1. Ramadan Fasting and Diabetes Mellitus
Dr. Tofail Ahmed,
Associate Prof. of Endocrinology, BIRDEM

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

3. Ramadan Fasting and Diabetes Mellitus
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.

4. Ramadan Fasting and Diabetes Mellitus
Some 40 – 50 million people with diabetes worldwide fast during Ramadan.

5. Ramadan Fasting and Diabetes Mellitus
During fasting a Muslim must abstain from
eating,
drinking,
use of oral medications and
smoking
from predawn (Suhur/ shehre) to after sunset (Ifter) and
however there is no restrictions on food or fluid from Ifter to shehre.

6. Ramadan Fasting and Diabetes Mellitus
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.

7. Ramadan Fasting and Diabetes Mellitus
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
Hypoglycemia,
Hyperglycemia,
Ketoacidosis,
Dehydration and thrombosis …. but..

8. Ramadan Fasting and Diabetes Mellitus
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.

9. Ramadan Fasting and Diabetes Mellitus
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.”

10. Ramadan Fasting and Diabetes Mellitus
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.

11. 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. )

12. Glucose Homeostasis after food intake
Insulin
Pancreas 1
Kidney
Fats 3 4
Liver
Glucose 2
Muscle
Glucose of gut

13. Glucose Homeostasis during fasting state
Glycogen from liver (kidney also) breakdown and pour into blood ‘Hepatic Glucose Output’ (HGU) (2).
Insulin 1 4
Glucose 2 5
Blood glucose is consumed mainly by vital organs like brain cells, RBC, renal & gut epitheliums. These cells are not insulin dependent cells(5).

14. DM
Insulin resistance
Insulin level

15. DM
Absolute lack of insulin

16. ADA workgroup has categories risk in patients with diabetes who fast during Ramadan as follows
Very high risk group
Severe hypoglycemia within the last 3 months prior to Ramadan
Patient with history of recurrent hypoglycemia
Patient with hypoglycemia unawareness
Patient with sustained poor glycemic control
Ketosis within the last 3 months prior to Ramadan
Type 1 DM
Acute illness
Hyperosmolar hyperglycemic coma within the last 3 months.
Patients who performs intense physical labour.
Pregnancy.
Patient on dialysis.  

17. ADA workgroup has categories risk in patients with diabetes who fast during Ramadan as follows
      High risk group
Patient with moderate hyperglycemia (average blood glucose between 150 and 300 mg/dl. HbA1c 7.5 – 9.0%)
Patients with renal insufficiency
Patients with advanced macrovascular complications
People living alone that are treated with insulin or sulfonylureas
Patients with co morbid conditions that presents additional risk factors.
Old age with ill health.
Drugs that may affect mentation 

18. 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

19. Management of diabetes during Ramadan
General considerations
Pre-Ramadan medical assessment and education
Management of DM (drug therapy)

20. Management of diabetes during Ramadan
General considerations
Several individual issues deserve special attention
Individualization: Each specific patient require his/her specific management plan. They should take Seheri (morning meal ) close to insak ( subuh) time.
Frequent monitoring of glycemic status ( multiple times daily – esp. patients on insulin: 2 to 4 hours after sheheri and 1 hour prior to ifter).

21. Management of diabetes during Ramadan
General considerations
Nutrition: In terms of calori and composition diet should remain same healthy and balanced as before Ramadan.
Ingestion of large amount of foods rich in carbohydrate and fats during ifter should be avoided.
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.

22. Management of diabetes during Ramadan
General considerations
Exercise: Normal level of activity. Excessive physical activities may lead to hypoglycemia. Tarawaih prayer can be considered part of daily exercise programme.
Breaking the fasting: If blood sugar goes < 3.3 mmol/L (60mg /dl) or > 16.7 mmol/L (300mg /dl). Sick days.

23. 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

24. Total daily insulin (U)
During Ramadan morning dose at ifter and half the evening dose at seheri ADA recommended guideline
Total daily insulin (U)
Ifter dose
Seheri dose
Total 20 13 3 16 21 14 17 22 15 18 23 4 19 24 25 26 5 27 28 29 30

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.

26. Thank You