugars; a portion of 1-2 dates may however not raise bloodglucose.
Dinner should be taken as early as possible after iftar andshould mainly consist of a combination of whole-wheat flour chapattis (or asmall portion of rice), vegetables and small amount of meat. Salads should betaken to increase the fiber content. A late night snack with a glass of milk ora portion of fruit will maintain normal blood glucose until suhur time.
Fluid intake should be increased during nonfasting hours.Avoid tea, coffee and cola because these result in excessive urination andhence water loss from the body. In summary diet during Ramadhan should not bedifferent from that of pre Ramadhan and should be rich in protein and essentialnutrients rather than in carbohydrates and fat.
Exercise (and Taraweeh prayers) during Fasting
Light and moderate exercise is safe; it is better to go foran exercise like daily walk after suhur or iftar. Exercise is not recommendedduring daytime and before iftar as this increases the risk of hypoglycemia(falling glucose level).
Taraweeh prayers and walking to the mosque should beaccounted for in the exercise regimen. Individuals should carry water and rapidacting carbohydrate drink (for correction of hypoglycemia in case such a thinghappens). A person going for Taraweeh prayers (which usually is completed in anhour) does not need to go for a regular walk
When to monitor blood glucose during fasting?
Following are recommended for blood glucose monitoring:
3. Blood glucose monitoring during fasting does not break the fast
4. Monitorblood glucose levels at the beginning of the fast, at mid day and before iftar
5. Bloodglucose levels should be checked if any symptoms of hypoglycemia (low bloodglucose) such as increased appetite, sweating, headache, nervousness or anyunpleasant feeling or if the patient becomes unwell.
When to terminate fast?
4. If at anytime blood glucose level is less than 75mgs/dl during the fast
5. Bloodglucose levels > 300mgs/dl any time during the fast
6. Symptomsof hypoglycemia (like increased appetite, sweating, headache, nervousness orany unpleasant feeling) even if blood glucose level is normal
7. Patient feels unwell
In these situations, it is dangerous not to terminate thefast
Changes in medications recommended during Ramadhan
9. Patientstaking metformin, pioglitazone, gliptins, acarbose, voglibose, SGLT2 inhibitorsand GLP1 receptor agonists, no change in medication required
10. Once a daysulfonylurea dose to be taken after iftar
11. Twice aday sulfonylureas: Morning dose to be halved and taken with Suhur, evening doseremains same
12. Basalinsulins like NPH, glargine or degludec: reduce daily dose by 20% and give atbed time
13. Insulin30/70, twice daily: Morning dose to be taken after iftar, evening dose to bereduced by half and taken before Suhur
Summary
A proper advice and knowledge about risks/benefits offasting will help to avoid any eventuality during the Holy month of Ramadhan.With an intense desire to fast, a pre Ramadhan advice should be taken from aphysician regarding its associated risks. Experience from the previous Ramadhancan act as a guide during the current month; particular attention should begiven to diet, exercise, glucose monitoring and avoidance of hypoglycemia.
Bashir Ahmad Laway is Professor & Head Endocrinology, SKIMS
Dr. Bashir Ahmad Laway