Diabetes and the month of fasting

What is Diabetes?

Diabetes mellitus or (high blood sugar) is a widespread and rapidly increasing condition where glucose levels (normal fuel for day to day energy) cross its upper limit (126 mg/dl in fasting state) of normal. This high glucose level ends up damaging most of the body tissues mainly blood vessels in heart, kidneys, eyes, feet.  This leads to very high morbidity (handicaps) and mortality (death) among populations if not taken care.

What is Ramdan

Ramdan is a lunar-based month in the Muslim calendar which is generally between 29 and 30 days duration. Its beginning and end is linked to the sighting of the new moon following month of Shaban. According to Muslim calendar Eid al-Fitr also sometimes referred to as ‘Sweet Eid’  in Asia marks the end of the fasting month of Ramadhan 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 all healthy Muslims, patients with one or more of the following are advised not to fast: Physiological conditions: Pregnancy and lactation (feeding baby). Co-existing major medical conditions such as: acute peptic ulcer, people prone to urinary stones formation with frequent urinary tract infections, cancers , overt cardiovascular diseases (recent MI, unstable angina), severe psychiatric conditions, pulmonary tuberculosis and uncontrolled infections, severe bronchial asthma, hepatic dysfunction (liver enzymes >2 x ULN). Besides some conditions 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 can eat through out night hours till predawn (Sehri) lower component of complex carbohydrate at the night meal and higher complex carbohydrate at predawn seems beneficial as shown by studies using diet popularly known as MaPi diet. Diet devised by Mario Pianesi is rich in complex carbohydrates, whole grains, vegetables and legumes, and fermented products, and low in unrefined sea salt and green tea, without fat or protein from animal sources (including milk and dairy products) and no added sugars and go well with ADA and European nutrition recommendations.

 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 the convenience and risk of hypoglycemia. Evening exercise after Iftiari or morning exercise after Sehri can be advised with avoidance of strenous exercise before Iftiari to avoid hypoglycemia. Taraweeh (long prayers) should be considered as a part of the daily exercise program. So patients are to be advised to monitor BG 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 with Diabetes opting to observe ROZA (Table 1). All these agents have simplified the diabetes care but the options need to be weighed against risks duly discussed fully with the patients. Patients on agents such as metformin, α-glucosidase inhibitors, TZDs, and DPP4 inhibitors do not need major dose adjustments as these appear to be safe.

Thus the  agents like metformin, pioglitazone, Gliptins (sitagliptin, Saxagliptin, Linagliptin and Vildagliptin) and alpha glycosidase inhibitors (Voglibose or Acarbose) are the first line choices provided diabetes is uncomplicated and is not so severe (high level of glucose). These agents can be given at any time (Iftiar or Sehri) and do not cause hypoglycemia (low glucose).

There is increasing knowledge on the efficacy and safety of DPP4 inhibitors as monotherapy or in combination with metformin therapy. The use 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 improving glycaemic control and in reducing appetite during Ramadhan. There is little data on the safety and efficacy of SGLT-2 inhibitors during the fasting period of Ramadhan

Insulin secretors such as Sulfonylureas and  Glinides having increased risk of hypoglycemia need dose adjustment of stopping before the start of the fast, depending on the degree of glycemic control, kidney function, and presence of diabetic complications. Patients with type 1 and type 2 diabetes treated with insulin should be educated on the appropriate use of insulin administration and the need for glucose monitoring during the fasting period. Most patients require a modification of the basal insulin dosage and on the use of premeal insulin 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 glucose level) and complications status (nephropathy, gatroperesis etc. ) is pivotal in formatting 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 but their requirement of doses should be less than half maximal. Important precaution is that these agents can be used at the time of Iftiar (evening meal) and patients have to be warned about hypoglycemia. A blood glucose level of <70 mg/dl at around 3-4 pm (10 hours fast) should be prompted to break the 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 a diabetic individual desiring to observe Ramdan fast, the pros and cons have to be discussed well before hand to ensure safety. Uncomplicated and well-controlled diabetics on diet, metformin, glitazone, or gliptin classes of drugs 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 of Eidul-Fitr (Sweet Eid) which is marked with festivities, sharing of food, and sweet beverages. This may pose risks of hyperglycemia during this time, as many individuals 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 of Endocrinology SKIMS Srinagar. He is former Additional Professor Endocrinology and 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 and unrestricted over eating during night can result in dehydration (deficiency of water inside body) and low blood glucose level during daytime and high blood glucose during feasting time. There also is an increased risk of clotting of blood in the vessels (because of dehydration and high blood glucose). Keeping these complications and balance of religious sentiments in mind, experts have recommended some guidelines for the physicians, patients and their caregivers.

Who can fast safely?

According to these guidelines, following group of patients can safely fast during Ramadhan:

1.            Well-controlled diabetes treated with one or more of the following modalities: diabetes controlled with diet and exercise only (lifestyle therapy)

2.            Diabetes well controlled on medications like metformin; gliptins like sitagliptin, vildagliptin, saxagliptin and teneligliptin; alpha glucosidase inhibitors like acarbose and voglibose; thiazolidinediones like pioglitazone; second-generation sulfonylureas (like glipizide, glimpiride and gliclazide); incretin-based therapy (like GLP-1 receptor agonists); gliflozins like canagliflozin, dapagliflozin, empagliflozin etc.

3.            Diabetes controlled on insulin dose of insulin given once daily in the form of basal insulin

To carry on fasting safely, this group of patients should 0follow 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 to fast:

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 diet is typically rich in carbohydrate and fat, both these factors are responsible for excessive rise in blood glucose and its consequences. Because of fear of blood glucose falling during daytime, people tend to overeat during suhur as well.

A healthy diet during Ramadhan consists of a balanced diet with distribution into 2-3 servings (rather than two big servings) during non-fasting hours. Pre dawn meal (suhur) should mainly comprise foods rich in complex carbohydrates like whole grain cereals, vegetables such as beans and lentils and fruits. Eating dates traditionally marks the end of a fast but are very rich in sugars; a portion of 1-2 dates may however not raise blood glucose.

Dinner should be taken as early as possible after iftar and should mainly consist of a combination of whole-wheat flour chapattis (or a small portion of rice), vegetables and small amount of meat. Salads should be taken to increase the fiber content. A late night snack with a glass of milk or a 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 and hence water loss from the body. In summary diet during Ramadhan should not be different from that of pre Ramadhan and should be rich in protein and essential nutrients rather than in carbohydrates and fat.

Exercise (and Taraweeh prayers) during Fasting

Light and moderate exercise is safe; it is better to go for an exercise like daily walk after suhur or iftar. Exercise is not recommended during daytime and before iftar as this increases the risk of hypoglycemia (falling glucose level).

Taraweeh prayers and walking to the mosque should be accounted for in the exercise regimen. Individuals should carry water and rapid acting carbohydrate drink (for correction of hypoglycemia in case such a thing happens). A person going for Taraweeh prayers (which usually is completed in an hour) 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.            Monitor blood glucose levels at the beginning of the fast, at mid day and before iftar

5.            Blood glucose levels should be checked if any symptoms of hypoglycemia (low blood glucose) such as increased appetite, sweating, headache, nervousness or any unpleasant feeling or if the patient becomes unwell.

When to terminate fast?

4.            If at any time blood glucose level is less than 75mgs/dl during the fast

5.            Blood glucose levels > 300mgs/dl any time during the fast

6.            Symptoms of hypoglycemia (like increased appetite, sweating, headache, nervousness or any unpleasant feeling) even if blood glucose level is normal

7.            Patient feels unwell

In these situations, it is dangerous not to terminate the fast

Changes in medications recommended during Ramadhan

9.            Patients taking metformin, pioglitazone, gliptins, acarbose, voglibose, SGLT2 inhibitors and GLP1 receptor agonists, no change in medication required

10.          Once a day sulfonylurea dose to be taken after iftar

11.          Twice a day sulfonylureas: Morning dose to be halved and taken with Suhur, evening dose remains same

12.          Basal insulins like NPH, glargine or degludec: reduce daily dose by 20% and give at bed time

13.          Insulin 30/70, twice daily: Morning dose to be taken after iftar, evening dose to be reduced by half and taken before Suhur

Summary

A proper advice and knowledge about risks/benefits of fasting 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 a physician regarding its associated risks. Experience from the previous Ramadhan can act as a guide during the current month; particular attention should be given to diet, exercise, glucose monitoring and avoidance of hypoglycemia.

Bashir Ahmad Laway is Professor & Head Endocrinology, SKIMS

Dr. Bashir Ahmad Laway