Dr , I have Diabetes, Can I fast?

Dr Majedah AbdulRasoulAssistant Professor

Pediatric Department Faculty of MedicineKuwait University

Dr, I have Diabetes, Can I

fast?

Learning Outcomes•Understand what happens in diabetics and

non-diabetics during fasting

• Improve knowledge and understand “ safe fast” during Ramadan

•Be able to empower patients to make the right decision to avoid risks associated with fasting during Ramadan

Muslims around the World•As of 2010, over 1.6 billion or about 23.4%

of the world population are Muslims *

•Growing by ~ 3% per year.

 *The Future of the Global Muslim Population. Pew Research Centre. 27 January 2011.

“O You who believe, fasting is prescribed to you as it was prescribed to those before you so that you can learn Taqwa. For a number of days, but for those who are ill, or on a journey, these days should be made

up from days later”

Ramadan

Surrah AlBaqara 2: 183

Ramadan

• The 9th months of the Islamic calendar

• Fasting in Ramadan is one of the 5 main pillars of Islam

•Complete fasting during daylight hours for one full Lunar month (29-30days) , for up to 20 hours depending on the geographical location.

Exception from fasting‘ Ramadan is the (month) in which was sent down the Quran as a guide to mankind, also clear ( Signs) for guidance and judgment (between right and wrong). So every one of you who is present (at his home) during that month should spend it fasting, but if any one is ill, or on a journey, the prescribed period (should be made up) by days later. Allah intends every facility for you; He does not want to put to difficulties. (He wants you) to complete the prescibed period, and to glorify Him in that he has guided you; and perchance ye shall be grateful’.

Surrah AlBaqara 2: 185

• Illness – Chronic• Diabetes

• Those who can not understand the purpose of fasting-mentally challenged• Frail elderly• Travelers•Women during menstruation, pregnancy, lactation • Pre-pubertal children

Exception from fasting

Exception from fasting•Many patients with diabetes insist on fasting during

Ramadan, thereby creating a medical challenge for themselves and their healthcare providers

• It is important that medical professionals be aware of potential risks associated with fasting during Ramadan and approaches to decrease those risks

•A large epidemiological study of Muslims with diabetes in 13 Muslim countries (the EPIDIAR study) showed that 43% of patients with type 1 and 79% of those with type 2 diabetes fasted during Ramadan.

Diabetes Care 2004; 27:2306

Back to Basics: CHO

•Carbohydrate metabolism in healthy persons:• Most of the studies show slight decrease in serum glucose

to 3.2-3.9 mmol/L in adults few hors after fasting• This may vary depending on:• Food habits• Differences in metabolism • Differences in energy regulation

• The fall in glucose cease due to:• Serum insulin decrease Increase glycogenlysis• Serum glucagon and GH increase Increase

gluconeogenesisDecrease

glycogenesisDeGroot and Jameason 2004Am J Med 200; 199: 341

Back to Basics: Lipids• Variable results

• Serum total cholesterol and triglycerides may decrease in the first days of fasting, then rise to pre fasting levels

• Increase in HDL-C

• Effect may be variable depending on quality and quantity of food consumed.

• Increase in Apo A-1concentration in both normal and diabetics.Am J Clin Nutr 1982; 30: 351Saudi Med J 1986; 7: 561 Eur J Clin Nutr 2000; 54:508

What happens in Diabetics

Most studies are in Type 2•Blood glucose variation in patients with diabetes• It may fall, nit change, or rise• The variation is due to the amount and type of food

consumed and/or decreased physical activity•HbA1c values showed no change or even improvement

during Ramadan.*• The amount of fructosamine, insulin, C-peptide also has

been reported no change before and during Ramadan fasting

*Int J Clin Pract 2010; 64: 1095 Ann Saudi Med 1994; 14:139*BMJ,2010; 340: 1407-1411 BMJ 1993; 307: 292

So, Can patients with Diabetes Fast?

The bulk of literature indicates that fasting Ramadan is safe for the majority of type 2 diabetic patients with proper education and diabetic management.

Type 1 Diabetes?

No Fasting

Your views?

Case 1

• 18 yrs old teenager• Type 1 diabetes since the age of 12yrs•On NPH and Actrapid• Because he can not get Lantus

• Testing his blood glucose at home 2-3 times per day•Mean HbA1c this year is 9.4 (was 9.8% last year)•He came to you in Shaaban asking about fasting this

year.

What will you do?

Your recommendations:•No fasting for patients with type 1 diabetes.

•More so if:• Poor control• On NPH• Coming close to Ramadan

•Have high risk for hyperglycemia, DKA, and hypoglycemia

Risks associated with fasting in T1DM• Hypoglycemia:

• 2-4% of mortality in patients with T1DM

•More with hypoglycemia unawareness, poor glycemic control and recurrent hypoglycemia in the past needing hospitalization

• EPIDIAR study:• 4.7- fold increase in severe hypoglycemia ( needing hospitalization) in patients

with T1DM• 3-14 events /100 people/month

Diabetes Care 2004; 27:2306

Risks associated with fasting in T1DM•Hyperglycemia: No information linking repeated yearly

episodes of short-term hyperglycemia and diabetes-related complications during Ramadan.• Deteriorate, improve, no change• EPIDIAR study:• 3 fold increase in severe hyperglycemia with or without

ketoacidosis in patients with T1DM (from 5 to 17 events /100 people/month.

• Due to excessive reduction of insulin to prevent hypoglycemia, increase intake of food and sugar drinks.

Diabetes Care 2004; 27:2306

•Diabetic Ketoacidosis:• More in patients with poorly controlled diabetes before

Ramadan*• The risk is increased because of decreased insulin dose

(assuming that food intake is reduced)• Risk for dehydration• Dose reduction in response to acute infection• However, it remains non-conclusive• 1.8% of T1DM patients developed DKA during Ramadan, same as

non-fasting months.**

Risks associated with fasting in T1DM

*Diabetes Care 2004; 27:2306** Abusrewil et al 2003 Jamahiriya Med J; 2:99

Risks associated with fasting in T1DM•Dehydration and thrombosis:• Increased incidence of retinal vein occlusion• However, coronary artery events or stoke were not

increased in Ramadan• Limitation of fluid intake can lead to dehydration• Hot and humid climates increase the risk• Also, hyperglycemia osmotic diuresis fluid and

electrolyte imbalance

Risk Categories for Fasting Ramadan In Diabetics: Very High Risk• T1DM• Severe Hypos within

the last 3 months• History of recurrent

hypos• Hypo unawareness• Acute illness• Chronic Dialysis

• Sustained poor control• DKA within the last 3

months• Pregnancy• Hyperosmolar

hyperglycemic coma in the last 3 months• Intensive physical

labor

Risk Categories for Fasting Ramadan In Diabetics: High Risk• Moderate

hyperglycemia: Average BG 8.5-16.5, HbA1c 7.5-9%• Renal Insufficiency• Living alone• Drugs affecting

mentation

• Advanced marcovascular complications• Co-morbid

conditions aggravating the above• Old age with ill

health

Risk Categories for Fasting Ramadan In Diabetics: Mod / Low

Moderate Risk• Well controlled

treated with short acting insulin, secretagogues

Low Risk • Well controlled

diabetes treated with lifestyle modification, metformin, acarbose, TZD.

Case 2

• 13 yrs old boy• Type 1 diabetes since the age of 5 yrs•On MDI• Glargine and Novorapid 4-5 times

• Testing his blood glucose at home 4-6 times per day•Mean HbA1c this year improved from 8.5% to 7.1%• This year he wanted to fast for the first time•He came to you in Rajab with his desire to fast

What will you do?

Your recommendations:•No fasting for patients with type 1 diabetes.

•More than 75-80% of our children with type 1 diabetes choose to fast, despite the recommendation, specially if:• they have been fasting before diagnosis• Have younger siblings who fast• Friends who fast

• If they did not bring the issue of fasting, you should.

General consideration:• Assess physical well being• Weight on the 50th centile – was 25-50th last yr• Height of the 75th centile – same centile for yrs

• Assessment of metabolic control• HBGM 4-6 per day• Fasting 5-8mmol/L, occasional 9mmol/L• Bed time 10mmol/L• 1-2 hypos (at school) over the last month, managed by

juice• No admission for DKA since the last 3 yrs

Your Opinion Now?

• Your recommendation : No Fasting

• If despite recommendation he decide to fast:• Discuss s/s of low blood sugar• Review management of hypoglycemia• Check if they have glucagon• Review diet routine with dietician• Check blood sugar 4-6 per day• Break the fast of blood glucose less than 4mmol/L• Break the fast if blood sugar is more than 13, specially with ketones

and act with hyperglycemia protocol.• May need revision of insulin dose (lantus) in fasting and adjust dose of

meal bolus• See after 1 week in Ramadan

What does the literature say?•A study on 20 patients on MDI•mean age of 12.4 yrs (fasting), 10.5 yr (not fasting)•Fasting was for 12.5 hours•Change in weight, HbA1c, lipid profile before anf after Ramadan•Results:•No statistical difference in HbA1c (9,2 &9.4% vs 9.13

&10%, p=0.9), weight or fasting lipids•No patient called the helpline and none had intercurrent

illness or ketosis

AlAlwan etal 2010; Int J Diabetes Mellitus

What does the literature say?•A study on 28 patients ( Amiri Hosp, & Royal London Hospital)•Ages: 9-18 yr• Poorly controlled, recurrent DKA and not willing to do HBGM

were excluded.• 2 groups (MDI basal bolus regimen vs conventional twice

daily (premix at Iftar and short acting at Suhur)•Mild Hypo (need to break the fast)• Severe hypo (need glucagon or hospital admission)•Hyperglycemia (> 15mmol) and DKA•No of fasting days

AlKhawari etal 2010; Pediatr Diabetes

AlKhawari etal 2010; Pediatr Diabetes

AlKhawari etal 2010; Pediatr Diabetes

AlKhawari etal 2010; Pediatr Diabetes

AlKhawari etal 2010; Pediatr Diabetes

•Conclusions and recommendations:• Adolescents on basal-Bolus regimen can fast if they wish to• They should receive sufficient education prior to fasting• Increase HBGM• CHO count

• Reduce basal by 10-20%, more if had hypoglycemia• If blood Glucose 15 correction given• Break fast if:• Develop ketones• BG < 4mmol

• Avoid skipping pre-dawn meal

•A study with insulin glargine suggest the relative safety and efficacy in relatively well controlled patients who fasted for 18 hours, with minimal decline in mean BG, and only 2 episodes of mild hypoglycemia.

Mucha GT etal, Diabetes Care, 2004

•A study in patients with type 1 diabetes using insulin Lispro or Aspart instead of regular insulin in combination with intermediate-acting insulin injected twice a day improved PP glycemia + fewer hypoglycemia

Kadiri et al. Diabetes Metab 2001

Fasting in T1DM on MDI

• Insulin Lispro, as a short acting instead of regular insulin , in combination with neutral protamine insulin in a basal bolus regimen lower 2-h post-prandial glucose level after sunset meal (p = 0.026) with less hypoglycemia (p < 0.01) in an open –label crossover study ( n=64).

• 3 slides

Fasting in T1DM on MDI

Kadiri et al 2010

Can a patient monitor blood sugar while fasting?• Patients should monitor their blood glucose during fast to recognize subclinical hypo and hyperglycemia

• Islam allows diabetics to have regular blood tests while fasing

• If blood glucose drops below 4 mmol/L (some recommend 3.5) the fats must be broken

• If blood glucose goes above 16.5 mmol/L, ketones should be checked, and medical advice sought

Case 3

• 13 yrs old teenager girl• Type 1 diabetes since the age of 8 yrs•Was on MDI of glargine and Aspart for 3 years.• On insulin pump since 2 years, and CGM since 8 months.• Testing his blood glucose at home 2-3 times per day (more

if feeling funny!!!)•Mean HbA1c this year is 6.9 (was 7.2% last year)• He came to you in Shaaban asking about fasting this year

for the first time since diagnosed.

What will you do?

Your recommendations:•No fasting for patients with type 1 diabetes.

•But:• On CSII• On CGMS• Excellent glycemic control

• I may allow her to fast

• 63 patients, aged 22+/-7 yrs, had diabetes for 9.8+/-5.6 yrs•On Medtronic MiniMed 722 for 20+/- 10 months•Outcome measures:• Days fasting• Hypoglycemia• Hyperglycemia• Emergency visits to the ER

What does the literature say?

Benbaraka et al 2010; Diabetes Technol Ther 12(4)

• Results:• Days fasting:• 61.2% fasted the whole month with no problems• 18.4% fasted 27-28 days• 16.3% fasted 24-25%• 4.1% fasted 23 days

• 50% decreased their basal by 5-50%• 27% had hypoglycemia break the fast• Fasting was broken in 3.8% of potential fasting days• No severe hypoglycemia• Unusual hyperglycemia in 18.4%, one needed hospital visit• 12 had pre and after Ramadan fructosamine level: 4+/-0.6 mmol

vs 3.6+/-0.6 mmol/L, p =0.007Benbaraka et al 2010; Diabetes Technol Ther 12(4)

•Conclusions:• Fasting Ramadan is feasible in patients with

T1DM on SCII with adequate counselling and support

Benbaraka et al 2010; Diabetes Technol Ther 12(4)

• 21 patients, median age 26 yr, adjusted their insulin in the routine way. All were on CGMS.•Outcome measures:• Body weight• HbA1c• Blood glucose• Total insulin dose• Overriding tendencies• Suspend time during fast• Hypoglycemia

What does the literature say?

(2)

Khalil et al 2012; Diabetes Technol Ther 14(9)

•Results:• Days fasting:• Median days 29

• Basal insulin was decreased by 5-20%, no overall sig.• Redistribution of insulin based on daily lifestyle and eating

times• No major hypoglycemia• Mild hypoglycemia in 8.4%, managed by basal adjustment

or suspension of pump

Khalil et al 2012; Diabetes Technol Ther 14(9)

•Conclusions:• The use of CGMS add advantage on CSII in

type 1 diabetic patients choosing to fast in Ramadan

Khalil et al 2012; Diabetes Technol Ther 14(9)

Conclusions & Recommendations

(1)• Patients with T1DM are excepted from fasting during

Ramadan

• Those who insist on fasting need to be aware of the associated risks

• They should adhere to the recommendation of of the healthcare providers to achieve a safe fast.

• Patients should maintain their strict diabetes routines, as social functions during Ramadan are frequent and food is plenty

• All patients should have a pre-Ramadan “fasting consultation”. Even those who choose not to fast need dose adjustment.

• Reviewing symptoms and management of hypoglycemia; ensure the availability of glucagon

• Doses of insulin should not be omitted, may be reduced based on CHO counting and amount of food

Conclusions & Recommendations

(2)

•Gentle physical activity should be encouraged

•Over-eating after breaking the fast is to be avoided, specially sweat drinks

• If hypoglycemia ( <4 mmol if the first few hrs of fasting or <3.3 after that time breaking fast is mandatory

• If Hyperglycemia (> 15 mmol) or ketosis develop, breaking fast is mandatory. Temptation to preserve fasting till the end is to be discouraged.

Conclusions & Recommendations

(3)

•Blood glucose testing during the day (noon), before and 2- hrs after Iftar , before Sohur is the minimum in T1DM.

•Reviewing the achievements and problems to the healthcare givers and receiving feedback is very important at the end of Ramadan

Conclusions & Recommendations

(4)