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Dr , I have Diabetes, Can I fast?

Dr , I have Diabetes, Can I fast? . Dr Majedah AbdulRasoul Assistant Professor Pediatric Department Faculty of Medicine Kuwait University. Understand what happens in diabetics and non-diabetics during fasting Improve knowledge and understand “ safe fast” during Ramadan

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Dr , I have Diabetes, Can I fast?

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  1. Dr, I have Diabetes, Can I fast? DrMajedahAbdulRasoul Assistant Professor Pediatric Department Faculty of Medicine Kuwait University

  2. Understand what happens in diabetics and non-diabetics during fasting • Improve knowledge and understand “ safe fast” during Ramadan • Be able to empower patients to make the right decision to avoid risks associated with fasting during Ramadan Learning Outcomes

  3. As of 2010, over 1.6 billion or about 23.4% of the world population are Muslims * • Growing by ~ 3% per year. Muslims around the World *The Future of the Global Muslim Population. Pew Research Centre. 27 January 2011.

  4. “O You who believe, fasting is prescribed to you as it was prescribed to those before you so that you can learn Taqwa. For a number of days, but for those who are ill, or on a journey, these days should be made up from days later” Ramadan SurrahAlBaqara 2: 183

  5. The 9th months of the Islamic calendar • Fasting in Ramadan is one of the 5 main pillars of Islam • Complete fasting during daylight hours for one full Lunar month (29-30days) , for up to 20 hours depending on the geographical location. Ramadan

  6. ‘ Ramadan is the (month) in which was sent down the Quran as a guide to mankind, also clear ( Signs) for guidance and judgment (between right and wrong). So every one of you who is present (at his home) during that month should spend it fasting, but if any one is ill, or on a journey, the prescribed period (should be made up) by days later. Allah intends every facility for you; He does not want to put to difficulties. (He wants you) to complete the prescibed period, and to glorify Him in that he has guided you; and perchance ye shall be grateful’. Exception from fasting SurrahAlBaqara 2: 185

  7. Illness – Chronic • Diabetes • Those who can not understand the purpose of fasting-mentally challenged • Frail elderly • Travelers • Women during menstruation, pregnancy, lactation • Pre-pubertal children Exception from fasting

  8. Many patients with diabetes insist on fasting during Ramadan, thereby creating a medical challenge for themselves and their healthcare providers • It is important that medical professionals be aware of potential risks associated with fasting during Ramadan and approaches to decrease those risks • A large epidemiological study of Muslims with diabetes in 13 Muslim countries (the EPIDIAR study) showed that 43% of patients with type 1 and 79% of those with type 2 diabetes fasted during Ramadan. Exception from fasting Diabetes Care 2004; 27:2306

  9. Carbohydrate metabolism in healthy persons: • Most of the studies show slight decrease in serum glucose to 3.2-3.9 mmol/L in adults few hors after fasting • This may vary depending on: • Food habits • Differences in metabolism • Differences in energy regulation • The fall in glucose cease due to: • Serum insulin decrease Increase glycogenlysis • Serum glucagon and GH increase Increase gluconeogenesis Decrease glycogenesis Back to Basics: CHO DeGroot and Jameason 2004 Am J Med 200; 199: 341

  10. Variable results • Serum total cholesterol and triglycerides may decrease in the first days of fasting, then rise to pre fasting levels • Increase in HDL-C • Effect may be variable depending on quality and quantity of food consumed. • Increase in Apo A-1concentration in both normal and diabetics. Back to Basics: Lipids Am J ClinNutr 1982; 30: 351 Saudi Med J 1986; 7: 561 Eur J ClinNutr 2000; 54:508

  11. What happens in Diabetics

  12. Blood glucose variation in patients with diabetes • It may fall, nit change, or rise • The variation is due to the amount and type of food consumed and/or decreased physical activity • HbA1c values showed no change or even improvement during Ramadan.* • The amount of fructosamine, insulin, C-peptide also has been reported no change before and during Ramadan fasting Most studies are in Type 2 *Int J ClinPract 2010; 64: 1095 Ann Saudi Med 1994; 14:139 *BMJ,2010; 340: 1407-1411 BMJ 1993; 307: 292

  13. So, Can patients with Diabetes Fast?

  14. The bulk of literature indicates that fasting Ramadan is safe for the majority of type 2 diabetic patients with proper education and diabetic management.

  15. No Fasting Type 1 Diabetes?

  16. Your views?

  17. 18 yrs old teenager • Type 1 diabetes since the age of 12yrs • On NPH and Actrapid • Because he can not get Lantus • Testing his blood glucose at home 2-3 times per day • Mean HbA1c this year is 9.4 (was 9.8% last year) • He came to you in Shaaban asking about fasting this year. What will you do? Case 1

  18. No fasting for patients with type 1 diabetes. • More so if: • Poor control • On NPH • Coming close to Ramadan • Have high risk for hyperglycemia, DKA, and hypoglycemia Your recommendations:

  19. Hypoglycemia: • 2-4% of mortality in patients with T1DM • More with hypoglycemia unawareness, poor glycemic control and recurrent hypoglycemia in the past needing hospitalization • EPIDIAR study: • 4.7- fold increase in severe hypoglycemia ( needing hospitalization) in patients with T1DM • 3-14 events /100 people/month Risks associated with fasting in T1DM Diabetes Care 2004; 27:2306

  20. Hyperglycemia: No information linking repeated yearly episodes of short-term hyperglycemia and diabetes-related complications during Ramadan. • Deteriorate, improve, no change • EPIDIAR study: • 3fold increase in severe hyperglycemia with or without ketoacidosis in patients with T1DM (from 5 to 17 events /100 people/month. • Due to excessive reduction of insulin to prevent hypoglycemia, increase intake of food and sugar drinks. Risks associated with fasting in T1DM Diabetes Care 2004; 27:2306

  21. Diabetic Ketoacidosis: • More in patients with poorly controlled diabetes before Ramadan* • The risk is increased because of decreased insulin dose (assuming that food intake is reduced) • Risk for dehydration • Dose reduction in response to acute infection • However, it remains non-conclusive • 1.8% of T1DM patients developed DKA during Ramadan, same as non-fasting months.** Risks associated with fasting in T1DM *Diabetes Care 2004; 27:2306 ** Abusrewil et al 2003 Jamahiriya Med J; 2:99

  22. Dehydration and thrombosis: • Increased incidence of retinal vein occlusion • However, coronary artery events or stoke were not increased in Ramadan • Limitation of fluid intake can lead to dehydration • Hot and humid climates  increase the risk • Also, hyperglycemia  osmotic diuresis  fluid and electrolyte imbalance Risks associated with fasting in T1DM

  23. T1DM • Severe Hypos within the last 3 months • History of recurrent hypos • Hypo unawareness • Acute illness • Chronic Dialysis • Sustained poor control • DKA within the last 3 months • Pregnancy • Hyperosmolar hyperglycemic coma in the last 3 months • Intensive physical labor Risk Categories for Fasting Ramadan In Diabetics: Very High Risk

  24. Moderate hyperglycemia: Average BG 8.5-16.5, HbA1c 7.5-9% • Renal Insufficiency • Living alone • Drugs affecting mentation • Advanced marcovascular complications • Co-morbid conditions aggravating the above • Old age with ill health Risk Categories for Fasting Ramadan In Diabetics: High Risk

  25. Moderate Risk • Well controlled treated with short acting insulin, secretagogues Low Risk • Well controlled diabetes treated with lifestyle modification, metformin, acarbose, TZD. Risk Categories for Fasting Ramadan In Diabetics: Mod / Low

  26. 13 yrs old boy • Type 1 diabetes since the age of 5 yrs • On MDI • Glargine and Novorapid 4-5 times • Testing his blood glucose at home 4-6 times per day • Mean HbA1c this year improved from 8.5% to 7.1% • This year he wanted to fast for the first time • He came to you in Rajab with his desire to fast What will you do? Case 2

  27. No fasting for patients with type 1 diabetes. • More than 75-80% of our children with type 1 diabetes choose to fast, despite the recommendation, specially if: • they have been fasting before diagnosis • Have younger siblings who fast • Friends who fast • If they did not bring the issue of fasting, you should. Your recommendations:

  28. Assess physical well being • Weight on the 50th centile – was 25-50th last yr • Height of the 75th centile – same centile for yrs • Assessment of metabolic control • HBGM 4-6 per day • Fasting 5-8mmol/L, occasional 9mmol/L • Bed time 10mmol/L • 1-2 hypos (at school) over the last month, managed by juice • No admission for DKA since the last 3 yrs General consideration:

  29. Your recommendation : No Fasting • If despite recommendation he decide to fast: • Discuss s/s of low blood sugar • Review management of hypoglycemia • Check if they have glucagon • Review diet routine with dietician • Check blood sugar 4-6 per day • Break the fast of blood glucose less than 4mmol/L • Break the fast if blood sugar is more than 13, specially with ketones and act with hyperglycemia protocol. • May need revision of insulin dose (lantus) in fasting and adjust dose of meal bolus • See after 1 week in Ramadan Your Opinion Now?

  30. A study on 20 patients on MDI • mean age of 12.4 yrs(fasting), 10.5 yr (not fasting) • Fasting was for 12.5 hours • Change in weight, HbA1c, lipid profile before anf after Ramadan • Results: • No statistical difference in HbA1c (9,2 &9.4% vs 9.13 &10%, p=0.9), weight or fasting lipids • No patient called the helpline and none had intercurrent illness or ketosis What does the literature say? AlAlwanetal 2010; Int J Diabetes Mellitus

  31. A study on 28 patients ( AmiriHosp, & Royal London Hospital) • Ages: 9-18 yr • Poorly controlled, recurrent DKA and not willing to do HBGM were excluded. • 2 groups (MDI basal bolus regimen vs conventional twice daily (premix at Iftar and short acting at Suhur) • Mild Hypo (need to break the fast) • Severe hypo (need glucagon or hospital admission) • Hyperglycemia (> 15mmol) and DKA • No of fasting days What does the literature say? AlKhawarietal 2010; Pediatr Diabetes

  32. AlKhawarietal 2010; Pediatr Diabetes

  33. AlKhawarietal 2010; Pediatr Diabetes

  34. AlKhawarietal 2010; Pediatr Diabetes

  35. AlKhawarietal 2010; Pediatr Diabetes

  36. Conclusions and recommendations: • Adolescents on basal-Bolus regimen can fast if they wish to • They should receive sufficient education prior to fasting • Increase HBGM • CHO count • Reduce basal by 10-20%, more if had hypoglycemia • If blood Glucose 15  correction given • Break fast if: • Develop ketones • BG < 4mmol • Avoid skipping pre-dawn meal

  37. A study with insulin glargine suggest the relative safety and efficacy in relatively well controlled patients who fasted for 18 hours, with minimal decline in mean BG, and only 2 episodes of mild hypoglycemia. Mucha GT etal, Diabetes Care, 2004 • A study in patients with type 1 diabetes using insulin Lispro or Aspart instead of regular insulin in combination with intermediate-acting insulin injected twice a day  improved PP glycemia + fewer hypoglycemia Kadiri et al. Diabetes Metab 2001 Fasting in T1DM on MDI

  38. Fasting in T1DM on MDI • Insulin Lispro, as a short acting instead of regular insulin , in combination with neutral protamine insulin in a basal bolus regimen  lower 2-h post-prandial glucose level after sunset meal (p = 0.026) with less hypoglycemia (p < 0.01) in an open –label crossover study ( n=64). • 3 slides Kadiri et al 2010

  39. Patients should monitor their blood glucose during fast to recognize subclinical hypo and hyperglycemia • Islam allows diabetics to have regular blood tests while fasing • If blood glucose drops below 4 mmol/L (some recommend 3.5) the fats must be broken • If blood glucose goes above 16.5 mmol/L, ketones should be checked, and medical advice sought Can a patient monitor blood sugar while fasting?

  40. Case 3 • 13 yrs old teenager girl • Type 1 diabetes since the age of 8 yrs • Was on MDI of glargine and Aspart for 3 years. • On insulin pump since 2 years, and CGM since 8 months. • Testing his blood glucose at home 2-3 times per day (more if feeling funny!!!) • Mean HbA1c this year is 6.9 (was 7.2% last year) • He came to you in Shaaban asking about fasting this year for the first time since diagnosed. What will you do?

  41. No fasting for patients with type 1 diabetes. • But: • On CSII • On CGMS • Excellent glycemic control • I may allow her to fast Your recommendations:

  42. What does the literature say? • 63 patients, aged 22+/-7 yrs, had diabetes for 9.8+/-5.6 yrs • On Medtronic MiniMed 722 for 20+/- 10 months • Outcome measures: • Days fasting • Hypoglycemia • Hyperglycemia • Emergency visits to the ER Benbaraka et al 2010; Diabetes TechnolTher 12(4)

  43. Results: • Days fasting: • 61.2% fasted the whole month with no problems • 18.4% fasted 27-28 days • 16.3% fasted 24-25% • 4.1% fasted 23 days • 50% decreased their basal by 5-50% • 27% had hypoglycemia  break the fast • Fasting was broken in 3.8% of potential fasting days • No severe hypoglycemia • Unusual hyperglycemia in 18.4%, one needed hospital visit • 12 had pre and after Ramadan fructosamine level: 4+/-0.6 mmol vs 3.6+/-0.6 mmol/L, p =0.007 Benbaraka et al 2010; Diabetes TechnolTher 12(4)

  44. Conclusions: • Fasting Ramadan is feasible in patients with T1DM on SCII with adequate counselling and support Benbaraka et al 2010; Diabetes TechnolTher 12(4)

  45. What does the literature say? (2) • 21 patients, median age 26 yr, adjusted their insulin in the routine way. All were on CGMS. • Outcome measures: • Body weight • HbA1c • Blood glucose • Total insulin dose • Overriding tendencies • Suspend time during fast • Hypoglycemia Khalil et al 2012; Diabetes TechnolTher 14(9)

  46. Results: • Days fasting: • Median days 29 • Basal insulin was decreased by 5-20%, no overall sig. • Redistribution of insulin based on daily lifestyle and eating times • No major hypoglycemia • Mild hypoglycemia in 8.4%, managed by basal adjustment or suspension of pump Khalil et al 2012; Diabetes TechnolTher 14(9)

  47. Conclusions: • The use of CGMS add advantage on CSII in type 1 diabetic patients choosing to fast in Ramadan Khalil et al 2012; Diabetes TechnolTher 14(9)

  48. Patients with T1DM are excepted from fasting during Ramadan • Those who insist on fasting need to be aware of the associated risks • They should adhere to the recommendation of of the healthcare providers to achieve a safe fast. Conclusions & Recommendations(1)

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