DIABETES and RAMADAN

2. FereidounAzizi, M.D. Professor of Internal Medicine & Endocrinology Research institute for Endocrine Sciences ShahidBeheshti University of Medical Sciences Tehran, I.R. Iran Ramadan & Health Conference Jinnah Sindh Medical University Karachi, Pakistan, October 2015 DIABETES and RAMADAN

3. OBJECTIVE • To review changes in metabolism of carbohydrates during fasting of Ramadan • To present the evidence-based management of diabetic patients during Ramadan • To adapt dietary recommendations in diabetic in Ramadan • To discuss practical management of diabetic cases during Ramadan

4. يَا أَيُّهَا الَّذِينَ آمَنُواْ كُتِبَ عَلَيْكُمُ الصِّيَامُ كَمَا كُتِبَ عَلَى الَّذِينَ مِن قَبْلِكُمْ لَعَلَّكُمْ تَتَّقُونَ The goal of fasting is to developself-restraint. Holy Quran states: “O you who believe! Fasting is prescribed to you as it was prescribed to those before you, so that you may develop Taqwa(self-restraint) ” [2:183] Example: God says about Mary in the Qur’an that she said: “Verily!, I have vowed a fast to the Most Beneficent…[Maryam 19:26]. What is Taqwa? Taqwa is an Arabic word. It is the state of heart that motivates virtuous conduct and prevents evil action. leads to Love of God + Fear of God Taqwa (Self-restraint) Taqwa is the ability to safe-guard.

5. Differences of fasting in Ramadan and experimental fasting Intermittent in Ramadan Fasting 11-18 hours daily Avoidance of liquid intake Various effects of temperature in each region Difference in food habits in various regions Change in sleep pattern Difference in aim of fasting and moral issues

6. Changes in Carbohydrates Metabolism During Fasting of Ramadan

8. Glucose Turnover Absorptive: 8-12 hr Post absorptive: 5-6 hr Gluconeogenesis

12. Serum glucose during Ramadan Serum glucose may decrease slightly in the first few days of Ramadan fasting, normalizing by the 20th day and showing a slight rise by the 29th day . The lowest serum glucose level in this study was 63 mg/dl. Other studies have shown a mild increase or variation in serum glucose concentration

13. Change in serum glucose concentration

14. Longer fasting During longer fasting days of >16 h, which follow a rather heavy meal taken before dawn (Sahur), the stores of glycogen, along with some degree of gluconeogenesis, maintain serum glucose levels within normal limits. Since gluconeogenesis becomes the only source of glucose after 16–24 h of fasting, it is recommended that observers of fasts do not skip Sahur, their predawn meal, because of the possibility of extended gluconeogenesis.

15. Changes in serum lipids Alterations in serum lipid may be related to consuming a large meal, as has been shown in individuals taking one large meal every day. In fasting subjects, who did not show any weight change during the month of Ramadan, it has been seen that serum leptin and insulin concentrations increased and neuropeptide Y levels decreased.

16. The effect of Ramadan fasting on etabolism and different organs in healthy individuals

17. Evidence- Based Management of Diabetes During Ramadan

18. Changing in lifestyle during Ramadan Dietary Habits Daily Physical Activity Sleeping Pattern Glycemic Control Weight& Dietary Intakes Lipid Profile 1. Introduction 2. Risk of fasting for diabetes 3.Nutritional considerations

19. Fasting in type 1 diabetics • Glucagon secretion fails to increase • Epinephrine secretion is defective • Prolonged fast: Excessive glycogen breakdown Increased gluconeogenesis Ketoacidosis

20. How many people with diabetes fast during Ramadan? Salti et al. Diabetes Care 2004; 27: 2306

21. A Population-Based Study of Diabetes and Its Characteristics During the Fasting Month of Ramadan in 13 Countries Results of the Epidemiology of Diabetes and Ramadan 1422/2001 (EPIDIAR) study Ibrahim Salti, MD, PHhD, Eric Benard, MD, Bruno Detournay, MD, MBA, Monique Biscay, MD, Corinne Le Brigand, Celine Voinet, Abdul Jabbar, MD, on behalf of the EPIDIAR Study Group* Diabetes Care 2004; 27: 2306

22. RESEARCH DESIGN AND METHODS: This was a population-based, retrospective, transversal survey conducted in 13 countries. A total of 12,914 patients with diabetes were recruited using a stratified sampling method, and 12,243 were considered for the analysis. RESULTS: Investigators recruited 1,070 (8.7%) patients with type 1 diabetes and 11,173 (91.3%) patients with type 2 diabetes. During Ramadan, 42.8% of patients with type 1 diabetes and 78.7% with type 2 diabetes fasted for at least 15 days. Less than 50% of the whole population changed their treatment dose (approximately one-fourth of patients treated with oral antidiabetic drugs [OADs] and one-third of patients using insulin). Severe hypoglycemic episodes were significantly more frequent during Ramadan compared with other months (type 1 diabetes, 0.14 vs. 0.03 episode/month, P = 0.0174; type 2 diabetes, 0.03 vs. 0.004 episode/month, P < 0.0001). Severe hypoglycemia was more frequent in subjects who changed their dose of OADs or insulin or modified their level of physical activity.

23. Recommenations and education, including counseling for blood glucose control and self-management of diabetes, were dispensed by physicians to 89% of patients with type 1 diabetes and to 80% of patients with type 2 diabetes. However, only 67% of patients with type 1 diabetes and 37% of patients with type 2 diabetes were monitoring blood glucose levels themselves. Salti, et al. Diabetes Care 2004; 27: 2306

24. Change in physical activity and food intake during Ramadan in patients with diabetes Salti, et al. Diabetes Care 2004; 27: 2306

25. Change in dosage of insulin and oral hypoglycemic drugs during Ramadan Salti, et al. Diabetes Care 2004; 27: 2306

26. Management of diabetes during Ramadan (continued) Hui E et al. BMJ 2010; 340: 1407-1411. AlMaatouq M. Diabetes, Metabolic syndrome and Obesity: Targets and Therapy 2012;5:109-11.

27. The principles of pre-Ramadan consideration are: Assessment of physical well being; Assessment of metabolic control; Adjustment of the diet protocol for Ramadan fasting; Adjustment of drug regimen; Encouragement of continued proper physical activity; Recognition of warning symptoms dehydration,hypoglycemia etc.

28. Proposed algorithm for pre-Ramadan review and adjustments of lifestyle and therapeutic regimens

29. Recommendations for Management of Diabetes During Ramadan Monira Al-Arouj, MD, Radhia Bouguerra, MD, John Buse, MD, PhD, Sherif Hafez, MD, FACP, Mohamed Hassanein, FRCP, Mahmoud Ashraf Ibrahim, MD, Faramarz Ismail-Beigi, MD, PhD, Imad El-Kebbi, MD, Oussama Khatib, MD, Phd, Suhail Kishawi, MD, Abdulrazzag Al-Madani, MD, Aly A. Mishal, MD, FACP, Masoud Al-Maskari, MD, Phd, Abdalla Ben Nakhi, MD and Khaled Al-Rubean, MD Diabetes Care 2004; 28: 2305 Al-Arouj et al. Diabetes Care 2010; 33: 1895

30. Major risks associated with fastingin patients with diabetes

31. Very high risk • Severe hypoglycemia within the last 3 months prior to RamadanPatient with a history of recurrent hypoglycemia • Patients with hypoglycemia unawarenessPatients with sustained poor glycemic controlKetoacidosis within the last 3 months prior to RamadanType 1 diabetesAcute illness • Hyperosmolar hyperglycemic coma within the previous 3 monthsPatients who perform intense physical labor • PregnancyPatients on chronic dialysis Categories of risks in patients with type 1 or type 2 diabetes who fast during Ramadan Al-Arouj et al. Diabetes Care 2010; 33: 1895

32. Categories of risks in patients with type 1 or type 2 diabetes who fast during Ramadan Al-Arouj et al. Diabetes Care 2010; 33: 1895

33. Categories of risks in patients with type 1 or type 2 diabetes who fast during Ramadan Al-Arouj et al. Diabetes Care 2010; 33: 1895 Moderate risk Well-controlled patients treated with short-acting insulin secretagogues such as repaglinide or nateglinide Low risk Well-controlled patients treated with diet alone, metformin, acarbose, thiazolidinedione or incretion drugs who are otherwise healthy

34. RECOMMENDATIONS DURING RAMADAN FASTING I.Nutrition and Ramadan fasting: Dietary indiscretion during the non-fasting period with excessive gorging, or compensatory seating, of carbohydrate and fatty foods contributes to the tendency towards hyperglycemia and weight gain. II. Physical activity and Ramadan fasting: It should be impressed upon diabetic patients that it is necessary to continue their usual physical activity especially during non-fasting periods.

35. RECOMMENDATIONS DURING RAMADAN FASTING III. Drug regiments for IDDM patients: It is fundamental to adjust the insulin regimen for good IDDM control during Ramadan fasting. IV. Drug regimens for Type 2 patients: With proper changes in the dosage of hypoglycemia agents there will be low risk for hypoglycemia and hyperglycemia. The authors of the largest series of patients treated with glibenclamide during Ramadan recommended that diabetics switch the morning dose of this drug with the dosage taken at sunset.

36. Site and mode of action of the most commonly used antidiabetic pharmacological agents, classified by their hypoglycemic risk potential and weight gain/loss characteristics. Almaatouq MA. Diabetes Metab Syndr Obes 2012; 5: 109

37. Recommended changes of treatment regimen in patients with type 2 diabetes who fast during Ramadan

38. General safety summary (number of patients, %) in the safety population (n=59) Hassanein M, Curr Med Res Opin 2011; 27: 1367

39. Recommended changes of treatment regimen in patients with type 2 diabetes who fast during Ramadan

40. Recommended changes of treatment regimen in patients on insulin therapy who fast during Ramadan

41. Algorithm for premixed insulin titration during Ramadan

42. Recommended changes of treatment regimen in patients on insulin therapy who fast during Ramadan

43. Insulin regimen adjustments in people with type 2 diabetes who are fasting for Ramadan

44. Self monitoring of blood glucose AL-Arouj M et al. Diabetes Care 2010; 33:1895-1902. • Essential for safe fasting • Glucose monitoring is useful for: • Meal planning to avoid hypoglycemia and dehydration during prolonged fasting hours • Appropriate meal choice to avoid postprandial hyperglycemia 3. Nutritional considerations 4. Case study 5. Diabetes education

45. Recommendations for prevention of hypoglycemia during Ramadan

46. Diabetic home management consists of: 1. Monitoring home blood glucose especially for type 1 patients, as described above; Checking urine for acetone (type 1 patients) 2. 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).

47. Diabetic home management consists of: 3. Education about the warning symptoms of dehydration, hypoglycemia and hyperglycemia. 4. Education about breaking or discontinuing of the 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 when available. 6. Further attention on fasting during the summer season and geographical areas with longer fasting hours.

48. Conclusion • Diabetics with complications and those who are high risk should not fast • Diabetics must visit the physician at least one month prior to Ramadan • Only those with appropriate diets and physical activity, having controlled diabetes could fast during Ramadan • Patient education must be conducted before entering Ramadan • Management of diabetics in Ramadan is a good example of “Patient Centered Care (PCC)”. • Appropriate self management is the key to Ramadan fasting for diabetics.