Survey on diabetic patients treated with insulin during the fasting month of Ramadan

Feelings, Difficulties and Attitudes in relation to Fasting: A Qualitative Study on Spiritual Coping Among Turkish Patients with Type 2 Diabetes

This study aims to reveal the feelings, difficulties, attitudes, and spiritual coping status of Turkish patients with Type 2 diabetes mellitus toward fasting during Ramadan. The sample of this descriptive qualitative study consists of 14 patients diagnosed with Type 2 diabetes. We determined two main themes and relevant sub-themes. The first was "the feelings and difficulties experienced due to diabetes mellitus" with the sub-themes of "negative emotions" and "difficulties in fasting." The second theme was identified as "religious and spiritual coping" with the sub-themes of "believing the disease comes from God," "having difficulty in adhering to disease-specific practices while fasting," and "feeling that fasting facilitates coping and provides relief." In conclusion, it was determined that the patients continued to fast despite the difficulties and that fasting facilitated coping and provided relaxation.

Sex as a Biological Factor in the Changes in Disease Patients During Ramadan Intermittent Fasting: A Systematic Review

Background

During Ramadan, many patients with diabetes, renal, cardiovascular, gastrointestinal diseases, headaches, and epilepsy choose to fast even against their doctor's advice. The impact of this intermittent fasting on health and disease could be different in men and women. The aim of this study was to determine the effect of sex as a factor in diseases outcomes of patients who opt to fast during Ramadan.

Main Body

The articles included in this study reported data on six diseases: diabetes, renal, cardiovascular, gastrointestinal diseases, headaches, and epilepsy. A systematic search was performed on PubMed and Scopus for observational and clinical studies mentioning Ramadan, diabetes, renal, cardiovascular, gastrointestinal diseases, headaches, and epilepsy in both men and women. Data was extracted by two independent reviewers using a standardized data-collection form. From 381 original articles, 38 studies were selected, including 25,023 patients of which 44.4% were women. Sex-based differences were reported by 18 studies for several variables such as body mass index, blood glucose, the frequency of hypoglycemia, renal colic, mortality, thrombosis, and gastrointestinal diseases in patients fasting during Ramadan. Most of the differences between men and women were reported both in the baseline period before Ramadan and during Ramadan. Indeed, during the period outside Ramadan, the frequency of renal colic, cardiovascular, gastrointestinal diseases, were higher in men; while body mass index, Thrombosis, and headache were higher in women. In the remaining 21 studies, it was reported that the sex factor was not associated with the effect of Ramadan fasting in the frequency and other outcomes of these diseases.

Conclusion

Currently, small attention is paid to sex as a determinant factor in patients while fasting during Ramadan. There appeared to be differences in the frequency and incidence of diseases in men and women during Ramadan. Closer attention to sex differences regarding the frequency and the progression of the diseases during fasting may help to improve patient care, especially to benefit those patients willing to fast during Ramadan.

The impact of Ramadan fasting on metabolic profile among type 2 diabetes mellitus patients: A meta-analysis

BACKGROUND AND AIMS

Majority of Muslims with type 2 diabetes mellitus (T2DM) fasted during Ramadan regardless of possible risk of complication. This systematic review aims to assess the impact of Ramadan fasting on metabolic profile and hypoglycemia event among T2DM patients.

METHODS

Literature searching was conducted on December 2019 at PUBMED, Medline (EBSCOhost), and ProQuest databases using the following keywords: Ramadan fasting, type 2 diabetes mellitus, glycemic and lipid profile, anthropometry measurements, and hypoglycemia. Observational studies in adults and published in English which analyze the glucose parameters, lipid profile, and hypoglycemia among T2DM patients during Ramadan were included in the analysis. All studies were assessed for its risk of bias using New-Castle Ottawa Scale. The heterogeneity of the studies was analyzed using I² (square) test and the overall mean difference between studied parameters before and after Ramadan fasting was calculated using Weighted Mean Difference (WMD) test using Stata 13.

RESULTS

A total of 28 observational studies that were conducted in Middle Eastern, African, and Asian countries were included. This review found decrease in FPG level by -15.28 (95% CI -17.22, -13.34) mg/dl, HbA1c by -0.27 (95% CI -0.32, -0.22)%, total cholesterol by -12.88 (95% CI -14.68, -11.09) mg/dL, LDL-C by -4.42 (95% CI -6.17, -2.66)mg/dl, HDL-C by -1.09 (95% CI -1.71 - 0.47) mg/dL, triglyceride by -2.47 (95% CI -3.69 - 1.24) mg/dL and decreased anthropometry measurement. No studies reported fatal hypoglycemia event.

CONCLUSIONS

Ramadan fasting resulted in slight improvement of overall metabolic profile and anthropometry among T2DM patients with relatively low incidence of hypoglycemia.

Recommendations for management of diabetes during Ramadan: update 2020, applying the principles of the ADA/EASD consensus

Fasting the Holy month of Ramadan constitutes one of the five pillars of the Muslim faith. Although there is some evidence that intermittent fasting during Ramadan may be of benefit in losing weight and cardiometabolic risk factors, there is no strong evidence these benefits apply to people with diabetes. The American Diabetes Association/European Association for the Study of Diabetes consensus recommendations emphasize the importance of patient factors and comorbidities when choosing diabetes medications including the presence of comorbidities, atherosclerotic cardiovascular disease, heart failure, chronic kidney disease, hypoglycemia risk, weight issues and costs. Structured education and pre-Ramadan counseing are key components to successful management of patients with diabetes. These should cover important aspects like glycemic targets, self-monitoring of blood glucose, diet, physical activity including Taraweeh prayers, medication and dose adjustment, side effects and when to break the fast. The decision cycle adapted for the specific situation of Ramadan provides an aid for such an assessment. Children with type 1 diabetes should strongly be advised not to fast due to the high risk of acute complications such as hypoglycemia and probably diabetic ketoacidosis (DKA), although there is very little evidence that DKA is increased in Ramadan. Pregnant women with diabetes or gestational diabetes should be advised to avoid fasting because of possible negative maternal and fetal outcomes. Hypoglycemia is a common concern during Ramadan fasting. To prevent hypoglycemic and hyperglycemic events, we recommend the adoption of diabetes self-management education and support principles. The use of the emerging technology and continuous glucose monitoring during Ramadan could help to recognize hypoglycemic and hyperglycemic complications related to omission and/or medication adjustment during fasting; however, the cost represents a significant barrier.

Patterns of Diabetes Care Among People with Type 1 Diabetes During Ramadan: An International Prospective Study (DAR-MENA T1DM)

INTRODUCTION

To describe the characteristics and care of participants with type 1 diabetes during Ramadan in the Middle East and North Africa.

METHODS

The DAR-MENA (Diabetes and Ramadan-Middle East and North Africa) study was a prospective, observational study of adults with type 1 and type 2 diabetes who were Muslim and did/did not intend to fast during Ramadan 2016. Baseline data were collected 6 weeks prior to Ramadan, with a follow-up visit 1-2 months after Ramadan. This is the analysis of the population with type 1 diabetes. Measurements included proportion who fasted, reasons for fasting and not fasting, changes in diabetes treatment, hypoglycemic events, and proportion with access to diabetes education.

RESULTS

Of 136 participants with type 1 diabetes, 76.9% (100/130) fasted for at least 1 day, 72.3% (94/130) fasted for at least 15 days, and 48.5% (63/130) fasted for 30 days. The majority (63.0%, 63/100) reported personal decision as a reason to fast. Fear of diabetic complications (58.6%, 17/29) and previous complications related to fasting (48.3%, 14/29) were the most common reasons for not fasting. Adjustment of diabetic medication regimen occurred for 84.6% (115/136) of participants, and 72.8% (99/136) changed their treatment dose. The incidence and number of adverse events for confirmed and severe hypoglycemia were similar before and during Ramadan. Almost half of participants had access to diabetes education (45.6%, 62/136).

CONCLUSION

The DAR-MENA study showed that despite the risks associated with fasting for people with type 1 diabetes, almost half fasted for the full 30 days of Ramadan with no significant change in hypoglycemia events. Since the current International Diabetes Federation and Diabetes and Ramadan guidelines do not endorse fasting for people with type 1 diabetes, it is important that those who insist on fasting work closely with their healthcare practitioner to avoid any complications.

Patient-Reported Outcomes and Impact of Type 2 Diabetes: A Cross-Sectional Study in the Kingdom of Saudi Arabia

BACKGROUND

The Kingdom of Saudi Arabia (KSA) has the second highest prevalence of type 2 diabetes mellitus (T2DM) in the Middle East. There is a paucity of research on the experiences and treatment preferences of patients with T2DM in KSA. This study explored Saudi patients' health-related quality of life, eating habits, experiences during Ramadan, and preference between two glucagon-like peptide-1 receptor agonist (GLP-1 RA) treatment devices.

METHODS

A cross-sectional, observational study was conducted in three cities in KSA. Participants completed sociodemographic and clinical forms, EQ-5D-5L, Impact of Weight on Self-Perceptions, and a diabetes treatment survey. Participants also viewed instructional videos on GLP-1 RA injection devices and indicated their device preference.

RESULTS

Of the 310 participants, 53% were male. The mean age was 43 years (range: 30.0-75.0), duration since diabetes diagnosis was 6.3 years (range: 0.2-27.1), the most commonly reported last HbA1c level was between ≥7.1% and 8% (45%). The mean EQ-5D-5L index score was 0.90, with some participants reporting problems with pain/discomfort (34.5%) and usual activities (33.2%). Patients reported a low-to-moderate impact of weight on self-perception. In preparation for Ramadan, participants sought physician advice on diabetes management (37%) and/or increased checks of their blood glucose (37%). After watching the videos, 89% (n=277) of participants indicated a device preference, with significantly more preferring the dulaglutide device (n=186, 67%) over the semaglutide device (n=91, 33%) (p<0.0001).

CONCLUSION

This study indicates that T2DM has a significant social, emotional, and behavioral impact on the lives of patients in KSA.

Diabetes and Ramadan: Utility of flash-glucose monitoring derived markers of glycaemic control and comparison with glycosylated haemoglobin

AIMS

Flash glucose monitoring (FGM)-derived markers of glucose control and variability and laboratory measured HbA1c among patients with diabetes on insulin in context of Ramadan fasting (RF) were examined and compared.

METHODS

FGM data on insulin-treated patients (n = 20, age 42.3 ± 11.4 years; 18 male, 2 female; 13 with type 1 and 7 with type 2 diabetes) who fasted during Ramadan were used to calculate Q-score as an indicator of glycaemia before, during and after RF. Post-hoc analysis in a group of patients (n = 12) who had HbA1c available and appropriate for these periods was performed. Other relevant data were extracted from patient records.

RESULTS

Mean glucose (9.6 ± 1.32 v 10.78 ± 1.64 mmol/l; P < 0.0001) and Q-score increased significantly with Ramadan fasting and reduced after Ramadan. Post-hoc subgroup analysis showed a significant rise in eA1c (7.2 ± 0.4%; 55.0 ± 4.4 mmol/mol v 7.7 ± 0.5%; 61.0 ± 5.5 mmol/mol) but not in laboratory HbA1c with Ramadan fasting; eA1c reduced after Ramadan (P = 0.018).

CONCLUSIONS

Ramadan fasting was associated with a deterioration in overall glucose control and time in hyperglycaemia in insulin-treated patients. FGM-derived markers are useful and a preferable alternative to HbA1c in Ramadan studies.

Continuous subcutaneous insulin infusion versus multiple daily insulin injections in patients with Type 1 diabetes mellitus who fast during Ramadan: A systematic review and meta-analysis

BACKGROUND

The benefits and risks of continuous subcutaneous insulin infusion (CSII) or multiple daily injections (MDI) in patients with Type 1 diabetes mellitus (T1DM) who fast during Ramadan are not known.

METHODS

Systematic review and meta-analysis of observational studies conducted in PubMed, Embase (Ovid), and the Cochrane Library. Quality of included studies was assessed using the ROBINS-I tool for risk of bias assessment and analyses were performed using RevMan version 5.1.

RESULTS

From 709 records, 306 full text studies were assessed. After exclusions, the final analysis included a total of 9 studies. Heterogeneity for outcomes was I² = 0%. There was no significant difference for the change in glycemic control (HbA_1c) between CSII and MDI (P > 0.05). There was no change in weight or the lipid profile in patients with T1DM on MDI during Ramadan. There were insufficient data to assess the impact on glucose profiles and the incidence of hypoglycemia or diabetic ketoacidosis (DKA) in patients on CSII or MDI during Ramadan.

CONCLUSIONS

Studies assessing the effect of CSII or MDI in patients with T1DM who fast during Ramadan are limited to observational studies and show no difference in the change in Hb_A1c, weight or lipids during Ramadan.