1. This presentation is a part of More on Islam presentation series. For other titles please contact moreonislam@hotmail.com

2. Management of Diabetes During Ramadan Amir Ziaee, M.D. Professor of Internal Medicine & Endocrinology

3. This presentation is a part of More on Islam presentation series. For other titles please contact moreonislam@hotmail.com يَا أَيُّهَا الَّذِينَ آمَنُواْ كُتِبَ عَلَيْكُمُ الصِّيَامُ كَمَا كُتِبَ عَلَى الَّذِينَ مِن قَبْلِكُمْ لَعَلَّكُمْ تَتَّقُونَ The goal of fasting is to develop self-restraint. Holy Quran Holy Quran states: “O you who believe! Fasting is prescribed to you as it was prescribed to those before you, so that you may develop Taqwa (self- restraint) ” [2:183] Fear of GodLove of God+ What is Taqwa? Taqwa is an Arabic word. It is the state of heart that motivates virtuous conduct and prevents evil action. leads to Taqwa (Self-restraint) Example: God says about Mary in the Qur’an that she said: “Verily!, I have vowed a fast to the Most Beneficent…[Maryam 19:26]. Taqwa is the ability to safe-guard.

4. This presentation is a part of More on Islam presentation series. For other titles please contact moreonislam@hotmail.com Benefits of Fasting in Islam : How character-building is achieved… Taqwa (Self- restraint) Fasting Patience Self-control Self-discipline Responsibility Obedience Purification of soul God-fearing nature Afterlife Accountability

5. This presentation is a part of More on Islam presentation series. For other titles please contact moreonislam@hotmail.com Changes in Carbohydrates Metabolism During Fasting of Ramadan

6. This presentation is a part of More on Islam presentation series. For other titles please contact moreonislam@hotmail.com 6

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8. The effect of Ramadan fasting on metabolism and different organs in healthy individuals Metabolism/organEffect CarbohydrateGlycogenolysis of the liver, some degree of gluconeogenesis in longer fasting days LipidsVariable, depending on the quality and quantity of diet and weight change Body weightVariable, mostly decreased or unchanged LiverSlight increase in indirect bilirubin in the first half of Ramadan fasting KidneySmall, insignificant changes in serum urea, creatinine and uric acid Hematological ProfileSmall decrease in both iron and total iron binding capacity NeuropsychiatricChange in chronotype and sleep patterns; increase in the prevalence of headaches; Endocrine GlandsSlight changes in protein binding of T4 and T3 and in serum calcium concentration Small reversible shifts in cortisol, testosterone and prolactin secretions Gastrointestinal tract, heart, lungs and eyes None

9. This presentation is a part of More on Islam presentation series. For other titles please contact moreonislam@hotmail.com How many people with diabetes fast during Ramadan? Type of diabetes 12 Fast During Ramadan 43%79% 50 million Muslims with diabetes fast each year Salti et al. Diabetes Care 2004; 27: 2306

10. This presentation is a part of More on Islam presentation series. For other titles please contact moreonislam@hotmail.com Major risks associated with fasting in patients with diabetes Hypoglycemia Hyperglycemia Diabetic ketoacidosis Dehydration and thrombosis Diabetes Care 2004; 28: 2305 Al-Arouj et al. Diabetes Care 2010; 33: 1895

11. This presentation is a part of More on Islam presentation series. For other titles please contact moreonislam@hotmail.com Categories of risks in patients with type 1 or type 2 diabetes who fast during Ramadan Very high risk Severe hypoglycemia within the last 3 months prior to Ramadan Patient with a history of recurrent hypoglycemia Patients with hypoglycemia unawareness Patients with sustained poor glycemic control Ketoacidosis within the last 3 months prior to Ramadan Type 1 diabetes Acute illness Hyperosmolar hyperglycemic coma within the previous 3 months Patients who perform intense physical labor Pregnancy Patients on chronic dialysis Al-Arouj et al. Diabetes Care 2010; 33: 1895

12. This presentation is a part of More on Islam presentation series. For other titles please contact moreonislam@hotmail.com Categories of risks in patients with type 1 or type 2 diabetes who fast during Ramadan High risk Patients with moderate hyperglycemia (average blood glucose between 150 and 300 mg/dl, A1C 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 comorbid conditions that present additional risk factors Old age with ill health Drugs that may affect mentation Moderate risk Well-controlled patients treated with short-acting insulin secretagogues such as repaglinide or nateglinide Low risk Well-controlled patients treated with diet alone, metformin, acarbose, thiazolidinedione or incretion drugs who are otherwise healthy Al-Arouj et al. Diabetes Care 2010; 33: 1895

13. This presentation is a part of More on Islam presentation series. For other titles please contact moreonislam@hotmail.com

14. Management of Patients with Type 2 Diabetes on Insulin Use of a rapid acting insulin analog instead of regular human insulin before meals in patients with type 2 diabetes who fast during Ramadan is associated with less hypoglycemia and smaller postprandial glucose excursions.

15. This presentation is a part of More on Islam presentation series. For other titles please contact moreonislam@hotmail.com Recommended changes to insulin regimen in patients with type 2 diabetes who fast during Ramadan

16. This presentation is a part of More on Islam presentation series. For other titles please contact moreonislam@hotmail.com If patient is on premix insulin therapy Use the usual morning dose at the sunset meal (Iftar) and half the usual evening dose at predawn (sahur), e.g., 70/30 premixed insulin 30 units in the morning and 20 units in the evening before Ramadan (BHI 30 or BIAsp 30), during Ramadan recommended dose will be 30 units in evening and 10 units at sahur; also consider changing to basal plus bolus.

17. This presentation is a part of More on Islam presentation series. For other titles please contact moreonislam@hotmail.com If on Basal Bolus insulin therapy ■Bolus portion Morning dose: Transfer full dose at iftaar. Evening dose: Transfer ½ dose at sahur. Lunch dose: If patient takes dinner, transfer the full dose at dinner.

18. This presentation is a part of More on Islam presentation series. For other titles please contact moreonislam@hotmail.com If on Basal Bolus insulin therapy Basal portion If patient is on NPH: 50% dose at sahur. If patient is on basal analog: Same dose at bed time.

19. This presentation is a part of More on Islam presentation series. For other titles please contact moreonislam@hotmail.com Blood Glucose Monitoring During Ramadan Adjust insulin dose at 3 days' interval - Pre-iftaar: adjust basal insulin dose - 2 hours post-iftaar: adjust iftaar bolus insulin dose - 2 hours postdinner: adjust dinner bolus insulindose - 2 hours post-sahur: adjust sahur bolus insulin dose.

20. This presentation is a part of More on Islam presentation series. For other titles please contact moreonislam@hotmail.com Blood Glucose Monitoring During Ramadan If blood glucose is noted to be low, fasting must be broken. If blood glucose > 300 mg/dl or 16.66 mmol/L, ketones in urine should be checked.

21. This presentation is a part of More on Islam presentation series. For other titles please contact moreonislam@hotmail.com Conclusion It is possible for people with diabetes to fast safely during Ramadan, but requires careful planning in order to avoid problems that could be serious and have long- term effects. The choice of insulin therapy is decided by the previous therapy that the patient is taking and also the blood glucose profiles.

22. This presentation is a part of More on Islam presentation series. For other titles please contact moreonislam@hotmail.com Conclusion The major objective of insulin therapy during Ramadan is to provide adequate insulin to prevent the post meal hyperglycemia and also prevent hypoglycemia during the period of fast. With the use of analogues these objectives may be met more easily.

23. This presentation is a part of More on Islam presentation series. For other titles please contact moreonislam@hotmail.com Thanks for your attention