fasting with diabtetes dr shahjada selim

Management of Management of DiabetesDiabetes

During RamadanDuring Ramadan

Dr Shahjada SelimMBBS MD (EM)

Registrar, Department of MedicineShaheed Suhrawardy Medical College Hospital,

Dhaka

Introduction

• Estimated 1.5-2.0 billion Muslims worldwide.

• Globally more than 20 million diabetic people fast during Ramadan.

• Approximately • 43% patients with type 1 diabetes and 79% of

patients with type 2 diabetes fast during Ramadan.

Bravis V, Hui E, Salih S, Mehar S, Hassanein M, Devendra D: Ramadan Education and Awareness in Diabetes (READ) programme for Muslims

with Type 2 diabetes who fast during Ramadan. Diabet Med 2010, 27:327–331.

Introduction• Fasting during Ramadan is obligatory on every

adult Muslim.

• Muslims fast for 29-30 days of lunar based month each year.

• Fasting starts before sunrise and end at sunset

and the duration of the day varies as the season. It is

about 14 hours this year.

Salti I, Benard E, Detournay B, Bianchi-Biscay M, Le Brigand C, Voinet C, Jabbar A: EPIDIAR study group. A population-based study of

diabetes and its characteristics during the fasting month of Ramadan in 1 countries: results of the Epidemiology of Diabetes and Ramadan

1422⁄2001(EPIDIAR) study. Diabetes Care 2004, 27:2306–2311.

The physiological state of diabetics during Ramadan

1. Carbohydrate metabolism in healthy persons Most of the studies show slight decrease in

serum glucose to 3.3 mmol to 3.9 mmol occurs in normal adults a few hours after fasting has begun.

Changes in serum glucose may occur in individuals depending upon food habits and individual differences in metabolism and energy regulation.

2.Body weight

Weight losses of 1.7-3.8 kg have been reported in normal weight individuals after they have fasted for the month of Ramadan.

Some studies also show no change or slight increase.


3.Blood glucose variations in patients with diabetesMost patients show no significant change in their

glucose control. In some patients, serum glucose concentration may

fall or rise (unstable glycemic status). This variation may be due to the amount or type of

food consumption, regularity of taking medications, engorging after the fast is broken, or decreased physical activities.


HbAIC values show no change during Ramadan. Only two studies have reported slight increases in glycated hemoglobin levels. (1-3)

The amount of fructosamine , insulin, C-peptide also has been reported to have no significant change before and during Ramadan fasting.(4-5)


Pathophysiology of Fasting

• Insulin secretion in healthy individuals is stimulated with feeding, which promotes the storage of glucose in liver and muscle as glycogen.

• In contrast, during fasting, circulating glucose levels tend to fall, leading to decreased secretion of insulin, levels of glucagon and catecholamines rise, stimulating the breakdown of glycogen, while gluconeogenesis is augmented

Pathophysiology of Fasting

• As fasting becomes protracted for more than several hours, glycogen stores become depleted, and the low levels of circulating insulin allow increased fatty acid release from adipocytes.

• Oxidation of fatty acids generates ketones that can be used as fuel by skeletal and cardiac muscle, liver, kidney, and adipose tissue, thus sparing glucose for continued utilization by brain and erythrocytes.

Major risks associated with fasting in patients with diabetes

Hypoglycemia

Hyperglycemia

Diabetic ketoacidosis

Dehydration and thrombosis

DIABETES CARE, VOLUME 28, NUMBER 9 SEPTEMBER 2005

…….Risks associated with fasting in patients with diabetes

Hypoglycemia:

It has been estimated that hypoglycemia accounts for 2–4% of mortality in patients with T1DM (much lesser with T2DM).

The recent EPIDIAR study showed that fasting during Ramadan increased the risk of severe hypoglycemia (4.7-fold in patients with T1DM and 7.5-fold in patients with T2DM).

Diabetes Care 2004;27:2306–2311

Hyperglycemia

The EPIDIAR study showed 5 fold increase in the incidence of severe

hyperglycemia (requiring hospitalization) in patients with T2DM.

3 fold increase in the incidence of severe hyperglycemia with or without ketoacidosis in patients with T1DM.


Diabetes Care 2004;27:2306–2311

Diabetic ketoacidosis

Patients with diabetes, who fast during Ramadan, are at increased risk for development of diabetic ketoacidosis, particularly if poorly controlled before Ramadan.

The risk may further increase due to excessive reduction of insulin dosage based on the assumption that food intake is reduced during the month.


Diabetes Care 2004;27:2306–2311

Dehydration and thrombosis

Reports have suggested an increased incidence of retinal vein occlusion.

However, hospitalizations due to coronary events or stroke were not increased during Ramadan

Limitation of fluid intake during the fast, especially if prolonged, is a cause of dehydration.

In addition, hyperglycemia produces an osmotic diuresis, further contributing to volume and electrolyte depletion.


DIABETES CARE, VOLUME 33, NUMBER 8, AUGUST 2010

M. al-Arouj et al, “Recommendations for management of diabetes during Ramadan,” Diabetes Care, 28(2005), 2305-2311.

Risks during fasting

“Most often, the recommendation will be to not undertake fasting.

However, patients who insist on fasting need to be aware of the associated risks and be ready to adhere to the recommendations of their health care providers to achieve a safer fasting experience.”

Categories of risks in patients with type 1 or type 2 diabetes who fast during Ramadan

Very High Risk

• Severe hypoglycemia within the last 3 months prior to Ramadan

• Patient with a history of recurrent hypoglycemia

• Patients with hypoglycemia unawareness• Acute illness• Pregnancy• Patients on chronic dialysis

...........Very High Risk

• Patients with sustained poor glycemic control (HbA1C > 9.0%)

• Ketoacidosis within the last 3 months prior to Ramadan

• Type 1 diabetes• Hyperosmolar hyperglycemic state within

the previous 3 months• Patients who perform intense physical

labor

High Risk

• Patients with moderate hyperglycemia (average blood glucose between 8.3 and 16.6 mmol/L, HbA1C 7.5–9.0%)

• Patients with renal insufficiency• Patients living alone• On drugs that may affect mentation

.....High Risk• Patients with advanced macrovascular

complications• People living alone that are treated with

insulin or sulfonylureas• Patients with comorbid conditions that

present additional risk factors• Old age with ill health

Moderate risk•Well-controlled diabetes treated with short-acting insulin secretagogues.

Low risk•Well-controlled diabetes treated with Medical nutrition therapy Metformin Acarbose, Thiazolidinediones, and/or incretin-based therapies in otherwise healthy patients

The principles of Pre-Ramadan considerations

(a) Physical well being assessment

(b) Assessment of metabolic control

(c) Adjustment of the diet protocol for Ramadan fasting

(d) Adjustment of the drug regimen (e.g. change long-acting hypoglycemic drugs to short-acting drugs to prevent hypoglycemia)

(e) encouragement of continued proper physical activity

(f) recognition of warning symptoms of dehydration,

hypoglycemia and other possible complications.

Recommendations during Ramadan fasting

I. Nutrition and Ramadan fasting:

Abstain from the high-calorie and highly-refined foods prepared during this month.

II. Physical activity and Ramadan fasting: It has been shown that fasting does not interfere with tolerance to exercise.

It is necessary to continue their usual physical activity especially during non-fasting periods.

Lancet. 1989; 1:1396N Engl J Med. 1991; 325: 196-199.


III. Other health tips for reduction of complications:

1. Implementation of the 3D Triangle of Ramadan --

Drug regimen adjustment,

Dietary management and

Daily activity -- as the three pillars for more successful fasting during Ramadan.


2. Diabetic home management that consists of: Monitoring home blood glucose especially for T1DM Checking urine for acetone (T1DM) Measuring daily weights and informing physicians of

weight reduction (dehydration, low food intake, polyuria) or weight increase (excessive calorie intake) above two kilograms;

Recording daily diet intake (prevention of excessive and very low energy consumption).


3. Education about warning symptoms/signs of dehydration, hypoglycemia and hyperglycemia.

4. Education about breaking fast as soon as any complication or new harmful condition occurs.

5. Immediate medical help for diabetics who need medical help quickly, rather than waiting for medial assistance the next day.

Ramadan Education and Awareness in Diabetes (READ) program for Muslims with Type 2 diabetes who fast during Ramadan

Diabet. Med. 27, 327–331 (2010)

Benefits of Education & Counselingaccording to the READ study

Diabet. Med. 27, 327–331 (2010)

Management

General considerations

• Several important issues deserve special attention:– Individualization– Frequent monitoring of glycemia– Nutrition– Exercise– Breaking the fast

Adjustment of DrugsAdjustment of Drugs

Before Ramadan During RamadanPatients on “diet and exercise”(MNT)

- No change is needed - Modify time & intensity of exercise- Ensure adequate fluid intake

Treatment RecommendationsTreatment Recommendations

Before Ramadan During RamadanSulfonylurea Once Daily: Morning dose.e.g., Gliclazide MR Glimepiride

Iftar: Full Morning Dose

Sulfonylurea Twice Daily: Morning & Evening dose.e.g., Gliclazide Glibenclamide

Iftar: Full Morning DoseSuhur: ½ Evening Dose


Majority of our type 2 diabetic patients are treatedMajority of our type 2 diabetic patients are treatedwith Sulfonylurea & Metforminwith Sulfonylurea & Metformin

Before Ramadan During RamadanMetformin 500 mg thrice daily

Iftar: 1,000 mg,Suhur: 500 mg


Before Ramadan During RamadanDPP4 inhibitor As usual at night

Glitazone As usual at night

Glinide As usual at night


Before Ramadan During RamadanPremixed insulin 30 (Mistard/Novomix)Morning: (30U)Dinner: (20U)

Iftar: Full Morning Dose (30U)Suhur: ½ Dinner Dose (10U)

Basal Analogue (Glargine/Levemir/Degludec)

At the same time 20-30% dose reduction

Split Mixed (R+N)R+0+RN+0+N

R+0+50%of RN+0+50%of N

R+R+R0+0+N

R+R+50% of R0+0+50% of N


Management of patients with T1DM

• Fasting at Ramadan carries a very high risk for people with T1DM.

• Risk is particularly exacerbated in poorly controlled patients and those with limited access to medical care, hypoglycemic unawareness, unstable glycemic control or recurrent hospitalizations.

• The risk is also very high in patients who are unwilling or unable to monitor their blood glucose levels several times daily at home.

Management of T1DM during Ramadan

• If patients choose to fast against medical advice, it is advantageous if they are on a basal bolus regime and are familiar with carbohydrate counting.

• A small study (n = 9) of patients with T1DM using insulin glargine and insulin Lispro or aspart, divided in a 6 : 4 ratio of the total 24-h insulin dose, reported no episodes of severe hypoglycaemia or diabetic ketoacidosis requiring hospitalization, and the haemoglobin A1c remained stable at the end of Ramadan.

Management of patients with T1DM• A recent small study with insulin glargine suggests the

relative safety and efficacy of this agent in 15 relatively well-controlled patients with T1DM who fasted for 18 h and experienced a minimal decline in mean plasma glucose from 125 to 93 mg/dl with only two episodes of mild hypoglycemia

• Another study in patients with T1DM using insulin glulisine, Lispro, or aspart instead of regular insulin in combination with intermediate-acting insulin injected twice a day led to improvement in postprandial glycemia and was associated with fewer hypoglycemic events

Mucha GT et al. Diabetes Care, 2004.

Kadiri A et al. Diabetes Metab, 2001.

Management of patients with T1DM

• Continuous subcutaneous insulin infusion (pump) management is an appealing alternative strategy, but at a substantially greater expense.

Benbarka MM et al. Diabetes Technol Ther, 2010.

Recommendations – PregnancyMuslim pregnant women are exemptd from

fasting during Ramadantype 1type 2 or Gestational

They should be strongly advised to not fast during Ramadan

These women constitute a high-risk group and their management requires intensified care

Diabetes Care. 2005; 28 (9).

Management of Hypertension and Dyslipidemia

• Dehydration, volume depletion, and a tendency toward hypotension may occur with fasting during Ramadan.

• Hence, the dosage of antihypertensive medications may need to be adjusted to prevent hypotension.

• It is common practice that the intake of foods rich in carbohydrates and saturated fats is increased during Ramadan. Appropriate counselling should be given to avoid this practice.

Post-Ramadan supervision The patients therapeutic regimen should be changed

back to its previous schedule.

Patients should also be required to get an overall education about the impact of fasting on their physiology

Degenerative complications check up

Monthly weight, blood pressure, HbA1c and renal function evaluation every six months.

Diabetes Care. 1997; 20:1925-1926.

Monitoring Recommendations Monitoring Recommendations

Patients should monitor their blood glucose Patients should monitor their blood glucose eveneven during the fast to recognize subclinical hypo during the fast to recognize subclinical hypo andand hyperglycemia hyperglycemia

Islam allows diabetics to have regular blood Islam allows diabetics to have regular blood testtest while fasting while fasting

If blood glucose is noted to be low (<60mg/dl), If blood glucose is noted to be low (<60mg/dl), thethe fast must be broken fast must be broken

If blood glucose is noted to be (>300mg/dl), If blood glucose is noted to be (>300mg/dl), ketonesketones in urine should be checked & medical advice in urine should be checked & medical advice soughtsought

Awareness: Physician’s GuidelineAwareness: Physician’s Guideline

Conclusion Majority of uncomplicated type 2 diabetic patients can fast

during Ramadan with minimum risks.

Pre-Ramadan medical assessment, education and motivation are very important to prevent diabetes related complications

Islam allows diabetics to have regular blood test while fasting

Fasting along with regular prayer have been proved to aid in better control of diabetes

Individualization and frequent monitoring of glycemia can significantly reduced the major risks associated with fasting

Thank YouThank You

fasting with diabtetes dr shahjada selim

Health & Medicine

diabetes diabetes care

fasting month of ramadan

ramadan education

epidemiology of diabetes

thrombosis diabetes

diabetic ketoacidosis

glucose levels

storage of glucose