Diabetes mellitus is very common condition in this country reaching to epidemic proportions leading to huge burden of morbidity (handicaps) and mortality (deaths). Diabetes type 1 is a condition that requires careful management, blood sugar control, appropriate diet and adherence to insulin. Type 2 diabetes (commoner type) depending on the stage may need diet and exercise, oral tablets on even insulin for the blood glucose control. In order to minimize adverse events related to diabetes such as hypoglycaemia during fasting, patient education, regular glucose monitoring and adjustment of treatment regimens should occur weeks prior to Ramadan. Accordingly subjects desirous of observing religious fast will need to see their physician well before for proper planning and the care requires individualization. We will briefly outline the issues in the management of diabetes during Ramdan: a type of prolonged religious fast as under:
What is Ramdan?
Ramdan is a lunar-based month in the Muslim calendar. It is generally between 29 and 30 days duration and 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’ marks the end of the fasting month of Ramadan observed by millions of Muslims across the world.
What is the philosophy of Fasting during the month of Ramadan?
Being considered as one of the five pillars of Islam, it has significant religious and psychological connotation. It teaches muslims self-discipline, self control and has great value of charity. Besides, it leads to recognition of the plight of under privileged. Fasting during Ramadan is an obligatory duty for all healthy adult Muslims as mentioned the holy book of Quran in
Surah Al-Baqarah: 183-184
• …..Observing As-Saum (the fasting) is prescribed for you as it was prescribed for those before you, ….
• ….., but if any of you is ill or on a journey, …… And as for those who can fast with difficulty, (e.g. elderly, etc),…….
• This exemption represent more than simple permission not to fast; the prophet Mohamad said “God like his permission to be fulfilled, as he likes his will to be executed.
Who are exempted?
Although the Ramdan fast (ROZA) is obligatory, patients with one or more of the following are advised not to fast:
Physiological conditions:
• Pregnancy
• 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)
Conditions related to diabetes:
• Multiple insulin injections per day (as type 1 DM)
• Recent hyperosmolar state or DKA
• Poorly controlled diabetes (Mean Random BG > 300)
• Hypoglycemia unawareness
• Nephropathy with serum creatinine more than 1.5 mg/dL
• Severe retinopathy
• Autonomic neuropathy: gastroparesis, postural hypotension
• Major macrovascular complications: coronary and cerebrovascular
What changes are expected in Ramdan?
• During Ramadan, Muslims must fast from dawn to sunset (8-20 hours depending up on region and season). Thus there is a sudden and major change in the daily meals.
• Changes include meal timing, total calories, food type and consistency etc.
• Food, fluids and oral medications may be consumed freely during the night, but forbidden during the daytime.
• Prior to the month of Ramadan, people usually take 3 major meals (breakfast, lunch, dinner/supper). During Ramdan it will be :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.
How do you plan the management of diabetes and what is the role of diabetes education?
• Although exempted from observing fast as per published studies (EPIDIAR study)
30-40% diabetic subjects still insist on fasting. Since diabetes management is not exactly compatible with the tradition of fasting during the month of Ramadan 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 Ramadan and the patient and his physician should discuss the pros and cons after a fresh evaluation.
What you do when 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). They 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 Ramadan. 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 Ramadan.
What are the steps in the management of diabetes ?
The management involves lifestyle (diet called as medical nutrition therapy and exercise) and pharmacological (drug) components.
What is the role of medical nutrition therapy ?
As you can eat through out night hours till predawn 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 is necessary about exercise?
Exercise 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.
What is the role of pharmacological therapy ?
Conventionally there are many choices for patients with Diabetes opting to observe the fast (ROZA). 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).
Sulfonylureas and insulin secretagogues 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.
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 Ramadan. There is no data on the safety and efficacy of SGLT-2 inhibitors during the fasting period of Ramadan.
How does pre Ramdan regimen guide in current management plan?
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
• Risk of fasting is quite low
• Risk for occurrence of post prandial hyperglycemia
• 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 Diabetes on Thiozolidinediones (TZDs) /DPP-4i /GLP-1 RA/SGLT2i/AGI
• No dose change required
• 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-short acting 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 quiet appropriate for fasting diabetics. Patients on peakless insulins such as Glargine (Glaritus, Basalog, Lantus), detmir (Levimer) or Degludec (Tresiba) in combination with the above analogues or oral agents, have to shift basal insulin with Iftiari. Subjects on insulin pump may require 20% reduction in basal rate with individualizations of blouses.
How should you monitor?
The self-glucose monitoring 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 Ramadan. 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 of glucose monitoring may result in a higher risk of hypoglycemia especially in sulphonylurea or insulin-treated patients with diabetes.
How have advances in Diabetes management influenced Ramdan fast?
Advances in Diabetes care are likely to improve life of Diabetics in general and those desiring to observe religious fast like that observed in the holy month of Ramadan. Although modes of insulin administration and types of analogues are constantly improving patient convenience, physicians have impart enough education and plan the management well before the start of Ramdan. In near future the agents such as Newer molecules like Semaglutide/ Lixenatide (once a week) etc. may may be popular in Ramadan as these do not cause low glucose. 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 Ramadan. 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 Ramadan
In conclusions, while respecting the faith and belief a diabetic individual desiring to observe Ramdan fast, the pros and cons have to be discussed 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 Ramadan I Diabetics.
Care during after Eid days
The end of Ramadan is followed by a 2-3 day festival of Eid ul-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 Associate Professor and Senior Consultant Endocrinology and Metabolism, AIIMS New Delhi.