ISPAD Clinical Practice Consensus Guidelines: Fasting during Ramadan by young people with diabetes

5. Facilitating Positive Health Behaviors and Well-being to Improve Health Outcomes: Standards of Care in Diabetes-2024

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Mitigating iftar-related glycemic excursions in adolescents and young adults with type 1 diabetes on MiniMed™ 780G advanced hybrid closed loop system: a randomized clinical trial for adjunctive oral vildagliptin therapy during Ramadan fasting

BACKGROUND

Ramadan Iftar meal typically causes glucose excursions. Dipeptidyl peptidase-4 inhibitors increase glucagon-like peptide-1 and thus, decrease blood glucose levels with low risk of hypoglycemia.

AIM

To investigate the efficacy and safety of vildagliptin as an add-on therapy on glucose excursions of Iftar Ramadan meals among adolescents and young adults with type 1 diabetes mellitus (T1DM) using advanced hybrid closed-loop (AHCL) treatment.

METHODS

Fifty T1DM patients on MiniMed™ 780G AHCL were randomly assigned either to receive vildagliptin (50 mg tablet) with iftar meal during Ramadan month or not. All participants received pre-meal insulin bolus based on insulin-to-carbohydrate ratio (ICR) for each meal constitution.

RESULTS

Vildagliptin offered blunting of post-meal glucose surges (mean difference - 30.3 mg/dL [- 1.7 mmol/L] versus - 2.9 mg/dL [- 0.2 mmol/L] in control group; p < 0.001) together with concomitant exceptional euglycemia with time in range (TIR) significantly increased at end of Ramadan in intervention group from 77.8 ± 9.6% to 84.7 ± 8.3% (p = 0.016) and time above range (180-250 mg/dL) decreased from 13.6 ± 5.1% to 9.7 ± 3.6% (p = 0.003) without increasing hypoglycemia. A significant reduction was observed in automated daily correction boluses and total bolus dose by 23.9% and 16.3% (p = 0.015 and p < 0.023, respectively) with less aggressive ICR settings within intervention group at end of Ramadan. Coefficient of variation was improved from 37.0 ± 9.4% to 31.8 ± 7.1%; p = 0.035). No severe hypoglycemia or diabetic ketoacidosis were reported.

CONCLUSION

Adjunctive vildagliptin treatment mitigated postprandial hyperglycemia compared with pre-meal bolus alone. Vildagliptin significantly increased TIR while reducing glycemic variability without compromising safety. Trial registration This trial was registered under ClinicalTrials.gov Identifier no. NCT06021119.

Glucose control during Ramadan in a pediatric cohort with type 1 diabetes on MiniMed standard and advanced hybrid closed‑loop systems: A pilot study

BACKGROUND

Hybrid closed-loop (HCL) systems have revolutionized the treatment of diabetes, enabling doctors to cope with challenging conditions that were previously almost impossible to manage or were very risky and difficult.

AIMS

To assess the efficacy and safety of a hybrid closed-loop (HCL) system during Ramadan fasting in a pediatric cohort with type 1 diabetes (T1D).

RESEARCH DESIGN AND METHODS

Glucose control outcomes in older children and adolescents aged 8-16 years with automated insulin delivery for T1D were analyzed during Ramadan and 1 month before Ramadan. Participants on MiniMed standard HCL (670G) or advanced HCL (780G) systems of Medtronic were categorized as fasting or nonfasting.

RESULTS

The average age of the 19 participants (8 and 11 were on standard and advanced HCL systems, respectively) was 11.35 ± 2 years. Eleven patients fasted during Ramadan. Pump setup and sensor statistics were the same during Ramadan and the month before; no significant difference was found between the two groups in terms of insulin and glucose control metrics, with practically the same coefficient of variation, time in range (TIR) and time spent in hypoglycemia, maintained within the international recommended targets. Total daily doses were paradoxically higher in patients who fasted during Ramadan (p = 0.01), without repercussions on glucose control metrics.

CONCLUSIONS

Standard and advanced HCL use during Ramadan were safe and were associated with a maintained optimum TIR (>70 %) and no significant hypoglycemia in adolescents and older children with T1D.

Insulin delivery patterns required to maintain postprandial euglycemia in type 1 diabetes following consumption of traditional Egyptian Ramadan Iftar meal using insulin pump therapy: A randomized crossover trial

OBJECTIVES

During Ramadan, traditional Egyptian Iftar meals have large amounts of high-glycemic index carbohydrate and fat. The efficacy of different bolus regimens on optimizing post prandial glucose (PPG) excursion following this Iftar meal was assessed.

METHODS

A randomized controlled trial evaluating 4-h PPG measured by continuous glucose-monitoring was conducted. A total of 25 youth with T1DM using insulin pumps were given the same Iftar meal (fat [45 g], protein [28 g], CHO [95 g]) on seven consecutive days. Insulin to carbohydrate ratio (ICR) was individualized, and all boluses were given upfront 20 min before Iftar. Participants were randomized to receive a standard bolus and six different split boluses delivered over 4 h in the following splits: dual wave (DW) 50/50; DW 50/50 with 20% increment (120% ICR); DW60/40; DW 60/40 with 20% increment; DW 70/30 and DW 70/30 with 20% increment.

RESULTS

Standard bolus and split 70/30 with 20% increment resulted in significantly lower early glucose excursions (120 min) with mean excursions of less than 40 mg/dL (2.2 mmol/L) compared to other conditions (p < 0.01). The split 70/30 with 20% increment significantly optimized late PPG excursion (240 min) in comparison to standard bolus (p < 0.01), as well as resulting in a significantly lower post meal glucose area under the curve compared with all other conditions (p < 0.01), with no late hypoglycemia.

CONCLUSION

To achieve physiologic PPG profile in traditional Iftar meal, a DW bolus with 20% increment given 20 min preprandial as split bolus 70/30 over 4 h, optimized both early and delayed PPG excursions.

Glycemic control during Ramadan fasting in adolescents and young adults with type 1 diabetes on MiniMed™ 780G advanced hybrid closed‑loop system: A randomized controlled trial

BACKGROUND

MiniMed^TM 780G is the most advanced insulin pump system approved for the treatment of type 1 diabetes mellitus (T1DM). Hypoglycemic events are a serious complication associated with T1DM management during Ramadan fasting.

AIM

This prospective study assessed the safety, effectiveness and optimization of advanced hybrid closed loop (AHCL) system on glycemic metrics and the level of hypoglycemia in T1DM patients who wished to fast Ramadan.

METHODS

Forty-two T1DM patients (mean age 15.2 ± 3.4 years) using AHCL system were divided into two groups (each n = 21): intervention group who adjusted AHCL settings and control group who kept the same settings as before Ramadan.

RESULTS

The most aggressive system settings among control group consisting of a 100 mg/dL glucose target, active insulin time of 2 h and bolus increment,maintained exceptional glycemia withtime in range reaching82.0 ± 10.2%, time above range >180 mg/dL of 12.1 ± 3.5% without an increase in hypoglycemia (time below range 3.0 ± 0.3%). All of which were non-significant in comparison to the intervention group. Overall time spent in closed loop (SmartGuard) by users averaged 98.7 ± 2.1% in Auto Mode and involved only 1.0 ± 0.7 exits per week indicating confidence in the system's performance. There were no severe hypoglycemic or diabetic ketoacidosis events during the study.

CONCLUSIONS

MiniMed™ 780G AHCL system assist in safe fasting with minimal user input and allows for achievement of recommended glycemic targets in people with T1DM during Ramadan fasting. The system demonstrated reduction in hypoglycemia exposure without compromising safety.

Ramadan Fasting Among Older Children and Adolescents With Type 1 Diabetes Mellitus: A Real-World Study From the UAE

Background

Ramadan fasting (RF) is a religious obligation for all healthy adult Muslims. The sick and pre-pubertal children are exempt, but many choose to fast for various reasons. In this “real world” study, glycaemic control has been investigated in the context of RF in children and adolescents with type 1 diabetes mellitus (T1DM) and compared multiple daily injections (MDI) and continuous subcutaneous insulin infusion (CSII) outcomes.

Methods

Children and adolescents with T1DM seen at Imperial College London Diabetes Centre who decided to fast in the ensuing Ramadan were educated with their families about diabetes mellitus management during RF using an adapted CHOICE (Carbohydrate, Insulin, and Collaborative Education) educational programme. Pertinent data including hypoglycaemia episodes and diabetic ketoacidosis (DKA) were obtained through patient/family interviews. Information on weight, glycated hemoglobin (HbA1c), and blood glucose levels from continuous glucose monitoring (CGM)/flash glucose monitoring (FGM) before (1 month prior), during, and after (1 month afterwards) Ramadan were retrieved retrospectively from the electronic database. Data are presented as mean ± SD.

Results

Forty-two patients [age 13.5 ± 2.4 years; 27 (64.3%) males; T1DM duration 4.9 ± 3.1 years] were included in the study and were able to fast for 22 ± 9 days during Ramadan. Twenty-three (54.8%) of the patients were on MDI and 19 (45.2%) were on CSII. No statistically significant differences were seen in CGM/FGM generated mean blood glucose level before, during, and after Ramadan [one-way ANOVA (F_{(2, 80)} =1.600, p = 0.21)]. HbA1c and weight after Ramadan did not change significantly compared to baseline (paired t-test; p = 0.02 and p = 0.08, respectively). Between MDI and CSII groups, there was no significant difference in fasting days (p = 0.49), frequency of hypoglycaemia episodes (p = 0.98), DKA frequency (p = 0.37), HbA1c level (p = 0.24), and weight (p = 0.11) after Ramadan.

Conclusion

Data show no significant deterioration in indicators of overall glycaemic control which remained inadequate. RF should be discouraged in children with poorly controlled T1DM.

Use of automated insulin delivery systems in people with type 1 diabetes fasting during Ramadan: An observational study

Fasting among people with type 1 diabetes imposes the risk of metabolic decompensation. Automated insulin dosing systems can allow better glycemic control without safety concerns. The utility in prolonged and repetitive fasting has not been studied. In this observational study, validated glycemic data were reviewed and analyzed from people with type 1 diabetes who observed fasting during Ramadan in 2019 and 2020 using automated insulin dosing systems. Six profiles met the inclusion criteria. The average age was 33.7 ± 4.8 years, diabetes duration was 23.5 ± 7.9 years, body mass index 23.6 ± 1.9 kg/m² and glycated hemoglobin was 6.3 ± 0.2% (45 ± 5 mmol/mol). The average glucose during Ramadan was 7.0 ± 0.5 mmol/L (126 ± 9 mg/dL), coefficient of variation 28.5%, percentage of time in range 3.9–10 mmol/L (70–180 mg/dL) 88.8 ± 7.3% and percentage time <3.9 mmol/L (<70.0 mg/dL) 2.5 ± 1.3%. The number of fasting days was 27.3 ± 3.3, and the number of days where fasting was broken due diabetes was 1 ± 1.5/participant. No significant differences in glycemic outcomes were noted between Ramadan and non‐Ramadan periods. In this first clinically validated study, automated insulin dosing systems showed a safe and effective management strategy to support prolonged and consecutive fasting in people with type 1 diabetes.

Use of continuous glucose monitoring trend arrows in the younger population with type 1 diabetes

Early control of glycaemia is key to reduce vascular complications in individuals with Type 1 diabetes. Therefore, encouraging children and adolescents with T1DM to take responsibility for controlling glucose levels is an important yet a challenging task. The rapid expansion of continuous glucose monitoring (CGM) systems has allowed for more comprehensive analysis of glycaemia in T1D. Moreover, CGM devices have the ability to calculate rate of change in glucose levels and display the information as trend arrows. In turn, this can help to take evasive actions to return glucose levels to near physiological glycaemia, which can be highly motivating for young people with T1DM. In the absence of standardised, evidence-based guidance, this consensus document, generated by experts from the Arab Society of Paediatric Endocrinology and Diabetes and international advisors, summarises recent literature on the use of trend arrows in young people with T1DM. The use of trend arrows in different CGM systems is reviewed and their clinical significance is highlighted. Adjusting insulin doses according to trend arrows is discussed while also addressing special situations, such as exercise, fasting, nocturnal hypoglycaemia and menstruation. Adequate understanding of trend arrows should facilitate optimisation of glycaemic control in the T1D population.

Ramadan fasting and diabetes, latest evidence and technological advancements: 2021 update

Development of updated guidelines for management of diabetes in Ramadan Fasting is of paramount importance. Nonetheless, evidence-based guidelines in the field of Ramadan Fasting and Diabetes are scarce. Moreover, findings of some recent research such as effects of Ramadan fasting on microbiota, genetics and epigenetics, hormonal changes (such as adiponectin, leptin, testosterone…), and alternations in circadian rhythm should also be reviewed and included on a yearly basis. It is documented that self-monitoring of blood glucose (SMBG) is of vital importance for patients with type 1 diabetes who fast, and advantages of continuous glucose monitoring (CGM) or flash glucose monitoring (FGM) techniques should be highlighted. Moreover, the recent findings about applications of advanced insulin delivery technology in patients with diabetes who fast in Ramadan should also considered in the annual updates of the guidelines.

Ramadan fasting and diabetes, latest evidence and technological advancements: 2021 update

Development of updated guidelines for management of diabetes in Ramadan Fasting is of paramount importance. Nonetheless, evidence-based guidelines in the field of Ramadan Fasting and Diabetes are scarce. Moreover, findings of some recent research such as effects of Ramadan fasting on microbiota, genetics and epigenetics, hormonal changes (such as adiponectin, leptin, testosterone…), and alternations in circadian rhythm should also be reviewed and included on a yearly basis. It is documented that self-monitoring of blood glucose (SMBG) is of vital importance for patients with type 1 diabetes who fast, and advantages of continuous glucose monitoring (CGM) or flash glucose monitoring (FGM) techniques should be highlighted. Moreover, the recent findings about applications of advanced insulin delivery technology in patients with diabetes who fast in Ramadan should also considered in the annual updates of the guidelines.

Use of ambulatory glucose monitoring and analysis of ambulatory glucose profile in clinical practice for diabetes management; a position statement of the Arab Society of Paediatric Endocrinology and diabetes

BACKGROUND AND AIM

Diabetes mellitus imposes a significant burden around the world generally and in the Middle East and North Africa specifically. Glucose monitoring is a cornerstone of diabetes management.

METHODS

Glycated haemoglobin has always been the main metric for assessing glycaemic control, but its use is linked with multiple pitfalls. As an alternative, continuous glucose monitoring is becoming a standard of care in many countries. Intermittent scanning glucose monitoring (isCGM) has acquired a worldwide popularity and has been proven to improve glycaemic control, hypoglycaemia detection and prevention, and quality of life.

RESULTS

The most recent International Society of Paediatric and Adolescent Diabetes practice. guidelines recommended its use in young people with diabetes observing Ramadan to ensure safe fasting. At a meeting in Abu Dhabi in November 2019, the Arab Society for Paediatric. Endocrinology and Diabetes brought together a number of regional diabetes experts, patient. representatives and international expert advisors to review the evidence for isCGM and propose. guidelines for its use in the Middle East and North Africa region.

CONCLUSION

In this paper, the authors strongly recommend the use of isCGM for patients in MENA and present general recommendations and compressive specific guidance for physicians and patients, which they believe will also have wider resonance.

High HbA1c is not a reason not to fast during Ramadan in Children, adolescents and young adults with Type 1 diabetes - An observational study in Bangladesh

AIMS

Our aim was to investigate the ability, frequency of acute complications and impact on glycemic control in uncontrolled T1DM who fasted during Ramadan.

METHODS

74 Patients with T1D who insisted on fasting were enrolled 1 month prior to Ramadan and given intensive education by Diabetes team on insulin dose, glucose monitoring and dietary adjustments. Patients were divided into two groups ; group A- HbA1c < 9%(<75 mmol/mol) and group B- HbA1c ≥ 9% (≥75 mmol/mol) and different variables were compared.

RESULTS

Most of the patients fasted 58 (78.4%) for more than 15 days. There was no significant difference (p = 0.790), while comparing the breaking the fast in the two groups. Hypoglycaemia was common acute complications among them. There was no significant difference in the frequency of hypoglycaemia between two groups (P = 0.448). There was increased insulin requirement in both groups during Ramadan (p = 0.00001), with an increase in basal insulin in well controlled (from 24 to 34 units). There was significant reduction of Post Ramadan mean HbA1C in both groups [P = 0.0001)].

CONCLUSION

Children, adolescents and young adults with T1D with poor glycaemic control can fast safely during Ramadan with proper education and intensive monitoring.

Quality of Life and Glycemic Control in Saudi Children with Type 1 Diabetes at Different Developmental Age Groups

Background:

Children with type 1 diabetes (T1D) at different stages of development have age-specific needs, which can influence their perception of quality of life (QoL). In our study, we aimed to emphasize these age-specific needs and assess the perception of QoL in Saudi children with T1D, as well as their parents correlating QoL scores with children’s glycemic control.

Methods:

This is a cross-sectional study in which children with T1D and their parents from 2 tertiary institutes in Saudi Arabia have answered a standard diabetes-specific QoL questionnaire (PedsQL™ 3.0 diabetes module, translated in Arabic). We also reported glycated hemoglobin (HbA1c) results for these children within a month of completing the questionnaire. The QoL total aggregate and domain scores for self (children) and proxy (parents’) reports were compared and correlated with children’s HbA1c.

Results:

A sample was 288 self and proxy reports from 144 children with T1D of 3 age groups: 5 to 7 years (7%), 8 to 12 years (49%), and 13 to 18 years (44%), and their parents. QoL differed significantly between self and proxy reports in the total aggregate and domain scores (P-values range from .02 to <.001). The impact on QoL was significantly higher in female patients (P = .043). Insulin pump users had better HbA1c (P = .007), and HbA1c level was worse in those who intended to fast at Ramadan (P = .005).

Conclusion:

Children with T1D at different developmental age groups perceive QoL differently than their parents. Adjusting management as per age-specific challenges could potentially improve these children’s QoL and glycemic control.

Diabetes education in pediatrics: How to survive diabetes

Diabetes mellitus is the most common abnormal carbohydrate metabolism disorder affecting millions of people worldwide. It is characterized by hyperglycemia as a result of ß-cell destruction or dysfunction by both genetic and environmental factors. Over time chronic hyperglycemia leads to microvascular (i.e., retinopathy, nephropathy and neuropathy) and macrovascular (i.e., ischemic heart disease, peripheral vascular disease, and cerebrovascular disease) complications of diabetes. Diabetes complication trials showed the importance of achieving near-normal glycemic control to prevent and/or reduce diabetes-related morbidity and mortality. There is a staggering rate of increased incidence of diabetes in youth, raising concerns for future generations' health, quality of life and its enormous economic burden. Despite advancements in the technology, diabetes management remains cumbersome. Training individuals with diabetes to gain life-long survival skills requires a comprehensive and ongoing diabetes education by a multidisciplinary team. Diabetes education and training start at the time of diagnosis of diabetes and should be continuous throughout the course of disease. The goal is to empower the individuals and families to gain diabetes self-management skills. Diabetes education must be individualized depending on the individual's age, education, family dynamics, and support. In this article, we review the history of diabetes, etiopathogenesis and clinical presentation of both type 1 and type 2 diabetes in children as well as adolescents. We then focus on diabetes management with education methods and materials.

Type 1 diabetes mellitus in children: experience in Indonesia

The prevalence of type 1 diabetes mellitus (T1DM) in children in Indonesia is increasing although the real number is unknown due to high rate of misdiagnosis. Public and healthcare awareness on T1DM in children is still low, reflected by the high number of children diagnosed with diabetic ketoacidosis (DKA). The Indonesian Pediatric Society (IPS) had published a guideline on T1DM management, which consists of insulin injection, daily monitoring of blood glucose, nutrition, physical activity, and education. Aside from low awareness, current challenges on T1DM management in Indonesia are funding by the national health insurance, fasting during Ramadan, and inequities on DM care. The involvement of society, healthcare workers, stakeholders, and the government is of importance to ensure optimal management for children with diabetes.

Are Physicians in Saudi Arabia Ready for Patients with an Insulin Pump? An Examination of Physician Knowledge and Attitude

Aims: The use of insulin pump therapy in patients with diabetes continues to expand worldwide. Although insulin pumps have been demonstrated to be successful and safe, physicians’ insufficient knowledge may carry a risk to the patients using insulin pumps. This study aimed to assess the attitude and knowledge among physicians in Saudi Arabia regarding insulin pump therapy. Methods: Three hundred and seven physicians, including 82 family physicians, 76 pediatricians, 48 internists, 27 pediatric endocrinologists, 17 adult endocrinologists, and 57 physicians from other specialties, completed a questionnaire that evaluated their knowledge and attitude toward insulin pump therapy. Results: Among the evaluated physicians, 56.7% had poor knowledge level, while 53.4% had positive attitude. Statistical tests revealed that older age, years of practice, consultancy, and endocrinology specialty were the influential factors of knowledge (p < 0.001). Non-endocrinologists demonstrated poor knowledge despite seeing patients with insulin pumps; however, those who had previously cared for such patients scored significantly higher knowledge scores. Conclusions: There was a significant lack of knowledge among physicians regarding insulin pump therapy; however, the perceived attitude of physicians toward this therapy was deemed positive. These findings support the implementation of insulin pump education programs.