Diabetes and Ramadan presentation · 2 A large number of Muslim patients with diabetes fast during Ramadan Global Muslim population 1 1.6 billion (2010) 2.2 billion (2030) 100 million

Between health and faith - Managing diabetes during Ramadan

Ahmed HusseinEndocrine and Diabetes RegistrarBlacktown-Mt Druitt Hospital

Acknowledgment Dr Ibrahim Abu Muhammed

Grand Mufti of Australia

Professor Glen Maberly Dr Marwan ObaidSenior Staff Specialist (Endocrinology) Endocrinologist

Blacktown and Mt Druitt Hospitals Bankstown Hospital

Program Lead Western Sydney Diabetes

Integrated and Community Health

Anita Ray

Communications Manager

Integrated and Community Health

Western Sydney Diabetes -Western Sydney Local Health District

Disclosure � Nill

� To understand the religious principles of Ramadan and its

significance to Islam.

� To discuss the different risk categories for patients with diabetes

who fast Ramadan .

� To discuss pre Ramadan planning and management during Ramadan.

� Brief outline of the guidelines that were formulated.

Outlines

2

•

Fasting

• Essential component to many religions

• Now even promoted as a means to healthy living

• Depending on religion, lasts for different lengths of time

• Fasting in Islam:– Ramadan

– Monday and Thursday any time of year

– 13 th , 14 th and 15 th of every Lunar month

2

A large number of Muslim patients with diabetes fast during Ramadan

Global Muslim population1

1.6 billion

(2010)

2.2 billion

(2030)

� 100 million people with diabetes are

estimated to fast during Ramadan

worldwide2,3

• The global prevalence of diabetes is projected to increase in emerging economies, including those with large

Muslim populations4,5

• The pattern of daytime fasting and night-time meals and use of anti-diabetic treatment increases the risk of

complications, including hypoglycaemia in patients with diabetes2,3

• Although the consensus from religious and medical leaders is that Muslims with diabetes are generally not obliged

to fast6 many choose to do so2,3

1The Pew Forum on Religion & Public Life. http://www.pewforum.org/The-Future-of-the-Global-Muslim-Population.aspx (Accessed March 2013); 2Al-Arouj M et al. Diabetes Care

2010;33:1895–902; 3Salti I et al. Diabetes Care 2004;27:2306–11; 4IDF Diabetes Atlas 5th edition. www.idf.org/diabetesatlas/5e/the-global-burden (Accessed March 2013); 5Whiting

DR et al. Diabetes Res Clin Pract 2011; 94: 311–21; 6Beshyah SA. Ibnosina J Med Biomed Sci 2009;1:58–60

Diabetes Prevalence in Muslim Majority Nations

� Estimated number of people with diabetes in the Middle East and North Africa

Region will double to 72.1 million by 20401

� Similar increase expected in South East Asia, where Islam predominates (78 to

140 million by 2040) 1

� 3 of the top 10 countries in the world with the highest diabetes prevalence rates

are located within Middle East1

-Kuwait, Saudi Arabia, Qatar (20% prevalence)

-Bahrain (19.6%), UAE (19.3%), Egypt (16.7%), Oman (14.8%), Lebanon (13.0%)..all well

the average global prevalence of 8.8%!

1. International Diabetes Federation. Diabetes Atlas 7th Edition, 2015. www.idf.org.

Why do Muslims Fast?

• 5 pillars of Islam form the foundations of faith and

worship:

1.

2.

3.

4.

5.

Shahada – declaration of faith

Salah – 5 compulsory daily prayers

Zakat – annual alms tax (2.5% savings) to poor and needy

Sawm – fasting the month of Ramadan

Hajj – pilgrimage to Mecca once in a lifetime for those who

are financially and physically able

Spiritual Significance

• The Holy Month of Ramadan is a very significant time for

Muslims all over the world

• Many Muslims look forward to this month in anticipation of the

spiritual blessings it brings

• Having an understanding of the spiritual significance of this

month to the patient can place the health practitioner in a

much stronger position to gain the trust of the patient and

enable honest and beneficial communication

Duration

• Muslims traditionally fast every day of the month from dawn to

sunset, abstaining from food, drink (including water) and sexual

relations during these hours

• Because it follows the lunar calendar it will occur 10 days earlier in

each subsequent Gregorian Calendar

• Depending on the geographical location and season, the duration

of the daily fast may range from a few to over 20 hours

Ramadan – meal times

� Most people take two meals a day during Ramadan:

suhoor (the pre-dawn meal, ends at sunrise, followed by fajr or morning prayer)

iftar (the sunset meal which breaks day fast after maghribprayer)

� No restrictions on food or fluid intake between sunset and dawn

Exemptions

Pregnant

Women**

Suckling

Women**

Menstruating

Women**

* Should donate a meal to the needy

* * Should fast an equivalent number of days afterwards

Mentally

Impaired

Kids Elderly Sick people* Traveler**

Allah(God) desires ease for you, and He does not desire for you difficulty, and (He desires)that you should complete the number and that you should exalt the greatness of God for

His having guided you and that you may give thanks.” -Quran- 2:185

Exemption Fatwa for Diabetes patients

Muslims who are exempt from fasting still

insist on fasting in the month of Ramadan,

including pregnant women with diabetes.

Why?

• Perceive themselves as fit to fast

• Pregnant women without diabetes often fast without any

complications

Exemptions and reality

• Not to feel different from other fasting Muslims and to

experience the spiritual environment

• Not to miss the promised rewards

The diet during Ramadan

� Varies depending on geographic region

� Is a major change to usual dietary pattern:

� Usually a sugar-sweetened beverage and/or dates

to break the fast

� Consumption of large feast of foods rich in

carbohydrates and fats (especially sunset meal)

� Higher consumption of sweets

� Tendency to over-eat

� Dates:

Very good source of fibre, carbohydrates, sugar,

magnesium, potassium

Benefits?

••

•

•

•

Weight management eg 5:2 diet

Lipid profile(Cholesterol)

Sugar control

Blood pressure control

Reduced inflammatory markers

Risks:

• Hypoglycaemia(low blood sugar level) during the fasting period.

• Uncontrolled hyperglycaemia (high blood sugar levels after

the sunset meal (Iftar).

• Ketoacidosis:A serious complication of diabetes that occurs when your body produces high levels of

blood acids called ketones formed by the breakdown of fatty acids .

• Dehydration

• Thrombosis:

The formation of a blood clot inside a blood vessel, obstructing the flow of blood

through the circulatory system

Pathophysiology of fasting in normal individuals and patients with DM

EPIDIAR study: fasting during Ramadan increases the risk of severe

hypoglycaemia and hyperglycaemia in patients with T2DM

211Salti I, et al. Diabetes Care 2004;27:2306–11; 2Al-Arouj M, et al. Diabetes Care 2010;33:1895–902

Inci

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0.4

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2

3

4

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5

0

1

2

3

4

5

67.5-fold increase* 5-fold increase

P<0.0001 P<0.0001

27% of patients who experienced hypoglycaemia during the day refused to ingest anything orally to correct the hypoglycaemia, as it would

break their fas

11,173 patients with T2DM;

78.7% chose to fast for at least 15 days during Ramadan1

Higher risk of severe Hypoglycemic events†

in overall population during Ramadan‡1,2

Higher risk of severe Hyperglycaemic events†

in overall population during Ramadan‡1,2

Pre-Ramadan During Ramadan

Incidence of Severe Hypoglycemia During Ramadan in 2009by Treatment Group

6.7% of SU-Treated Muslim Patients With Type 2 DM Experienced Severe

Hypoglycemia During Ramadan Fasting1

SU=sulfonylurea.

1. Aravind SR et al. Curr Med Res Opin. 2011;27(6):1237–1242.

.

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Insulin Lispro

Regular insulin

Sunrise

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Sunrise

meal

Sunset

meal

2-h 6-h 2-h 6-h

27

5

12

27

11

5

2

43

0

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Sunrise

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Kadiri A et al. Diabetes Metab (Paris) 2001;27:482-6.

Hypoglycemia by Time of Day

• Patients with type 1 diabetes had an increased risk

for DKA if their diabetes was poorly controlled

before Ramadan (EPIDIAR study)1

• Excessive reduction in medication dosages based

on assumption that food intake is reduced during

the month2

Diabetic Ketoacidosis

1. Salti I et al. Diab Care 2004; 27: 2300–11. 2. Al-Arouj M et al. Diab Care 2010; 33: 1895–1902.

• Hypovolaemia and hypotension:

Limitation of fluid intake

Excessive perspiration in hot and humid climates

Osmotic diuresis related to hyperglycaemia

• Dehydration exacerbates hypercoagulable state and enhances risk of

thrombosis and stroke

• Fasting patients during Ramadan had increased incidence of retinal vein

occlusion

• Hospitalisations due to coronary events or stroke were not increased during

Ramadan

• No data concerning the effect of fasting on mortality in patients with or

without diabetes

1. Al-Arouj M et al. Diab Care 2005; 28: 2305–11

Dehydration and Thrombosis1

� However many Muslims with diabetes:1,2

Are passionate about fasting

• Don’t perceive themselves as being sick

• Enjoy the spiritual atmosphere during Ramadan

• Don’t want to miss out on the collective fasting and

community spirit created

� Healthcare providers need to provide appropriate and

culturally sensitive advice regarding risk on an individual

basis1,2

Most often the medical recommendation is NOT TO FAST1,2

1. Hassanein MM. Br J Diabetes Vasc Dis 2010; 10: 246–50. 2. Alzaid A. Br J Diab Vasc Dis 2012; 12: 57–9

Diabetes and Ramadan:Practical Guidelines

International Diabetes Federation(IDF), in collaborationwith the Diabetes and Ramadan(DAR) International AllianceApril 2016

DAR, Diabetes and Ramadan International Alliance;

IDF, International Diabetes Federation

1. International Diabetes Federation-Diabetes and Ramadan Practical Guidelines 2016

Category 1: very high risk

Listen to medical advice

MUST NOT fast

Category 3: moderate/low risk


Decision to use licence not to fast

based on discretion of medical opinion

and ability of the individual to tolerate

fast

Category 2: high risk


Should NOT fast

In all categories people

with diabetes should

follow

medical opinion if

the advice is not to fast

due to high probability

of harm

It should be noted that

some countries may

have different religious

views

IDF-DAR Practical Guidelines include the religious opinion from the Mofty of

Egypt1

Risk category

Religious opinion

Patient characteristics Comments

Category 1:

very high risk

Listen to

medical

advice

MUST NOT

fast

One or more of the following:• Severe hypoglycaemia within the 3 months prior to Ramadan

• DKA within the 3 months prior to Ramadan• Hyperosmolar hypoglycaemic coma within the 3 months prior to Ramadan

• History of recurrent hypoglycaemia• History of hypoglycaemia unawareness• Poorly controlled T1DM• Acute illness• Pregnancy in pre-existing diabetes, or GDM treated with insulin or SUs

• Chronic dialysis or CKD stage 4 & 5• Advanced macrovascular complications• Old age with ill health

If patients insist on fasting then they

should:

• Receive structured education• Be followed by a qualified diabetes

team• Check their blood glucose regularly

(SMBG)• Adjust medication dose as per

recommendations• Be prepared to break the fast in case

of hypo- or hyperglycaemia• Be prepared to stop the fast in case

of frequent hypo- or hyperglycaemia or worsening of other related medical conditions

Risk categories1

Very high risk patients should not fast


Risk category

Religious opinion

Patient characteristics Comments

Category 2:

high risk

Listen to

medical

advice

Should NOT

fast

One or more of the following:

•T2DM with sustained poor glycaemic control*•Well-controlled T1DM•Well-controlled T2DM on MDI or mixed insulin•Pregnant T2DM or GDM controlled by diet only or metformin

•CKD stage 3•Stable macrovascular complications•Patients with comorbid conditions that present additional factors

•People with diabetes performing intense physical labour

•Treatment with drugs that my affect cognitive function

If patients insist on fasting then they

should:

• Receive structured education• Be followed by a qualified diabetes

team• Check their blood glucose regularly

(SMBG)• Adjust medication dose as per

recommendations• Be prepared to break the fast in

case of hypo- or hyperglycaemia• Be prepared to stop the fast in case

of frequent hypo- or hyperglycaemia or worsening of other related medical conditions

Risk categories1

High risk patients should not fast


Risk categories1

Moderate/low risk patients should discuss fasting with their physician

Risk category

Religious opinionPatient characteristics Comments

Category 3: moderate/

low risk

Listen to medical adviceDecision to use licence not to fast based on discretion of medical opinion and ability of the individual to tolerate fast

Well-controlled T2DM treated with one or

more of the following:

•Lifestyle therapy

•Metformin

•Acarbose

•Thiazolidinedoines

•Second-generation SUs

• Incretin-based therapy

•SGLT2 inhibitors

•Basal insulin

Patients who fast should:

•Receive structured education

•Check their blood glucose

regularly (SMBG)

•Adjust medication dose

as per recommendations


Patients with one or more of the followingare advised not to fast

�Co-existing major medical conditions such as:

- Acute peptic ulcer- Severe Pulmonary Tuberculosis- Severe infection- Severe bronchial asthma- Recurrent stones formation- Cancer with poor general condition- Overt cardiovascular diseases (Recent MI)- Severe psychiatric conditions- Hepatic dysfunction (liver enzymes > 2 × ULN)

Special populations need specific advice and close monitoring1

1.International Diabetes Federation-Diabetes and Ramadan Practical Guidelines 2016

T1DM

• People with T1DM will be

advised not to fast because of

the risks of hypoglycaemia

• If people with T1DM insist on

fasting they should:

• Check BG levels frequently

• Be otherwise healthy

• Have good hypoglycaemic

awareness

• Comply with their

individualised management

plan under medical

supervision

• The elderly should not be

categorised as high risk based

on a specific age but rather on

health status and their social

circumstances

• Comorbidities may exist that

impact on the safety of fasting

and present additional

challenges to HCPs

• Assessments of functional

capacity and cognition should

be performed and the care

provided adapted accordingly

Elderly

• People with T1DM will be

advised not to fast because of

the risks of hypoglycaemia

• If people with T1DM insist on

fasting they should:

• Check BG levels frequently

• Be otherwise healthy

• Have good hypoglycaemic

awareness

• Comply with their

individualised management

plan under medical

supervision

T1DM

• Pregnant women with pre-

existing diabetes or GDM are

advised not to fast until

further research data are

available to support any

change in risk category

• Many pregnant women will

choose to fast

• Hyperglycaemia is associated

with high risk for both mother

and baby

Pregnant women

Management

Benefits of Education & Counseling according to the READ study

2010 Mar;27(3):327-31

Management Recommendations1,2

• Avoid large amounts of foods rich in carbohydrates and saturated fats

• Foods containing complex carbohydrates/low GI advisable before and after fasting

• Predawn meal eaten as late as possible

• Fluid intake increased during non fasting hours

• Maintain normal physical activity

• Avoid excessive physical activity

o Particularly during few hours before the sunset meal

o And if taking sulphonylureas or insulin

• Prayers involving standing, bowing, prostrating, and sitting considered as exercise

• Does not constitute the break of fast

• All patients should be provided with the means to monitor their blood glucose

• Test capillary blood glucose if:

o Hypoglycaemic symptoms

o Unwell (e.g. has a fever)

o At other times if willing to adjust diabetes treatment regimens i.e. insulin

dosage

Diet

Exercise

Blood

glucose

monitoring

1. Al-Arouj M et al. Diab Care 2005; 28: 2305–11. 2. Hui E et al BMJ 2010; 340: 1407–11.

Management

Diabetes Care 2014;37:e47–e48 | DOI: 10.2337/dc13-2063

Dietary Patterns & Glycemic Control and Compliance to Dietary

Advice Among Fasting Patients with DM During Ramadan

All patients should break their fast if:

Blood glucose <3.9 mmoI/L

Re-check within 1 h if blood glucose 3.9–5.0 mmoI/L)

Blood glucose 16.6 mmoI/L

Symptoms of hypoglycaemia, hyperglycaemia,

dehydration or acute illness occur

Breaking the fast1


1. Pre-Suhur (Pre dawn meal)

2. 2 hours post-Suhur (Post dawn meal)

3. Midday

4. Pre-Iftar

5. 2 hours post-Iftar

6. Whenever symptoms of hypoglycemia occur

7- Midnight blood glucose if needed

BGM: Blood glucose Monitoring

BG: Blood Glucose

BGM for high risk groups

Consider BG check done at the following times:

Pre Ramadan planning and management during Ramadan

Diet Controlled GDM (If fasting )

• before pre dawn meal

• 1-2 hours after predawn meal (depending onpatient or usual practice)

• anytime they feel unwell

• at least once during the day whilst fasting

• before the sunset meal

1. Ensure patients are aware thattesting blood glucose levels (BGL)with a fingerprick test DOES NOTbreak their fast and ensure they

record at least:

• 1-2 hours post the sunset meal

2. There is a risk of post prandial hyperglycaemia if the meal portions are too large at thistime. Dietitian review may be appropriate to review carbohydrate content prior to

commencing insulin.

3. Exercise should still be encouraged but may need to be varied in its intensity and timing,e.g.2h after the sunset meal. If patient is in the habit of performing the tarawih prayer this may

form part of the exercise routine. Otherwise suggest other exercise as usual.

Insulin treated Pregnant patients

1. Glucose monitoring- as recommended for the diet controlled group andemphasis on any time during the day where the patient may be feelingunwell, or display other signs of low blood glucose (hypoglycaemia).

•

•

•

•

BGL < 4 mmol/L during fasting hours

Feeling unwell

Reduced fetal movement

Insufficient weight gain, or weight loss

2. Explain to the patientthey must agree to break

their fast if any of thefollowing occur:

Metformin

Management of fasting in type 2 diabetes

No RCTs have been conducted on metformin monotherapy in fasting patients with diabetes

However, the risk of hypoglycaemia is low for this medication

Patients with diabetes on

METFORMIN may need

to ADJUST THEIR

MEDICATION during

Ramadan

Changes to metformin dosing during Ramadan

No dose

modification

usually required

Take at iftar

No dose

modification

usually required

Take at iftar

and Suhoor 2/3

and 1/3

Morning dose

to be taken before

suhoor

Combine afternoon

dose with dose

taken at iftar

No dose

modification

usually required

Take at iftar

Three timesdaily dosing

Twice-daily dosing

Once-daily dosing

Prolonged-release

metformin

RCT= randomised controlled trial; T2DM = type 2 diabetes

International Diabetes Federation-Diabetes and Ramadan Practical Guidelines 2016

Sulphonylureas need dose adjustment in fasting patients with diabetes1


Changes to SU dosing during Ramadan1

Once-daily dosing

Take at iftar

In patients with well-

controlled BG levels the

dose may be reduced

Twice-daily dosing

Iftar dose remains the same

In patients with well-controlled

BG levels, the suhoor dose

should be reduced

Older drugsin the class

Older drugs (e.g. glibenclamide)

with a higher risk of hypoglycaemia

should be avoided

Second-generation SUs

(glicazide,glimepiride) should

be used in preference

The use of SUs should be individualised following clinician guidance and MEDICATIONS

ADJUSTED


Agent Recommendations1,2

• No dose change needed during Ramadan

• If in combination, sulfonylureas may need dose or timing changed as mentioned

• If in combination with metformin:

o Take with sunset and predawn meal

o Or change to gliptin/metformin XR combination taken all at sunset meal

DPP4 inhibitors


1. Al-Arouj M et al. Diab Care 2010; 33: 1895–1902. 2. Hui E et al BMJ 2010; 340: 1407–11

International Diabetes Federation-Diabetes and Ramadan Practical Guidelines 2016

Low risk of hypoglycaemia

Maintain good glycaemiccontrol*

Do not require dose titration

prior to Ramadan

Taken orally

Taken independently

of meals

Not associated with weight gain

Other drugs in this

class may also

present with these

advantages but

evidence during

Ramadan is lacking

GLP1-RA during Ramadan1-3

1. Azar S, Echtay A, Wan Bebakar W, et al. 2016. 2. Brady E, Davies M, Gray L, et al. 2014.3 International Diabetes Federation-Diabetes and

Ramadan Practical Guidelines 2016

Low risk

of hypoglycaemia

Effective in reducing

HbA1c levels

Effective in

reducing weight

As long as GLP-1 RAs have been appropriately DOSE-TITRATED prior to Ramadan,

NO FURTHER TREATMENT MODIFICATIONS are required4

RCTs during Ramadan with liraglutide have demonstrated significantly lower hypoglycaemic

events than SU comparators1-3

Data on exenatide are limited to one study but its short duration of action and dosing suggests

the risk of hypoglycaemia during Ramadan is low1

SGLT2 - Dapagliflozin during Ramadan1,2

Study drug Comparator Study details HypoglycaemiaGlycaemic

control

Additional

observations

Dapagliflozin

(plus

metformin)

SU

n=110,

Open label RCT

(Malaysia)

Hypoglycaemic

events significantly

lower in

dapagliflozin group

No significant

difference

between

groups

Incidence of

postural

hypotension &

UTIs higher in

dapagliflozin

group (NS)1

• With SGLT2 therapy, an increase in risk of ketoacidosis and dehydration3 has been observed

• In the Ramadan study with dapagliflozin incidences of postural hypotension and UTIs were

greater in the dapagliflozin group than in the SU group, but did not reach significance1

1. Wan Juani WS, Najma K, Subashini R, et al. 2016. 2. International Diabetes Federation-Diabetes and Ramadan Practical Guidelines 2016 3.

FORXIGA Approved Product information.

• Dose adjustment not needed during Ramadan

• However cause diuresis and fluid loss:

o Initiation should be done at least 2-4 weeks prior to fast

o Warn to watch out for dehydration, especially in the setting of absence of fluid intake

during fasting

Dose adjustments for long- or short-acting insulins during Ramadan1

Adjust the insulin dose taken before suhoor

**Adjust the insulin dose taken before iftar


Changes to long- and short-acting insulin dosing during Ramadan

Long/intermediate-acting (basal) insulin

NPH/determir/glargine/ once-daily

Reduce dose by 15–30% Take at iftar

NPH/determir/glargine twice-daily

Take usual morning dose at iftar

Reduce evening dose by 50% and take at suhoor

Short-acting insulin

Normal dose at iftar

Omit lunch-time dose

Reduce suhoor dose

by 25–50%

Fasting/pre-iftar/ pre-suhoor BGPre-iftar* Post-iftar*/ post-suhoor**

Basal insulin Short-acting insulin

<70 mg/dL (3.9 mmol/L) or symptoms Reduce by 4 units Reduce by 4 units

70–90 mg/dL (3.9–5.0 mmol/L) Reduce by 2 units Reduce by 2 units

90–130 mg/dL (5.0–7.2 mmol/L) No change required No change required

130–200 mg/dL (7.2–11.1 mmol/L) Increase by 2 units Increase by 2 units

>200 mg/dL (11.1 mmol/L) Increase by 4 units Increase by 4 units

Dose adjustments for premixed insulins during Ramadan1,2

1. Hassanein M, Belhadj B, Abdallah, et al. 2014. 2. International Diabetes Federation-Diabetes and Ramadan Practical Guidelines 2016

Changes to premixed insulin dosing during Ramadan

Once-daily dosing

Take normal dose at iftar

Twice-daily dosingTwice-daily dosing

Take normal dose at iftar

Reduce suhoor dose by 25–

50%

Three times daily dosing

Omit afternoon dose

Adjust iftar and suhoor

doses

Carry out dose-titration

every 3 days (see below)

Fasting/pre-iftar/pre-suhoor BGPremixed insulin

modification

<70 mg/dL (3.9 mmol/L) or

symptomsReduce by 4 units

70–90 mg/dL (3.9–5.0 mmol/L) Reduce by 2 units

90–126 mg/dL (5.0–7.0 mmol/L) No change required

126–200 mg/dL (7.0–11.1

mmol/L)Increase by 2 units

>200 mg/dL (11.1 mmol/L) Increase by 4 units

• If taking twice daily premix insulin:

o Consider switching to a Mix 50 preparation if

postprandial glucose remain elevated after

sunset meal

• Consider changing to long-acting in the evening and

rapid-acting insulin with meals

Post Ramadan follow up

� 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

� complications check up

� Monthly weight, blood pressure, HbA1c and renal

function evaluation every six months.

Conclusions

� Majority of uncomplicated type 2 diabetic patients can fast during Ramadan safely

� Pre-Ramadan medical assessment, education and motivation are very important to prevent

diabetic related complications

� Islam allows diabetes patients not to fast and if fasting could check their blood sugar

regularly

� Individualization and frequent monitoring of glycaemia can significantly reduced the major

risks associated with fasting

� Although they may not always consult healthcare providers, pregnant Muslim women do

value their opinion.

� Healthcare providers need to be confident and respectful in their discussions with Muslim

patients and provide care on an individual basis.

Thank You

Documents

Diabetes and Ramadan presentation · 2 A large number of Muslim patients with diabetes fast during Ramadan Global Muslim population 1 1.6 billion (2010) 2.2 billion (2030) 100 million