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Abstract

Fasting during the month of Ramadan, the ninth month of Islamic lunar calendar, is obligatory for all healthy adult and adolescent Muslims from the age of 12 years. Fasting starts from early dawn (Sohur/Sehri) till sunset (Iftar). During this period one has to abstain from eating and drinking. Islam has allowed many categories of people to be exempted from fasting, for example, young children, travelers, the sick, the elderly, pregnant, and lactating women. According to expert opinion, patients with type 1 diabetes (type 1 DM) who fast during Ramadan are at a very high risk to develop adverse events. However, some experienced physicians are of the opinion that fasting during Ramadan is safe for type 1 DM patients, including adolescents and older children, with good glycemic control who do regular self-monitoring and are under close professional supervision. The strategies to ensure safety of type 1 diabetic adolescents who are planning to fast include the following: Ramadan-focused medical education, pre-Ramadan medical assessment, following a healthy diet and physical activity pattern, modification in insulin regimen, and blood glucose monitoring as advised by the physician.
Indian Journal of Endocrinology and Metabolism / Jul-Aug 2012 / Vol 16 | Issue 4
516
Fasting during the month of Ramadan, the ninth month
of Islamic lunar calendar, is obligatory for all healthy adult
and adolescent Muslims from the age of 12 years. Fasting
starts from early dawn (Sohur/Sehri) till sunset (Iftar).
During this period one has to abstain from eating and
drinking. Islam has allowed many categories of people to
be exempted from fasting, for example, young children,
travelers, the sick, the elderly, pregnant, and lactating
women. Major risks associated with fasting in diabetic
patients include hypoglycemia, hyperglycemia, diabetic
ketoacidosis, dehydration, and thrombosis. Fasting is
not meant to create excessive hardship on the Muslim
individuals according to religious tenets. Nevertheless,
many patients with type 1 diabetes (T1DM) insist on
fasting during Ramadan, thereby creating a challenge for
themselves and their health care providers. Following are
the patients with diabetes who are in a very high-risk group
who fast during Ramadan[1]:
Severe hypoglycemia within the 3 months prior to
Ramadan
A history of recurrent hypoglycemia
Hypoglycemia unawareness
Sustained poor glycemic control
Ketoacidosis within the 3 months prior to Ramadan
Type 1 diabetes
Acute illness
Hyperosmolar hyperglycemic coma within the previous
3 months
Performing intense physical labor
Corresponding Author: Dr. Fauzia Mohsin, Associate Professor, Department of Paediatrics, BIRDEM General Hospital-2 (Mohila O Shishu),
1/A, Ibrahim Sharani, Shegun Bagicha, Dhaka-1000, Bangladesh. E-mail: fauzia_mohsin@yahoo.com
Fasting guidelines for diabetic children and
adolescents
Kiswhar Azad, Fauzia Mohsin, Abdul Hamid Zargar1, Bedowra Zabeen, Jamal Ahmad2, Syed Abbas Raza3,
Samin Tayyeb, Sarita Bajaj4, Osama Ishtiaq5, Sanjay Kalra6
Paediatrics, BIRDEM and Ibrahim Medical College, Dhaka, Bangladesh, 1Department of Endocrinology, Advanced Center for Diabetes and
Endocrine Care, Srinagar, 2Rajiv Gandhi Centre for Diabetes and Endocrinology, J. N. Medical College, Aligarh Muslim University, Aligarh,
India, 3Endocrinologist, Shaukat Khanum Cancer Hospital and Research Center, Lahore, Pakistan, 4MLN Medical College, Allahabad, India,
5Endocrinologist, Shifa International Hospital, Islamabad, Pakistan, 6BHARTI Hospital and B.R.I.D.E., Karnal, India
ABSTRACT
Fasting during the month of Ramadan, the ninth month of Islamic lunar calendar, is obligatory for all healthy adult and adolescent
Muslims from the age of 12 years. Fasting starts from early dawn (Sohur/Sehri) till sunset (Iftar). During this period one has to abstain
from eating and drinking. Islam has allowed many categories of people to be exempted from fasting, for example, young children,
travelers, the sick, the elderly, pregnant, and lactating women. According to expert opinion, patients with type 1 diabetes (type 1 DM)
who fast during Ramadan are at a very high risk to develop adverse events. However, some experienced physicians are of the opinion
that fasting during Ramadan is safe for type 1 DM patients, including adolescents and older children, with good glycemic control who
do regular self-monitoring and are under close professional supervision. The strategies to ensure safety of type 1 diabetic adolescents
who are planning to fast include the following: Ramadan-focused medical education, pre-Ramadan medical assessment, following a
healthy diet and physical activity pattern, modication in insulin regimen, and blood glucose monitoring as advised by the physician.
Key words: Adolescent, Ramadan, type 1 diabetes
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DOI:
10.4103/2230-8210.97998
South Asian Guidelines for Management of Endocrine Disorders
in Ramadan
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Indian Journal of Endocrinology and Metabolism / Jul-Aug 2012 / Vol 16 | Issue 4 517
Azad, et al.: Fasting guidelines for diabetic children and adolescents
Pregnancy
Chronic dialysis
Some experienced physicians are of the opinion that
fasting during Ramadan is safe for type 1 DM patients,
including adolescents and older children, with good
glycemic control who do regular self-monitoring and are
under close professional supervision.[2-4]
Following recommendations can be made for adolescents
who are in good health and who wish to fast[1-5]:
Individualization
Management plan must be individualized for each patient
according to the need.
Ramadan-focused patient education
The role of structured education for patients is well
established in the management of diabetes. This should be
extended to Ramadan-focused diabetes education. Patients
should receive education regarding the following:
1. Self-monitoring of blood glucose at home.
2. Focus on the causation, early recognition, and emergency
management of hypoglycemia, hyperglycemia,
dehydration, and impending diabetic ketoacidosis.
3. Meal planning and dietary advice.
4. Timing and intensity of physical activity.
5. Compliance to medications.
Pre-Ramadan medical assessment
1. Preferably undertaken 1–2 months before the fasting
month starts.
2. Physical status, glycemic status, and appropriate blood
studies.
3. Look for any acute and chronic complications and
individual risk stratication to identify those not t to
fast.
Diet and nutrition
1. Ingestion of large amount of foods rich in carbohydrate
and fat during Iftar should be avoided.
2. Meal at Sehri should contain complex carbohydrate,
as this will delay digestion and absorption (slow-
digesting foods). This should be taken as late as
possible.
3. Inclusion of fruits, vegetables, lentils, yogurt, cereal
(e.g., puffed rice).
4. Fluid should be taken liberally during nonfasting hours.
Exercise and physical activity
1. Normal level of physical activity should be maintained.
2. Rigorous exercise during fasting hours should be
avoided.
Checking glycemic status
1. Under Al Shariaa and Al Fatwa law, neither blood testing
nor administration of insulin is forbidden and neither is
considered to invalidate the fasting state. Patients should
be encouraged to do frequent home monitoring.
2. Urine should be checked for ketone if blood glucose
is high (>15 mmol/L).
Breaking the fast
1. Patient should break fasting if blood sugar levels are low
(<4 mmol/L) or patient experiences signs/symptoms of
hypoglycemia and if blood glucose level is >16.7 mmol/L.
2. Patient should avoid fasting on sick days.
insulin reGiMens for Type 1 DiABeTic
pATienTs
It is fundamental to adjust the insulin regimen for good
glycemic control during Ramadan.
It has been shown that the incidence and frequency of
hypoglycemia were lower in patients taking insulin lispro
instead of soluble insulin as the short-acting component.[4]
Basal–bolus insulin regimens, with use long-acting synthetic
analog (e.g., insulin glargine or insulin detemir) are less likely
to cause hypoglycemia than with more conventional twice
daily insulin regimens, and have been recommended.[6]
Fasting at Ramadan may also be successfully accomplished in
people with T1DM if they are fully educated and comfortable
with the use of insulin pump and are otherwise metabolically
stable. Most will need to reduce their basal infusion rate while
increasing the bolus doses to cover the Sehri and Iftar.[1]
Recommendations for adolescents with T1DM on basal–
bolus insulin
i. Reduction of basal insulin (e.g., glargine) by 10–20%
and further if needed.
ii. To take rapid-acting analog (e.g., aspart) with meal.
iii. If glucose rises above 15 mmol/L, a correcting dose
of rapid-acting insulin should be given.
iv. To use carbohydrate counting for meals to match the
insulin dose.
v. If long- and rapid-acting insulin analogs are unavailable,
it may be sufcient to use intermediate and short-acting
insulin instead.[2]
Two-dose insulin regimen
Majority of children and adolescents with diabetes in
developing countries are from poor socioeconomic
background and the conventional twice daily insulin
regimen is most suitable for them. They are advised to
change their dosage such that they take combined short-
and intermediate-acting insulin before Iftar, which is their
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518
Azad, et al.: Fasting guidelines for diabetic children and adolescents
usual morning dose and only short-acting insulin before
Sehri at a dose of 0.1–0.2 U/kg.[3]
Three-dose insulin regimen
Two doses before Sehri and Iftar of short- acting insulin
and one dose in the late evening of intermediate-acting
insulin.
Frequent home blood glucose monitoring should be
performed, especially before Iftar and 3 h afterwards and
before and 2 h after the Sehri to adjust the insulin dose and
prevent any hypoglycemia and postprandial hyperglycemia
following overeating.
references
1. Al-Arouj M, Assaad-Khalil S, Buse J, Fahdil I, Fahmy M, Hafez S,
et al
.
Recommendations for management of diabetes during Ramadan,
Update 2010. Diabetes Care 2010;33:1895-902.
2. Al-Khawari M, Al-Ruwayeh A, Al-Doub K, Allgrove J. Adolescents
on basal-bolus insulin can fast during Ramadan. Pediatric Diabetes
2010;11:96-100.
3. Salman H, Abdullah MA, Abanamy MA, Al Howasi M. Ramadan
fasting in diabetic children in Riyadh. Diabet Med 1992;9:583-4.
4. Kadiri A, Al-Nakhi A, El-Ghazali S, Jabbar A, Al Arouj M, Akram J,
et al
. Treatment of type 1 diabetes with insulin lispro during
Ramadan. Diabetes Metab 2001;27:482-6.
5. Jaleel MA, Raza SA, Fathima FN, Jaleel BN. Ramadan and
diabetes: As-Saum (The fasting). Indian J Endocrinol Metab
2011;15:268-73.
6. Al Arouj M, Bouguerra R, Buse J, Hafez S, Hassanein M, Ibrahim MA,
et al
. Recommendations for management of diabetes during
Ramadan. Diabetes Care 2005;28:2305-11.
Cite this article as: Azad K, Mohsin F, Zargar AH, Zabeen B, Ahmad J,
Raza SA, et al. Fasting guidelines for diabetic children and adolescents. Indian
J Endocr Metab 2012;16:516-8.
Source of Support: Nil, Conict of Interest: None declared.
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... These conditions are considered to be applicable only to individuals without co-morbidities and have stable diabetes control. 19,26,36,[39][40][41] Many studies have shown that children and adolescents are able to fasting a significant number of days during the Ramadan month. 18,42 However, unplanned fasting may predispose an individual with diabetes to hypoglycemia and hyperglycemia with or without ketosis. ...
... 5,15 Others consider fasting during Ramadan safe for T1DM patients, including adolescents and older children, with good glycemic control, regular self-monitoring and close professional supervision. 41 Ramadan fasting has potential complications; however, the available data suggest that it can be safely practiced by some children and adolescents with diabetes. In a study of a pediatric population by Kaplan and Afandi, 42 symptomatic hypoglycemia resulted in breaking the fasting on 15% of the days. ...
... 8 The South Asian Guidelines for Management of Endocrine Disorders in Ramadan recommends reducing basal insulin by 10% to 20% during the fasting days. 41 However, these recommendations are not based on data from large study cohorts or randomized-controlled studies. ...
... Previous studies have shown that effective counseling before RF delivered by health care providers reduces the incidence of hypoglycaemia (17). Patient education before Ramadan provides a platform to remind patients about the importance of diet, exercise, dose adjustment and that regular glucose monitoring is vital to avoid complications while reassuring them that this does not invalidate the fast (9). ...
... International guidelines on diabetes mellitus management for adults during RF confirm that poor control of diabetes mellitus is considered as one of the main contraindications for fasting (17,(25)(26)(27). Well-controlled children and adolescents with T1DM are expected to have less complications making RF feasible for them (28). ...
Article
Full-text available
Background Ramadan fasting (RF) is a religious obligation for all healthy adult Muslims. The sick and pre-pubertal children are exempt, but many choose to fast for various reasons. In this “real world” study, glycaemic control has been investigated in the context of RF in children and adolescents with type 1 diabetes mellitus (T1DM) and compared multiple daily injections (MDI) and continuous subcutaneous insulin infusion (CSII) outcomes. Methods Children and adolescents with T1DM seen at Imperial College London Diabetes Centre who decided to fast in the ensuing Ramadan were educated with their families about diabetes mellitus management during RF using an adapted CHOICE (Carbohydrate, Insulin, and Collaborative Education) educational programme. Pertinent data including hypoglycaemia episodes and diabetic ketoacidosis (DKA) were obtained through patient/family interviews. Information on weight, glycated hemoglobin (HbA1c), and blood glucose levels from continuous glucose monitoring (CGM)/flash glucose monitoring (FGM) before (1 month prior), during, and after (1 month afterwards) Ramadan were retrieved retrospectively from the electronic database. Data are presented as mean ± SD. Results Forty-two patients [age 13.5 ± 2.4 years; 27 (64.3%) males; T1DM duration 4.9 ± 3.1 years] were included in the study and were able to fast for 22 ± 9 days during Ramadan. Twenty-three (54.8%) of the patients were on MDI and 19 (45.2%) were on CSII. No statistically significant differences were seen in CGM/FGM generated mean blood glucose level before, during, and after Ramadan [one-way ANOVA ( F (2, 80) =1.600, p = 0.21)]. HbA1c and weight after Ramadan did not change significantly compared to baseline (paired t -test; p = 0.02 and p = 0.08, respectively). Between MDI and CSII groups, there was no significant difference in fasting days ( p = 0.49), frequency of hypoglycaemia episodes ( p = 0.98), DKA frequency ( p = 0.37), HbA1c level ( p = 0.24), and weight ( p = 0.11) after Ramadan. Conclusion Data show no significant deterioration in indicators of overall glycaemic control which remained inadequate. RF should be discouraged in children with poorly controlled T1DM.
... The South Asian Guidelines for Management of Diabetes in Ramadan recommends reducing basal insulin by 10% to 20% during the fasting days. [40] Current recommendations for patients treated with multiple daily injection (MDI) include a reduction of the total daily dose (TDD) of insulin to 70% to 85% of the pre-fasting TDD or to 60% to 70% of the basal insulin. [9,36,41] In our study population there was significant reduction of basal insulin dose in both groups during Ramadan although there was episodes of mild hypoglycaemia. ...
... In many diabetes centers with a Muslim population, health-care professionals agree that adolescents can fast if they have reasonable glycemic control, good hypoglycemia awareness and are willing to frequently monitor their blood glucose levels during the fasting. [40] Over the past decade, several studies have evaluated fasting among adolescents with T1DM and its associated safety during the month of Ramadan. Kaplan et al used CGM to assess the impact of fasting on interstitial glucose concentrations in 14 adolescents with T1DM. ...
Article
Objective Muslim people with T1DM should be actively discouraged from fasting during the COVID-19 pandemic, as diabetes has emerged as a significant risk factor for adverse outcomes of COVID-19 infection. We report the experience of young patients with type 1, type 2 and other types diabetes who fasted during Ramadan 2020 at the time of the COVID-19 pandemic time lockdown. Research Design and Methods A Post- Ramadan survey was designed for young patients who fasted during Ramadan in 2020 during COVID pandemic time. The study was conducted to compared the basal characteristics and other parameters in children and adolescents (< 18 years), with young adults (≥ 18 years) with diabetes at Paediatric Diabetes Center in BIRDEM in Bangladesh. Results Among the study participants, a significantly higher number of participants were in older age group who fasted for more than 15 days (p=0.045). A considerable proportion (30.7%) of patients developed mild hypoglycaemia, and only eight patients (2.6%) developed moderate to severe hypoglycemia. There was significant reduction of post Ramadan basal insulin dose in both groups (p =0.001). Although increased bolus insulin dose requirements were observed in older age group, but decreased requirement was observed in younger age group during Ramadan (p =0.001). Post Ramadan median HbA1C in both groups was increased with marked increase in older age group compared to younger age group though it did not reach the statistical significance. (p=0.239) Conclusions COVID-19 pandemic had minor impact on fasting during Ramadan in our cohort, they could fast safely with less complications during Ramadan. Our data supports Ramadan focused diabetes education with ample self-care, young people with diabetes can fast safely during Ramadan.
... Fasting during the month of Ramadan, the ninth month of Islamic lunar calendar, is obligatory for all healthy adult and adolescent Muslims from the age of 12 years. [1] Islam has allowed many categories of people to be exempted in specific situations where fasting may pose a danger to health. [2 ] Although patients with type 1 diabetes are medically exempt, many insist on fasting during Ramadan. ...
... Patients were instructed to break the fast if blood sugar level was <4 mmol/L or if they experience symptoms of hypoglycemia and if blood glucose level >16.7 mmol/L. [1] All patients were instructed to call healthcare providers for dose adjustment whenever necessary or if there was any episode of hypoglycemia or hyperglycaemia. The initial dose was adjusted after first week and there after weekly or even earlier when required. ...
Article
Full-text available
Our aim was to report our telemedicine experience with type 1 diabetes patients on insulin pumps who fasted during Ramadan 2020 at COVID 19 pandemic time. The routine diabetes outpatient care in our CDiC Paediatric Diabetes Center in BIRDEM hospital was closed as there was lock down since March 26 in Bangladesh. The diabetes team in our center started tele medicine care for routine follow up of patients. Nine patients contacted our diabetes team over phone who wished to fast this Ramadan. Mean age was 19.3 ± 5.0 years, 5 (55.6%) were female. Most of the patients fasted more than 20 days. Hyperglycaemia and mild hypoglycemia were common complications during fasting. There was no episode of severe hypoglycaemia or DKA and none of them required admission.During COVID‐19 crisis in Bangladesh, patients with type 1 diabetes on insulin pump, could fast safely in Ramadan with support of telemedicine service by diabetes team.
... About 20-40% dose reduction is recommended in the last 3-4 h of fasting for those treated with insulin pumps. The South Asian Guidelines recommend a reduction in basal insulin dose by 10-20% during the fasting days of Ramadan [163]. However, these recommendations of South Asian Guidelines were not based on data from large study cohorts or randomized controlled studies. ...
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The Research Society for the Study of Diabetes in India (RSSDI) has regularly updated its Clinical Practice Guidelines on various aspects of diabetes. The pharmacotherapeutic management of diabetes involves a plethora of agents targeting different aetiopathogenic mechanisms administered orally or via injections as well as insulin. While most people with type 1 diabetes need complete insulin replacement therapy with multiple-daily subcutaneous injections of insulin or a continuous subcutaneous insulin infusion pump, patients with type 2 diabetes may also need insulin as and when needed, especially owing to the declining beta cell function due to the progressive nature of their diabetes. To date, various insulin regimens including basal-bolus, split-mixed, premix, and prandial therapy are available which can be individualized based on the patient profile though their prescription is often perceived as complex for management of diabetes, forming a major barrier in the acceptability of insulin. In order to provide physicians with a simple guidance on different aspects of insulin use including choosing the right insulin and regime to match the individual patient, the RSSDI for the first time has formulated this guideline on insulin therapy using simple algorithms for insulin initiation as well as titrations based on a systematic literature search of new clinical evidences on all aspects of insulin use. Insulin therapy is hereby proposed as easy to initiate and maintain, efficacious, and a safer option which when administered appropriately can almost mimic physiological insulin secretion in diabetic patients and help them achieve target glucose control and minimize complications while improving their quality of life.
... [13] On the other hand, some experienced physicians believe that fasting during Ramadan is safe for T1DM patients, including adolescents and older children, with good glycemic control who can do regular self-monitoring and are under close professional supervision. [14] The strategies to ensure the safety of T1DM adolescents who are planning to fast include the following: Ramadan-focused medical education, pre-Ramadan medical assessment, following a healthy diet and physical activity pattern, modification in insulin regimen, and blood glucose (BG) monitoring as advised by the physician. Some experts uphold the opinion that recent studies have demonstrated that individuals with T1DM who are otherwise healthy and stable, provided enough evidence that they can fast during Ramadan if they comply with the Ramadan focused management plan and are under close professional supervision. ...
Article
Full-text available
Although children in general and patients with type 1 diabetes mellitus, in particular, are exempted from fasting during Ramadan, many elect to observe the fast. There is a sizeable amount of opinion and research data that warrants revisiting. This is a narrative nonsystematic review to explore the views and supporting data on Ramadan fasting and to examine the safety of fasting and its impact on diabetes control and management in children and adolescents. The key areas covered include epidemiology, the physiology of fasting, risk stratification, counseling strategy, nutrition advice, insulin therapy adjustment with a particular focus on multiple injection regimen, and insulin pump therapy. Findings from various studies and expert opinions were appraised and presented to illustrate points of agreements and differences. This review should enhance knowledge and form the basis to clear some doubts and differences of opinions surrounding the issue of diabetes and Ramadan fasting in young people. It should also empower healthcare professionals to develop consensus based on the most up‑to‑date advice and the best possible support to patients and families regarding fasting during Ramadan.
Article
Background and aims Evaluating the impact of Ramadan fasting on Ambulatory Glucose Profile (AGP) among Patients with Type 1 Diabetes (T1D) using Flash Glucose Monitoring (FGM) System. Methods The present study is a comparative study, performed using 87 patients with T1D, whose health status permitted them to fast, based on the risk stratification adopted by Diabetes and Ramadan (DAR Guidelines). Besides the demographic data, other data connected with the glycemic profile such as the mean Time in Range (TIR), mean Time Above Range (TAR), mean Time Below Range (TBR), mean glucose level, hemoglobin A1c (HbA1c), Glucose Variability (GV), and Glucose Monitoring Indicator (GMI %), were recorded at three specific periods, namely, pre- (prior to), during and post Ramadan. Results The mean age of the study population was 24.3 ± 8.2 years, and 52.9% of this population was female. Compared to the pre-Ramadan data, no significant alterations (p > 0.05) were noted in terms of the low glucose events, percentage of glucose level below 70 mg/dL, the average duration of hypoglycemic events, and percentage of glucose level below 54 mg/dL, from the values observed during and post-Ramadan. In comparison with the pre-Ramadan data, no significant changes appeared (p > 0.05) concerning the GV, average glucose, GMI, percentage within target, TAR (181–250 mg/dL), and percentage >250 mg/dL), for the periods during and post-Ramadan, except scanning of FreeStyle Libre (p = 0.042) during Ramadan month compared to pre-Ramadan. Conclusion Fasting during Ramadan was achievable in patients with T1D who received adequate counseling and support.
Article
Aims Our aim was to investigate the ability, frequency of acute complications and impact on glycemic control in uncontrolled T1DM who fasted during Ramadan. Methods 74 Patients with T1D who insisted on fasting were enrolled 1 month prior to Ramadan and given intensive education by Diabetes team on insulin dose, glucose monitoring and dietary adjustments. Patients were divided into two groups ; group A- HbA1c <9%(<75 mmol/mol) and group B- HbA1c ≥ 9% (≥ 75 mmol/mol) and different variables were compared. Results Most of the patients fasted 58 (78.4%) for more than 15 days. There was no significant difference (p= 0.790), while comparing the breaking the fast in the two groups. Hypoglycaemia was common acute complications among them. There was no significant difference in the frequency of hypoglycaemia between two groups (P = 0.448). There was increased insulin requirement in both groups during Ramadan (p=.00001), with an increase in basal insulin in well controlled (from 24 to 34 units). There was significant reduction of Post Ramadan mean HbA1C in both groups [P = 0.0001)]. Conclusion Children, adolescents and young adults with T1D with poor glycaemic control can fast safely during Ramadan with proper education and intensive monitoring.
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Full-text available
Background Fasting in the holy month of Ramadan is among the five pillars of Islam and is considered as a religious obligation by the Muslim population. People with diabetes observing the practice of fasts are at a higher risk of complications such as hypoglycaemia, hyperglycaemia and ketoacidosis due to changes in eating patterns and circadian rhythms. With the objective of mitigating these complications, the South Asian Health Foundation (UK) has developed the present guidelines based on robust evidence derived from epidemiological studies and clinical trials. Methods We have highlighted the role of pre-Ramadan risk stratification and counselling by healthcare professionals with emphasis on the need for advice on adequate dietary and fluid intake, blood glucose monitoring and awareness of when to break the fast. Results We reviewed the current literature and have given clinically-relevant recommendations on lifestyle modifications and glucose-lowering therapies such as metformin, sulphonylureas, dipeptidyl peptidase-4 inhibitors, sodium glucose co-transporter-2 inhibitors, thiazolidinediones, glucagon-like peptide-1 receptor agonists and insulin. Conclusions An individualised patient-centric treatment plan is essential to not only achieve optimal glycaemic outcomes but also enable people with diabetes to observe a risk-free month of fasting during Ramadan.
Article
Objective To evaluate the safety of fasting during the holy month of Ramadan among children and adolescent with type 1 diabetes (T1D). Methods A retrospective cohort study of 50 children and adolescents with T1D whose mean age was 12.7 ± 2.1 years was conducted. Twenty-seven patients (54%) were on multiple daily injections (MDI) insulin regimen and 23 (46%) were on insulin pump therapy. Before fasting for Ramadan, children and their families were evaluated and educated about diabetes management during Ramadan. Hemoglobin A 1c (HbA 1c ), weight, number of days fasted, hypoglycemia and hyperglycemia episodes, and emergency hospital visits were collected and analyzed after completing the month. Participants were compared according to the insulin treatment regimen and their glycemic control level before Ramadan. Results The children were able to fast 20 ± 9.9 days of Ramadan, and the most common cause for breaking the fast was mild hypoglycemia (7.8% among all cases). There was no significant difference between the two insulin regimen groups in breaking fast days, frequency of hypo- or hyperglycemia, weight and HbA 1c changes post Ramadan. Patients with HbA 1c ≤ 8.5% were able to fast more days during Ramadan with significantly less-frequent hypoglycemic attacks as compared to patients with HbA 1c > 8.5 (1.2 ± 1.5 vs. 3.3 ± 2.9 days of hypoglycemia, p = 0.01, respectively). Conclusions Fasting for children with T1D above the age of 10 years is feasible and safe in both pump and non-pump users, and well-controlled patients are less likely to develop complications. Education of the families and their children before Ramadan, along with intensive monitoring of fasting children during the month are crucial.
Article
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Since our last publication about diabetes and fasting during Ramadan (1), we have received many inquires and comments concerning important issues that were not discussed in the previous document, including the voluntary 1- to 2-day fasts per week that many Muslims practice throughout the year, as well as the effect of prolonged fasting (more than 18 h a day) in regions far from the equator during Ramadan when it occurs in summer—a phenomenon expected to affect millions worldwide for the next 10–15 years. Since 2005, there have been substantial additions to the literature, including two studies examining the effect of structured education and support for safe fasting, both of which had promising results (2,3). In addition, new medications, such as the incretin-based therapies, have been introduced with less risk for hypoglycemia. According to a 2009 demographic study, Islam has 1.57 billion adherents, making up 23% of the world population of 6.8 billion, and is growing by ∼3% per year (4). Fasting during Ramadan, a holy month of Islam, is a duty for all healthy adult Muslims. The high global prevalence of type 2 diabetes—6.6% among adults age 20–79 years (5)—coupled with the results of the population-based Epidemiology of Diabetes and Ramadan 1422/2001 (EPIDIAR) study, which demonstrated among 12,243 people with diabetes from 13 Islamic countries that ∼43% of patients with type 1 diabetes and ∼79% of patients with type 2 diabetes fast during Ramadan (6), lead to the estimate that worldwide more than 50 million people with diabetes fast during Ramadan. Ramadan is a lunar-based month, and its duration varies between 29 and 30 days. Muslims who fast during Ramadan must abstain from eating, drinking, use of oral medications, and smoking from predawn to after sunset; however, there are no restrictions on food or fluid intake between sunset and dawn. Most people consume two meals per day during this month, one after sunset and the other before dawn. Fasting is not meant to create excessive hardship on the Muslim individual according to religious tenets. Nevertheless, many patients with diabetes insist on fasting during Ramadan, thereby creating a medical challenge for themselves and their health care providers. It is increasingly important that medical professionals be aware of potential risks associated with fasting during Ramadan and with approaches to mitigate those risks. These issues are rapidly becoming global issues, not only in Indonesia, Pakistan, and the Middle East, but also in North America, Europe, and Oceania. Although recommendations for management of diabetes in patients who elect to fast during Ramadan were proposed in 1995 at a conference in Casablanca (7), our previous document was prompted by the EPIDIAR study (6). The purpose of this review is to evaluate new data that has emerged since the publication of the 2005 article and to refine our recommendations. In this revised document, we continue to avoid use of the terms “indications” or “contraindications” for fasting because fasting is a spiritual issue for which patients make their own decision after receiving appropriate advice from religious teachings and from health care providers. However, we emphasize that fasting, especially among patients with type 1 diabetes with poor glycemic control, is associated with multiple risks.
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More than 50 million people with diabetes mellitus fast during Ramadan, a religious obligation for all healthy adult Muslims. Fasting leads to several physiological changes in the body and these may result in acute complications in persons with uncontrolled diabetes such as hyperglycemia, hypoglycemia, diabetic ketoacidosis, dehydration and thrombosis. Evidence from existing literature guides the physicians in their assessment of Muslim patients with diabetes who wish to fast. Assessment should include risk stratification based on existing control of diabetes and its chronic complications. In the light of this assessment medical recommendation is given which includes dose modification of oral medication and insulin, dietary advice and structured patient education.
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Ramadan, the ninth month of Islamic lunar calendar, is marked by religious ritual of fasting from early dawn till sunset by Muslims. Islam has allowed many categories of people to be exempt totally or temporarily from fasting. Patients with uncontrolled diabetes face possible major metabolic risks including hypoglycemia, hyperglycemia with or without the risk of impending ketosis, dehydration, and thrombosis. Diabetics can be stratified into four categories based on their level of risk associated with fasting. The recommended ruling for persons in categories 1 and 2 is that they are prohibited from fasting to prevent harming themselves based on the certainty or the preponderance of probability that harm will occur, whereas the recommended ruling for those in categories 3 and 4 is that they should fast. The strategies to ensure safety of diabetics who are planning to fast include Ramadan-focused patient education, pre-Ramadan medical assessment, following a healthy diet and physical activity pattern, physician-recommended modifications in medication protocol and therapeutic recommendations and checking blood glucose as and when required.
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Al-Khawari M, Al-Ruwayeh A, Al-Doub K, Allgrove J. Adolescents on basal-bolus insulin can fast during Ramadan. Fasting during Ramadan is a major tenet of the Muslim religion. All adults after the age of puberty are required to do so if health permits. However, there are exemptions to this requirement and having a chronic condition such as diabetes is one. Nevertheless, many adults and adolescents feel obliged to fast during Ramadan even though there is no absolute need to do so. This obligation must be respected. There are few data to support this practice in those whose condition, such as diabetes, potentially makes them vulnerable to developing problems during prolonged fasting. This study was designed to examine the ability and safety of young people with diabetes to be able to fast if they so desire. Two groups of patients were studied, those on a multiple injection, so-called basal-bolus, regimen and those on a ‘conventional’ twice daily pre-mixed insulin regimen. All patients showed a tendency to high blood glucose at the time of commencing their fast. Those on twice daily insulin continued to have hyperglycaemia during the day whilst those on basal-bolus insulin showed a steady fall in blood glucose towards normal by the time of breaking their fast. Although there was a greater tendency to hypoglycaemia in the basal-bolus group, this could be successfully prevented by reducing the dose of basal insulin by 10–20%. We recommend that it is safe for adolescents with diabetes to fast during Ramadan as long as they reduce their basal insulin by this amount and continue to monitor their blood glucose regularly.
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To compare insulin lispro with regular human insulin with respect to blood glucose control and frequency of hypoglycaemia in patients with type 1 diabetes who wished to fast during the month of Ramadan. Insulin lispro or regular human insulin was given together with NPH insulin, twice daily before the morning and evening meals, for two weeks each in an open-label, randomised, cross-over design, and 64 patients completed the protocol. Blood glucose was self-monitored at fasting morning and evening, and 1-h and 2-h after the post-sunset meal on three consecutive days at the end of each treatment period. The 2-h blood glucose excursion after the post-sunset meal was significantly (p=0.026) lower with insulin lispro (2.50 +/- 0.46 mmol/l) than with regular human insulin (3.47 +/- 0.49 mmol/l). Daily insulin doses did not differ between treatments but compliance with recommended time of injection was better with insulin lispro. Hypoglycaemia incidence (insulin lispro, 15 (23.4%) patients; regular human insulin 31 (48.4%) patients; p=0.004) and frequency (insulin lispro, 0.70 +/- 0.19; regular human insulin 2.25 +/- 0.36 episodes/patient/30 days; p<0.001) were lower with insulin lispro. Five (22.7%) of the episodes during insulin lispro occurred during the nocturnal period compared with 27 (36.5%) of the episodes while on regular human insulin. Glycaemic control, measured by postprandial glycemic excursions, was improved and hypoglycaemia was significantly reduced with insulin lispro compared with regular human insulin. Patients with type 1 diabetes who insist on fasting during Ramadan may be better managed with insulin lispro.
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