Ramadan Fasting and Diabetes Mellitus

Dr. Tofail Ahmed, Associate Prof. of Endocrinology,

BIRDEM

Fasting during daytime in the Fasting during daytime in the month of Ramadan is an month of Ramadan is an obligatory duty of all healthy obligatory duty of all healthy adult Muslims.adult Muslims.

Ramadan is a lunar-based month, and its duration varies between 29 to 30 days. It’s timing changes with respect to season.

Depending on the geographical location and season, duration of daily fast may range from a few to more than 20 hours.

Some 40 – 50 million people with diabetes worldwide fast during Ramadan.

During fasting a Muslim must abstain During fasting a Muslim must abstain fromfrom eating, drinking, use of oral medications and smoking from predawn (Suhur/ shehre) to after

sunset (Ifter) and however there is no restrictions on however there is no restrictions on

food or fluid from Ifter to shehrefood or fluid from Ifter to shehre.

The Koran specifically exempts the sick from the duty of fasting (Holy Koran, Al-Bakara, 183 –185), especially if fasting may lead to harmful consequences for the individual.

Diabetic patients are at risk of harmful consequences due to the changes in pattern and amount of food and fluid intake during Ramadan.

The harmful consequences associated with fasting are

1. Hypoglycemia, 2. Hyperglycemia, 3. Ketoacidosis, 4. Dehydration and thrombosis …. but..

Severity of the risk in an individual i.e. categorization depends on many factors such as status of diabetic control, treatment regimen, co-existing disease etc.

ADA workgroup has categories risk in patients with diabetes who fast during Ramadan into

Very high risk, High risk, Moderate risk and Low risk group.

Management guidelines are available to perform fasting by the diabetics with low and moderate risk groups.

But cases with very

high-risk categories need to enjoy exemption of duty of fasting.

Because this exemption represents more than a simple permission not to fast; the Prophet Mohammad said, “ Allah likes his permission to be full led, as he like his will to be executed.”

Management of diabetes during fasting should consist of Pre-Ramadan medical assessment and educational counseling.

Cases eligible for fasting needs appropriate modification in diet and drugs and perform monitoring on regular basis.

CONTINUOUS LOW LEVEL SECRETION BETWEEN MEALS & THROUGH NIGHT ( Called BASAL secretion . Rate is approximately 1 iu per hour, so in total 24 iu of insulin is secreted as basal )

STIMULATED INSULIN SECRETION FOLLOWING MEALS ( PRANDIAL secretion and rate & total amount secretion is influenced by amount and composition of meals. )

GlucoseGlucose

Glucose of gut

Insulin

3

2

4

1

Glucose Homeostasis after food intake

Pancreas

Fats

Muscle

Liver

Kidney

Glucose Homeostasis during fasting state

GlucoseGlucose

Insulin

4

5

2

1

Glycogen from liver (kidney also) breakdown and pour into blood ‘Hepatic Glucose Output’ (HGU) (2).

Blood glucose is consumed mainly by vital organs like brain cells, RBC, renal & gut epitheliums. These cells are not insulin dependent cells(5).

DMDM

Natural history of T2DM

0

50

100

150

200

250

-10 -5 0 5 10 15 20 25 30

Time (years)

% N

orm

al F

un

ctio

n

Insulin resistance

Insulin level

DMDM

Natural history T1DM

020406080100120

-5 -2.5 0 1 2 3

Time (years)

% N

orm

al F

un

ctio

n

Absolute lack of insulin

ADA workgroup has categories risk in patients with diabetes who fast during Ramadan as follows

Very high risk group1. Severe hypoglycemia within the last 3 months prior to

Ramadan2. Patient with history of recurrent hypoglycemia3. Patient with hypoglycemia unawareness4. Patient with sustained poor glycemic control5. Ketosis within the last 3 months prior to Ramadan6. Type 1 DM7. Acute illness8. Hyperosmolar hyperglycemic coma within the last 3

months.9. Patients who performs intense physical labour.10. Pregnancy.11. Patient on dialysis.  

ADA workgroup has categories risk in patients with diabetes who fast during Ramadan as follows

      High risk group1. Patient with moderate hyperglycemia (average

blood glucose between 150 and 300 mg/dl. HbA1c 7.5 – 9.0%)

2. Patients with renal insufficiency3. Patients with advanced macrovascular

complications4. People living alone that are treated with insulin or

sulfonylureas5. Patients with co morbid conditions that presents

additional risk factors.6. Old age with ill health.7. Drugs that may affect mentation 

ADA workgroup has categories risk in patients with diabetes who fast during Ramadan as follows

     „   Moderate risk group Well controlled patients treated

with short acting secretagogues such as repaglinide or nataglinide „       Low risk group

Well-controlled patients treated with diet alone, metformin or a thiazolidinedione

who are otherwise healthy

Management of diabetes during Ramadan

General considerations Pre-Ramadan medical assessment and educationManagement of DM (drug therapy)

Management of diabetes during Ramadan

General considerations General considerations Several individual issues deserve special attention 1. Individualization: Each specific patient require

his/her specific management plan. They should take Seheri (morning meal ) close to insak ( subuh) time.

2. Frequent monitoring of glycemic status ( multiple times daily – esp. patients on insulin: 2 to 4 hours after sheheri and 1 hour prior to ifter).

Management of diabetes during Ramadan

1. General considerations 2. Nutrition: In terms of calori and composition diet

should remain same healthy and balanced as before Ramadan.

3. Ingestion of large amount of foods rich in carbohydrate and fats during ifter should be avoided.

4. A complex carbohydrate that delays in digestion and absorption is good choice for sheri and while food with more simple carbohydrate may be taken during ifter.

Management of diabetes during Ramadan

1. General considerations 2. Exercise: Normal level of activity.

Excessive physical activities may lead to hypoglycemia. Tarawaih prayer can be considered part of daily exercise programme.

3. Breaking the fasting: If blood sugar goes < 3.3 mmol/L (60mg /dl) or > 16.7 mmol/L (300mg /dl). Sick days.

Management of diabetes during Ramadan

• Patient on diet: No change in total calorie intake. Ensure three at least meals and adequate fluid intake .

• Patient on metformin: Start with single dose at meal after.

• Patient on glitazone: No change.• Patient on sulfonylurea: Use glimiperide at

ifter or rapaglinide/ netiglinide. • Patient on insulin: Use prmixed or

combination of analogs

During Ramadan morning dose at ifter and half the evening dose at

seheriADA recommended guidelineADA recommended guideline

Total daily insulin (U)

Ifter dose Seheri dose

Total

20 13 3 1621 14 3 1722 15 3 1823 15 4 1924 16 4 2025 17 4 2126 17 5 2227 18 5 2328 19 5 2429 20 5 2530 20 5 25

Conclusion

Fasting during Ramadan for patients with diabetes carries a risk of an assortment of complications.

But a careful, individualized management plan with close follow-up can reduce the risk.

There is need of population based epidemiology of diabetes and Ramadan.

Thank You