Ramadan fasting in people with diabetes and chronic kidney disease (CKD) during the COVID-19 pandemic: The DaR global survey

BACKGROUND AND AIMS

The DaR Global survey was conducted to observe the impact of the COVID-19 pandemic on the intentions to fast and the outcomes of fasting in people with diabetes and chronic kidney disease (CKD).

METHODS

Muslim people with diabetes and CKD were surveyed in 13 countries shortly after the end of Ramadan 2020, using a simple Survey Monkey questionnaire.

RESULTS

This survey recruited 6736 people with diabetes, of which 707 (10.49%) had CKD. There were 118 (16.69%) people with type1 diabetes (T1D), and 589 (83.31%) were with type2 diabetes (T2D). 62 (65.24%) people with T1D and 448 (76.06%) people with T2D had fasted with CKD. Episodes of hypoglycaemia and hyperglycaemia were more frequent among people with T1D compared to T2D, 64.52% and 43.54% vs 25.22% and 22.32% respectively. Visits to the emergency department and hospitalization were more frequent among people with CKD, however no significant difference was found between people with T1D and T2D.

CONCLUSION

The COVID-19 pandemic had only a minor effect on the intention to fast during Ramadan in people with diabetes and CKD. However, hypoglycaemia and hyperglycaemia were found to be more frequent, as well as emergency visits and hospital admissions among people with diabetic kidney disease. Prospective studies are needed in future to evaluate the risk indicators of hypoglycaemia and hyperglycaemia among fasting people with CKD, especially in the context of different stages of kidney disease.

Fasting Ramadan in patients with T1DM - Saudi Arabia versus other countries during the COVID-19 pandemic

BACKGROUND AND AIMS

To compare Saudi Arabia with other countries regarding patient attitudes towards fasting Ramadan and complications related to fasting during the COVID-19 pandemic.

METHODS

Data collected from Saudi Arabia and 12 other mostly Muslim majority countries, via physician administered questionnaire within post Ramadan 2020.

RESULTS

1485 Type1 diabetes (T1DM) patients analyzed; 705 (47.5%) from Saudi Arabia vs. 780 (52.5%) from other countries. 1056 (71.1%) fasted Ramadan; 636 (90.2%) of Saudi patients vs. 420 (53.8%) of other countries. Experiencing Ramadan during the COVID-19 pandemic did not affect the Saudi T1DM patients' decision to fast while it significantly influenced their decision in other countries (1.4 vs 9.9%, P < 0.001). More Saudi patients needed to break the fast due to a diabetes related complication compared to other countries (67.4% vs. 46.8%, p=<0.001). The mean number of days fasted in Saudi and other countries was 24 ± 7 and 23 ± 8 days respectively. Hypoglycemic events were more common among Saudi patients during Ramadan compared to other countries 72% and 43.6% (p < 0.001) respectively. There was a significant difference in timing; the largest peak for Saudi Arabia patients was after dawn (35% vs 7%, p < 0.001), while it was pre-sunset for the other countries (23 vs 54%, p = 0.595). Day time-hyperglycemia was also more common among Saudi patients (48.6% vs. 39%, p < 0.001), however it was a less likely cause to break the fast (25.6% vs 38.3%, p < 0.001).

CONCLUSION

Observing the fast of Ramadan is extremely common among Saudi T1DM patients compared to other Muslim countries and was not affected by the COVID-19 pandemic. However, it was associated with higher frequency of hypoglycemic and hyperglycemic episodes.

Ramadan fasting in people with type 1 diabetes during COVID-19 pandemic: The DaR Global survey

OBJECTIVES

The DaR Global survey was conducted to determine the impact of the COVID-19 pandemic on the intentions to fast and the outcomes of fasting in <18 years versus ≥18 years age groups with type 1 diabetes mellitus (T1DM).

METHODS

Muslim people with T1DM were surveyed in 13 countries between June and August 2020, shortly after the end of Ramadan (23rd April-23rd May 2020) using a simple questionnaire.

RESULTS

71.1% of muslims with T1DM fasted during Ramadan. Concerns about COVID-19 were higher in individuals ≥18 years (p = 0.002). The number of participants who decided not to fast plus those who received Ramadan-focused education were significantly higher in the ≥18-year group (p < 0.05). Hypoglycemia (60.7%) as well as hyperglycemia (44.8%) was major complications of fasting during Ramadan in both groups irrespective of age.

CONCLUSION

COVID-19 pandemic had minor impact on the decision to fast Ramadan in T1DM cohort. This was higher in the age group of ≥18 years compared to those <18 years group. Only regional differences were noted for fasting attitude and behavior among T1DM groups. This survey highlights the need for Ramadan focused diabetes education to improve glucose control and prevent complications during fasting.

Taxation of Beverages and Sweetened Products in Morocco: A Major Achievement and a Model to Follow In the Mena Region

The analysis of the various reports of the epidemiological situation of obesity and diabetes in Morocco with in particular the reports of the WHO, the High Commission for Planning of Morocco (HCP) and the report of the American Mc Kinsey Study Bureau in 2014, shows a sharp increase in diabetes, obesity and their morbidity and mortality. With a Moroccan population of 35 million inhabitants in 2017, the number of people with diabetes (2.5 million), pre-diabetes (2.4 million), obesity (3.6 million), overweight (10 million including 63% of women and 16% of children) is alarming. The consequences in terms of morbidity and mortality and direct and indirect health costs through reduced productivity for the economy of Morocco and for society as a whole are very high. Total annual expenditure related to obesity amounts to $ 2.4 billion, or 3% of Morocco's GDP. The causes of this increase in obesity and diabetes are closely linked to profound changes in lifestyle: high-calorie diet rich in fast sugars, reduction in physical activity, etc. This is how it is demonstrated that too much consumption of sugary drinks is harmful to weight maintenance, metabolic balance and cardiovascular health. Conversely in many experiments around the world, the number of people with overweight and a risk of diabetes decreases significantly when the reduction of refined sugars is carried out by several preventive measures including increasing the tax on sodas, juices and other sugary drinks. The members of the Working Group who have been working together for several years in Morocco on the “Taxation of sweet products” within the framework of the Moroccan League for the Fight against Diabetes and the Moroccan Society of Nutrition, Health and Environment, have carried out multiple actions advocacy and sensitization with the government, the ministry of health, the parliament, the university, civil society and the media. The soda tax was finally adopted by the Moroccan Parliament in the 2019 finance bill. A first in the Middle East and North Africa region. In December 2019, a new acquisition was made during the discussion of the Finance Law Project (FLP) 2020 by the introduction of a progressive Internal Consumption Tax (ICT) on sugary drinks in proportion to their sugar concentration. The aim is to encourage manufacturers to reduce the sugar content of sugary drinks and energy drinks to avoid over-taxation. On the other hand, the support recently given in 2020 by the National Council of Human Rights of Morocco to this tax constitutes a very large acquisition, with a new institutional and socio-cultural dimension of human rights for the preservation health in Morocco. Members of the working group will continue their efforts to extend this tax to all products containing a significant amount of sugar. The same is true for other toxic products such as salt, fat and tobacco. Keywords: Diabetes, Obesity, Prevention, Tax soda, Morocco

Tackling diabetes: how nurses can make the difference

This year, World Diabetes Day on 14 November coincides with the International Year of the Nurse and the Midwife, and therefore focuses on highlighting the role of nurses in the prevention and management of diabetes.

Diabetes is recognized as an important cause of premature death and disability globally and in the Eastern Mediterranean Region, where its prevalence has been steadily increasing since 1990. Although the annual decline of the risk of dying from a major noncommunicable disease between the ages of 30 and 70 years is slowing globally, diabetes is showing a 5% increase in attributed premature mortality. In 2016, diabetes was the direct cause of 1.6 million deaths globally and 43% of all deaths before the age of 70 years occur due to high blood glucose. Overweight and obesity are the strongest risk factors for type 2 diabetes. In addition, diabetes increases the risk of heart disease and stroke and is a leading cause of blindness, lower limb amputation and kidney failure. A study conducted in 35 countries indicated that people living with diabetes are more likely to experience catastrophic health expenditures with an estimated increase of 4% between diabetic and non-diabetic individuals, regardless of their insurance status.

COVID-19 and diabetes from IDF MENA region

The whole world are facing the current COVID-19 pandemic, the most serious health crisis in modern times. All countries with the support of national and international agencies are making great efforts to fight this devastating pandemic with disastrous medical, economic and social consequences. This pandemic affects all people but it's serious in case of diabetes, elderly and in chronic and complicated diseases. The current work on the theme " COVID-19 and Diabetes" attempts to bring together all the data available at MENA level through medical and scientific publications. It also includes all the efforts made by the governments and the responses of associations and their efforts in this field. Even if it is admitted that diabetes with its comorbidity represents a high risk factor for severe forms and mortality, the health consequences of the epidemic, does not seem as dramatic in terms of both morbidity and mortality of COVID-19 with diabetes in the majority of MENA countries. If the crises continues longer, the supply of insulin, oral drugs, self monitoring equipment of diabetes and other tools, will be affected. To this, we must expect great difficulties in supplying food for many countries. Certainely, it is important to remember that containment and hygiene measures, associated with other factors such as the young average age of the population, the higher temperature in these countries, the differences in the immune status of populations and the role of BCG vaccine have something to do with it. All of this deserves to be studied in depth.

Diabetes and the Prospect of a National and Global Disaster

Diabetes, obesity with their cardiovascular consequences are now a worldwide epidemic with medical, social and economic devastating and unprecedented. These diseases are no longer limited to "rich countries", and now a growing public health problem in developing countries; where the "Western" dietary pattern spreads and often replaces the traditional and healthy food. To this must be added the profound changes associated with rapid urbanization, changes in social, family and technological advances and comfort. The role of the food industry is highly present in a consumer society living under the influence and pressure of advertising... Keywords: Challenge, Diabetes, Epidemic, Lifestyle., Morocco

Barriers to the delivery of diabetes care in the Middle East and South Africa: a survey of 1,082 practising physicians in five countries

AIMS

Developing countries face a high and growing burden of type 2 diabetes. We surveyed physicians in a diverse range of countries in the Middle East and Africa (Egypt, Kingdom of Saudi Arabia, United Arab Emirates, South Africa and Lebanon) with regard to their perceptions of barriers to type 2 diabetes care identified as potentially important in the literature and by the authors.

METHODS

One thousand and eighty-two physicians completed a questionnaire developed by the authors.

RESULTS

Most physicians enrolled in the study employed guideline-driven care; 80-100% of physicians prescribed metformin (with lifestyle intervention, where there are no contraindications) for newly diagnosed type 2 diabetes, with lifestyle intervention alone used where metformin was not prescribed. Sulfonylureas were prescribed widely, consistent with the poor economic status of many patients. About one quarter of physicians were not undertaking any form of continuing medical education, and relatively low proportions of practices had their own diabetes educators, dieticians or diabetic foot specialists. Physicians identified the deficiencies of their patients (unhealthy lifestyles, lack of education and poor diet) as the most important barriers to optimal diabetes care. Low-treatment compliance was not ranked highly. Access to physicians did not appear to be a problem, as most patients were seen multiple times per year.

CONCLUSIONS

Physicians in the Middle East and South Africa identified limitations relating to their patients as the main barrier to delivering care for diabetes, without giving high priority to issues relating to processes of care delivery. Further study would be needed to ascertain whether these findings reflect an unduly physician-centred view of their practice. More effective provision of services relating to the prevention of complications and improved lifestyles may be needed.

Safety and effectiveness of insulin analogues in Moroccan patients with type 2 diabetes: a sub-analysis of the A₁chieve study

AIM

To determine the safety and effectiveness of insulin analogues in the Moroccan cohort of the prospective, multinational, non-interventional, 24-week A₁chieve study.

METHODS

Moroccan patients with type 2 diabetes (T2D) starting biphasic insulin aspart 30, insulin detemir, and insulin aspart alone or in combination were included. The primary outcome was the evaluation of serious adverse drug reactions including major hypoglycaemic events. Secondary outcomes were changes in hypoglycaemic events, glycaemic parameters (HbA1c, fasting plasma glucose [FPG], postprandial plasma glucose [PPPG]), systolic blood pressure (SBP), body weight and lipid profile. Quality of life (QoL) was evaluated using the EQ-5D questionnaire.

RESULTS

In this analysis, 1641 patients (923 insulin-naive, 718 insulin-experienced) having a mean age 57.1 years, mean BMI 26.8 kg/m(2) and mean diabetes duration 10.3 years, were included. Baseline HbA1c in the entire cohort was poor (9.7%, 83 mmol/mol). Insulin analogues statistically significantly improved glucose control (HbA1c, FPG and PPPG, p < 0.001) at Week 24. The rate of hypoglycaemia decreased from 9.31 to 4.71 events/patient-year (change in proportion of patients affected, p = 0.0002). A statistically significant improvement in lipid parameters (except HDL cholesterol) was observed while body weight changed minimally. Additionally, QoL was positively impacted (mean change in visual analogue scores from EQ-5D was 15.8 points, p < 0.001).

CONCLUSIONS

Insulin analogue therapy resulted in improved glycaemic control and a significant overall decrease in hypoglycaemia in Moroccan T2D patients.

Comparison of NovoPen 3 and syringes/vials in the acceptance of insulin therapy in NIDDM patients with secondary failure to oral hypoglycaemic agents

This open, randomised, cross-over study compared the acceptance and safety of NovoPen 3 with that of conventional syringes and vials when initiating insulin treatment in 96 NIDDM patients with secondary failure to oral hypoglycaemic agents. These patients had not previously been treated with insulin. All patients used each insulin administration system for 12 weeks. Group A started therapy using NovoPen 3 and crossed over to syringe/vial administration; Group B started with syringe/vial administration followed by NovoPen 3. In total, 78 patients completed the study. Most patients in Group A initially found the insulin injections very easy or easy and many of those who found injections easy at first found them very easy by the end of week 12. During the first period, patients in Group B found insulin administration more difficult than those in Group A. Injection pain was significantly lower with NovoPen 3 than with syringes and vials (P = 0.0018). Patients in Group B reported a significantly lower level of injection pain after the switch to using NovoPen 3 (P = 0.0003). Acceptance of insulin injections was significantly higher by patients using NovoPen 3 than by those using syringes and vials (P = 0.0059). Setting and drawing up the dose of insulin was also easier for patients using NovoPen 3 (P = 0.0490). At the end of the study, most patients (89.5% (68/76 replies)) said that they preferred NovoPen 3 to syringes and vials. Glycaemic control improved compared with baseline after starting insulin therapy, with no differences between Groups A and B, or between the two injection systems. The number of reported hypoglycaemic episodes was very low and was not significantly different between Groups A and B, or between the two administration systems. No treatment-related adverse events were reported. We conclude that use of NovoPen 3 provides better acceptance of insulin injection than use of conventional syringes and vials during initiation of insulin therapy in NIDDM patients with secondary failure to treatment with oral hypoglycaemic agents.

Muslims with non-insulin dependent diabetes fasting during Ramadan: treatment with glibenclamide

OBJECTIVE

To compare the efficacy of two glibenclamide regimens in patients with non-insulin dependent diabetes who were fasting during Ramadan and regular glibenclamide treatment in the non-fasting group.

DESIGN

Non-randomised control group of patients who did not fast during Ramadan and two groups of patients who fasted randomised equally to one of two regimens: to take their usual morning dose of glibenclamide in the evening and their usual evening dose before dawn; or to follow this pattern but to reduce the total dose by a quarter.

SETTING

Two university hospitals, one private hospital, and two private clinics in Casablanca and Rabat, Morocco.

SUBJECTS

591 diabetic patients (198 men, 391 women, two unspecified) with similar duration of diabetes and length and amount of glibenclamide treatment, of whom 542 completed the study.

MAIN OUTCOME MEASURES

Serum fructosamine and total glycated haemoglobin concentrations and number of hypoglycaemic events.

RESULTS

At the end of Ramadan there were no significant differences between the groups in fructosamine concentration (400 mumol/l in controls and 381 mumol/l and 376 mumol/l in the fasting groups); percentage of glycated haemoglobin (14.7%, 14.0%, and 13.6%); or number of hypoglycaemic events during Ramadan (11, 14, and 10).

CONCLUSION

Glibenclamide is effective and safe for patients with non-insulin dependent diabetes who fast during Ramadan. The easiest regimen is to take the normal morning dose (together with any midday dose) at sunset and any evening dose before dawn.

Correlation between amount of carbohydrate in mixed meals and insulin delivery by artificial pancreas in seven IDDM subjects

The effects of mixed meals containing varying amounts of carbohydrate (CHO) on blood glucose levels and insulin delivery by an artificial pancreas were studied in seven insulin-dependent diabetes mellitus subjects. Each patient received, at random over 3 consecutive days, three mixed meals containing 60, 80, and 140 g complex CHOs. There was a high and linear correlation between total amount of insulin delivered to restore blood glucose values and amount of CHO consumed: 12.1 +/- 1.3 to 31.2 +/- 5.2 U insulin were needed for 116 +/- 16 to 198 +/- 24 min. However, neither the time lapse between the beginning of meal intake and blood glucose increase nor the peaking time for blood glucose variation were significantly different between meals. We suggest that some of the data obtained in this study might be useful in programming an open-loop insulin-infusion system.