Diabetes and Ramadan Practical Guidelines 2021
Ramadan fasting can result in a number of physiological effects on both homeostatic and endocrine processes. With the consideration that many diabetic Muslims are willing to fast during Ramadan, there is a need for evidence-based practical guidance. A group of authors has contributed to developing these guidelines, published by International Diabetes Federation (IDA) in collaboration with the Diabetes and Ramadan (DAR) International alliance under the title “Diabetes and Ramadan Practical Guidelines 2021”. The summary of these guidelines is discussed below:
Objective:
To provide real-world recommendations to people with diabetes who choose to fast and health professionals in order to ensure a safe and healthy fast.
Method:
This is an updated version of IDF-DAR Practical Guidelines (2016) which includes new guidance based on a greater and more recent body of evidence.
Guidelines:
POTENTIAL ADVERSE PHYSICAL AND MENTAL EFFECTS OF FASTING DURING RAMADAN
1. Sleep deprivation and disruption of circadian rhythm leading to a reduction in cognition and
increase in fatigue.
2. Glucose excursions causing feelings of being unwell.
3. Greater feelings of lethargy.
4. Heightened feelings of fear for diabetes related complications.
5. Temporary changes in weight.
6. Short term feelings of stress anxiety, irritability and agitation.
RECOGNISED FACTORS THAT MAY INFLUENCE THE DEVELOPMENT OF PERSONALISED CARE FOR PEOPLE WITH DIABETES THAT FAST-DURING RAMADAN
1. Ramadan related factors: Length of fasting hours, Season of fasting, Weather, Geographical location, Social changes, Past experiences
2. Diabetes related factors: Type of diabetes, Duration of diabetes, Diabetic complications, Antidiabetic therapies, Previous control, Proneness to hypoglycemia, Hypoglycemic unawareness, Access to care
3. Factors concerning the individual: Age (adolescents and elderly), Gender, Occupation,
Pregnancy/Lactation, Meal pattern, Exercise nature/timing, Motivation, Personal preferences
RISK STRATIFICATION
Following the new IDF-DAR elements for risk calculation and the relevant risk score, people with diabetes mellitus that seek to fast during Ramzan can be categorized as follow:
Low Risk (0-3 points) – Type 1 diabetes, Type 2 diabetes, Duration (≥ 10 / <10), Hypoglycemia less than 1 time per week, No hypoglycemia, HbA1c levels > 9% (11.7 mmol/L), HbA1c levels 7.5–9% (9.4–11.7 mmol/L), HbA1c levels < 7.5% (9.4 mmol/L), Multiple daily mixed insulin Injections, Basal Bolus/Insulin pump, once daily Mixed insulin, Basal Insulin, Glibenclamide, Gliclazide/MR or Glimepride or Repeglanide, Other therapy not including SU or Insulin, patients in which self-monitoring of blood glucose (SMBG) is Indicated but not conducted are at higher risk than those individuals where SMBG is indicated but conducted sub-optimally and conducted as indicated, patient with no diabetic ketoacidosis (DKA)/ hyperglycaemic hyperosmolar nonketotic coma (HONC), patient with DKA/ HONC in last 6 month/ 3 month / 12 months, patients with no microvascular disease (MVD) / stable MVD, eGFR 45–60 mL/min, eGFR >60 mL/min, not pregnant, No frailty or loss in cognitive function, no physical labour or moderate intense physical labour, people with overall negative risk are at little higher risk than people with no negative or positive experience in previous Ramzan, fasting hour ≥ 16 hours and less risky than < 16 hours.
Moderate Risk (3.5-6 points)- Multiple weekly Hypoglycaemic episode, Recent Severe hypoglycaemia, eGFR 30–45 mL/min, Pregnant within targets, > 70 years old with no home support, Highly Intense physical labour. Higher Risk (>6 points) – Hypoglycemia unawareness, Unstable MVD, eGFR < 30 mL/min, Pregnant not within targets, Impaired cognitive function or Frail. Individuals in high risk or moderate risk category are advised not to fast and even if they insist on fasting, they should be aware about the strategies and recommendation to reduce the risk.
MEDICAL & RELIGIOUS RISK SCORE RECOMMENDATIONS
Risk score/level: Low risk 0-3 points
Medical Recommendations: Fasting is probably safe with Medical Evaluation, Medication adjustment, Strict monitoring
Religious Recommendations: Fasting is obligatory, advice not to fast is not allowed, unless patient is unable to fast due to the physical burden of fasting or needing to take medication or food or drink during the fasting hours
Risk score/level: Moderate risk 3.5-6 points
Medical Recommendations: Fasting safety is uncertain. Patients are encouraged for medical evaluation, medication adjustment, strict monitoring
Religious Recommendations: Fasting is preferred but patients may choose not to fast if they are concerned about their health after consulting the doctor and taking into account the full medical circumstances and patient’s own previous experiences. If the patient does fast, they must follow medical recommendations including regular blood glucose monitoring
Risk score/level: High risk >6 points
Medical Recommendations: Fasting is probably unsafe
Religious Recommendations: Advise against fasting
Pregnant and breastfeeding women have the right to not fast regardless of whether they have diabetes
THE MAIN AREA OF DIABETES EDUCATION THAT SHOULD BE PROVIDED BEFORE RAMDAN ARE AS FOLLOW:
• Risk quantification and exemptions, and removing misconceptions
• Blood glucose monitoring
• Fluids and dietary advice
• Physical activity and exercise advice
• Medication adjustment and test fasting
• When to break the fast
• Recognition of hypoglycaemia and hyperglycaemia symptoms
PRE-RAMDAN ASSESSMENT
All individuals seeking to fast should attend a pre-Ramadan visit 6-8 weeks before Ramadan.
Following should be assessed to stratify risk and develop an individualized management plan:
1. Detailed medical history
2. Aspects of diabetes and ability to self-manage
3. Presence of comorbidities
4. The individual’s experience in managing diabetes during prior Ramadan fasting
5. The individual’s ability to self-manage diabetes
6. Other aspects increasing the risk of fasting
DURING RAMDAN GUIDE
Frequency of SMBG needs to be guided by risk stratification and individualized
It is advised for individuals to break their fast if:
• Blood glucose <70 mg/dL (3.9 mmol/L)
• Re-check within 1 hour if blood glucose 70–90 mg/dL (3.9–5.0 mmol/L) Blood glucose levels >300 mg/dL (16.6 mmol/L)
• Symptoms of hypoglycemia or acute illness occur
SMBG – 7- POINT GUIDE FOR RAMADAN
1. Pre-dawn meal (suhoor)
2. Morning
3. Midday
4. Mid-afternoon
5. Pre-sunset meal (iftar)
6. 2 hours after iftar
7. At any time when there are symptoms of hypoglycemia/ hyperglycemia or feelings of being unwell
DIETARY ADVICE FOR PEOPLE WITH DIABETES FASTING DURING RAMADAN
• Divide the daily calories between Suhoor and Iftar, plus one to two snacks if necessary
• Ensure meals are well balanced with 45% – 50% complex carbohydrates E.g., barley, wheat, oats, millet, semolina, beans, lentils. 20% – 30% protein and <35% fat (preferably mono- and polyunsaturated)
• Include low glycaemic index, high-fibre foods that release energy slowly before and after fasting. E.g., granary bread, beans, rice
• Include plenty of fruit, vegetables and salads
• Minimize foods that are high in saturated fats. E.g. ghee, samosas, pakoras
• Avoid sugary desserts
• Use small amounts of oil when cooking. E.g., olive, canola oil, rapeseed
• Keep hydrated between sunset and sunrise by drinking water or other non-sweetened beverages
• Avoid caffeinated and sweetened drinks
EXERCISE RECOMMENDATION
• Rigorous exercise during last hour of fasting should be avoided
• Patient should be reminded that taraweeh prayers are considered part of their daily exercise activities
CALORIC TARGETS FOR MEN AND WOMEN WHEN FASTING DURING RAMADAN
• Men
Weight maintenance – 1800 – 2200 kcal/day
Weight reduction – 1800 kcal/day
• Women > 150 cm tall
Weight maintenance – 1500 – 2000 kcal/day
Weight reduction – 1500 kcal/day
• Women < 150 cm tall
Weight maintenance – 1500 kcal/day
Weight reduction – 1200 kcal/day
CALORIE AND CARBOHYDRATE DISTRIBUTIONS FOR THE RAMADAN NUTRITION PLAN
• Suhoor
Percentage of calories: 30 – 40%
Carbohydrate distributions: 3 – 5 exchanges
• Iftar Snack
Percentage of calories: 10 – 20%
Carbohydrate distributions: 1 – 2 exchanges
• Iftar Meal
Percentage of calories: 40 – 50%
Carbohydrate distributions: 3 – 6 exchanges
• Healthy Snack (if necessary)
Percentage of calories: 10 – 20%
Carbohydrate distributions: 1 – 2 exchanges
(1 Carbohydrate exchange = 15 g Carbohydrates)
MACRONUTRIENT MEAL COMPOSITION
1) CARBOHYDRATES
Amount:
• The total daily intake of carbohydrates should be at least 130 g/day and ideally about 40-45% of total caloric intake
• Intake should be adjusted to meet the cultural setting and food preferences of each individual
Recommended:
• Carbohydrates with a low glycaemic index and glycaemic load should be selected. These include whole grains, legumes, pulses, temperate fruits, green salad, and most vegetables
• High fibre foods such as unprocessed food, vegetables, fruits, seeds, pulses, and legumes should be consumed. It is recommended to consume about 20-35g/day (or 14g /1000 kcal). Fibre helps to provide satiety during Iftar and to delay hunger after Suhoor
Not recommended:
• The consumption of foods rich in sugar, refined carbohydrate or processed grains, and starchy foods should be limited; especially sugary beverages, traditional desserts, white rice, white bread, low fibre cereal and white potatoes
2) PROTEIN
Amount:
• Protein intake should not be less than 1.2g/kg of adjusted body weight^ and usually accounts for 20-30% of the total caloric intake. Protein is essential as it enhances satiety and the sensation of fullness. Protein helps to maintain lean body mass [
Recommended:
• Fish, skinless poultry, milk and dairy products, nuts, seeds, and legumes (beans) are recommended
Not recommended:
• Sources of protein with a high saturated fat content such as red meat (beef, lamb) and processed meats should be minimised as they increase the risk of CVD
• Although high-fat dairy products contain saturated fats, a study has shown, increasing dairy consumption to ≥3 servings/day compared with < 3, while maintaining energy intake, servings/ day does not affect HbA1c levels, body weight, body composition, lipid profile, or blood pressure in patients with T2DM
3) FATS
Amount:
• Fat intake should be between 30–35% of the total calorie intake. The type of fat is more important than the total amount of fat in reducing the risk of CVD.
• Limit saturated fat to < 7%. PUFA and MUFA should comprise the rest of the fat intake.
• Limit dietary cholesterol to < 300 mg/day or < 200 mg /day if LDL cholesterol > 2.6 mmol/L
Recommended:
• Consume fat from PUFA and MUFA (e.g., olive oil, vegetable oil, or blending oil (PUFA and Palm oil)). Oily fish (e.g. such as tuna, sardines, salmon, and mackerel) as a source of omega 3-fatty acids are also recommended.
Not recommended:
• Minimise the intake of foods high in saturated fat, including red meat (beef and lamb), ghee and foods high in trans-fats (e.g., fast foods, cookies, some margarines).
RECOMMENDATIONS FOR INSULIN DOSE ADJUSTMENTS BASED ON TYPE OF REGIMEN
A) Type of Insulin Regimen: Continuous subcutaneous insulin infusion pump (CSII)/ Insulin pump
Methods of monitoring during Ramadan: Continuous glucose monitoring (CGM)
Adjustment for fasting during Ramadan:
1) Basal rate adjustment
• 20-40% decrease for the last 3-4 hours of fast
• 10-30% increase for the first few hours after Iftar
2) Bolus doses
• Same principles as prior to Ramadan
B) Type of Insulin Regimen: MDI (basal bolus) with analogue insulin
Methods of monitoring during Ramadan: 7-point glucose monitoring
Adjustment for fasting during Ramadan:
1) Basal insulin
• 30-40% reduction in dose and to be taken at Iftar
2) Rapid Analogue Insulin
• Dose at suhoor to be reduced by 30-50%
• Pre-lunch dose to be skipped
• The dose around Iftar to be adjusted based on the 2-hour post-Iftar glucose reading
C) Type of Insulin Regimen: MDI (Basal bolus) with conventional insulin
Methods of monitoring during Ramadan: 7-point blood glucose monitoring or 2-3 staggered readings throughout the day
Adjustment for fasting during Ramadan:
1) NPH insulin
• The usual pre-Ramadan morning dose to be taken in the evening during Ramadan
• 50% of the pre-Ramadan dose to be taken at suhoor
2) Regular insulin
• Dose at evening meal remains unchanged
• Suhoor dose to be 50% of the pre-Ramadan evening dose
• Afternoon dose to be skipped
D) Type of Insulin Regimen: Premixed (analogue or conventional)
Methods of monitoring during Ramadan: At least 2-3 daily readings and whenever any hypoglycemic symptoms develop
Adjustment for fasting during Ramadan:
• Shift the usual pre-Ramadan morning dose to Iftar
• 50% of the pre-Ramadan evening dose at Suhoor
MANAGEMENT OF T2DM WHEN FASTING DURING RAMADAN
A) DOSE ADJUSTMENT FOR METFORMIN DURING RAMADAN
1) Once-daily dosing
• No dose modification usually required
• Take at Iftar
2) Twice-daily dosing
• No dose modification usually required
• Take at Iftar and Suhoor
3) Three times daily dosing
• Morning dose to be taken before Suhoor
• Combine afternoon dose with dose taken at Iftar
4) Prolonged release metformin
• No dose modification usually required
• Take at Iftar
B) No dose modification is considered necessary in people on acarbose, SGLT2 inhibitors, pioglitazone medications as the risk of hypoglycaemia are low.
C) According to meal sizes during Ramadan, the daily dose of short-acting insulin secretagogues (based on a three-meal dosing) may be reduced or redistributed to two doses during Ramadan.
D) No further modification is required, as long as liraglutide, lixesenatide, exenatide have been appropriately dose titrated prior to Ramadan (at least 2–4 weeks).
E) DPP4-I do not require treatment modification during Ramadan.
F) DOSE ADJUSTMENT FOR SULPHONYLUREASE IN PEOPLE WITH T2DM FASTING DURING RAMADAN
1) Once-daily dosing
• Take at Iftar
• In individuals with well-controlled BG levels, the dose may be reduced
2) Twice-daily dosing
• Iftar dose remains the same
• In individuals with well-controlled BG levels, the Suhoor dose should be reduced
3) Older drugs in SU class
• Older drugs (e.g. glibenclamide) should be avoided as they carry a higher risk of hypoglycaemia
• 2nd generation SUs such as glicazide, glicazide MR, glimepiride should be used instead
G) CHANGES TO LONG AND SHORT-ACTING INSULIN DOSING IN T2DM PATIENTS DURING RAMADAN
1) Long/intermediate-acting (basal) insulin
• NPH/detemir/glargine/glargine 300/degludec (once daily): – Reduce dose by 15-30% Take at Iftar
• NPH/detemir/glargine (twice daily): – Take usual morning dose at Iftar, reduce evening dose by 50% and take at Suhoor
2) Short-acting insulin
• Normal dose at Iftar
• Omit lunch-time dose
• Reduce Suhoor dose by 25-50%
3) Modification of insulin dose as per blood glucose levels
• <70 mg/dL (3.9 mmol/L) or symptoms
Pre iftar basal insulin- Reduce by 4 units
Pre-Iftar/post-Suhoor short-acting insulin – Reduce by 4 units
• <90 mg/dL (5.0 mmol/L)
Pre iftar basal insulin- Reduce by 2 units
Pre-Iftar/post-Suhoor short-acting insulin – Reduce by 2 units
• 90-126 mg/dL (5.0-7.0 mmol/L)
Pre iftar basal insulin – No change required
Pre-Iftar/post-Suhoor short-acting insulin – No change required
• >126 mg/dL (7.0 mmol/L)
Pre iftar basal insulin- Increase by 2 units
Pre-Iftar/post-Suhoor short-acting insulin- Increase by 2 units
• >200 mg/dL (11.1 mmol/L)
Pre iftar basal insulin – Increase by 4 units
Pre-Iftar/post-Suhoor short-acting insulin – Increase by 4 units
H) CHANGES TO PREMIXED INSULIN DOSING DURING RAMADAN
1) Once daily dosing
• Take normal dose at Iftar
2) Twice daily dosing
• Take normal dose at Iftar
• Reduce Suhoor dose by 20-50%
3) Three-times daily dosing
• Omit afternoon dose
• Adjust Iftar and Suhoor doses
• Carry out dose-titration every 3 days
4) Modification of pre-iftar insulin dose as per blood glucose levels
• <70 mg/dL (3.9 mmol/L) or symptoms – Reduce by 4 units
• <90 mg/dL (5.0 mmol/L) – Reduce by 2 units
• 90-126 mg/dL (5.0-7.0 mmol/L) – No change required
• >126 mg/dL (7.0 mmol/L) – Increase by 2 units
• >200 mg/dL (11.1 mmol/L) – Increase by 4 units
I) CHANGES TO INSULIN PUMP DOSES DURING RAMADAN
1) Basal rate
• Reduce dose by 20-40% in the last 3-4 hours of fasting
• Increase dose by 0-20% early after Iftar
2) Bolus rate
• Normal carbohydrate counting and insulin sensitivity principles apply
MANAGEMENT OF HYPERGLYCEMIA IN PREGNANCY WHEN FASTING DURING RAMADAN
A) It should be explained to pregnant women that regardless of their fasting status, they need to sustain the standard blood glucose targets during pregnancy of
• Fasting between 70-95 mg/dL (3.9 – 5.3 mmol/L).
• Post-prandial < 120 mg/dL (6.7 mmol/L).
B) Additionally, they should be aware that during pregnancy they should break their fast if any of the following occur:
• BG levels < 70 mg/dL (3.9 mmol/L) during fasting hours.
• Feeling unwell.
• Reduced fetal movement.
GUIDELINES FOR ELDERLY INDIVIDUALS SEEKING TO FAST DURING RAMADAN
A) MEDICATIONS AND REGIMENS
• Pre- Ramadan assessment, and discussion with your diabetes specialist is must
• Choose medications that have a lower risk towards hypoglycaemia
• Dose adjustments should be made to lower the risk of hypoglycaemia.
B) SMBG
• Increase the frequency of SMBG when fasting during Ramadan than before Ramadan.
• Consider the using a continuous means of monitoring blood glucose levels if available.
C) DIET
• There needs to be an emphasis on staying properly hydrated, particularly in individuals prone to diabetes related comorbidities.
• It is important to have an adequate intake of nutrients when breaking the fast.
• An individualized nutrition plan should be made prior to Ramadan and adhered to during the Ramadan fast.
D) PHYSICAL ACTIVITY
• Physical activity levels should be curtailed but not halted during fasting hours.
• Activities should be planned ahead of time and thought of holistically — i.e., in conjunction with nutrition plans and medication regimens.
E) SOCIAL CONSIDERATIONS AND COMMUNITY SUPPORT
• Adequate support mechanisms should be in place to ensure that elderly individuals with diabetes wishing to fast receive adequate support from family members, friends, carers or community members. This should provide greater levels of safety and confidence.
F) RISKS OF COMPLICATIONS AND AWARENESS
• There needs to be an active effort to increase personal awareness of symptoms of hypoglycaemia and hyperglycaemia
• Symptoms and events should be recorded to help with recognition.
• The effects of fasting in people with comorbidities such as dementia, impaired renal function, CVD and others should be considered and discussed with a medical specialist prior to conducting Ramadan fasting.
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