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Ethnic Minorities and Religious Issues

Diabetes and Ramadan

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Background and Religious Perspective

Fasting during the holy month of Islam is an obligatory duty for all healthy adult Muslims.

Fasting in Ramadan is one of the 5 pillars of Faith in Islam.

Both the Quran (holy book of Islam) and Hadith (Practices & Sayings of Holy Prophet Mohammed – PBUH) exempt Muslims from Fasting during any illness if there is a risk to individual health but many Muslims with diabetes, despite religious and medical advice, choose to observe “Fasting” during Ramadan and therefore require medical education & support to observe Fasting as safely as possible.

Ramadan is a lunar based and its duration varies from 29 to 30 days and hence its occurrence in Calendar Year falls roughly two weeks earlier than the previous year.

Some Muslims also observe Fasting outside the month of Ramadan as well but typically it involves fasting from Dawn (preceded by a meal - SEHARI) till Sunset (breakfast meal – IFTARI)

Duration of Fasting therefore varies from few to over 20 hours depending on season and geographical location.

Due to higher prevalence ethnic minorities with Islam as religion, it is estimated over 10% of all adult with diabetes in Bedfordshire may observe Fasting (at least for some days) in Ramadan.

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Health Risks with Fasting in people with Diabetes

There is poor scientific database to evaluate true impact of fasting in people with diabetes. Much of the information is based on personal experiences and recommendations of experts. Most clinicians will recommend against fasting among people on insulin therapy especially in type 1 diabetes. Many factors adversely affect health during fasting:

Hypoglycaemia: EPIDIAR study (largest database for the effects of Fasting in diabetes) observed higher risk of hypoglycaemia with Fasting, 7.5 fold (3-14/100 patient) greater risk of severe hypoglycaemia (requiring hospitalisation) in people with type 1 diabetes and 4.7fold (0.4 to 3/100) greater risk in people with type 2 diabetes.

Hyperglycaemia: EPIDIAR study highlighted 5 fold greater incidence of severe hyperglycaemia (requiring hospitalisation) in people with type 2 diabetes and 3 fold greater risk in people with type 1 diabetes. This may partly be due to restricted periods of food consumption coupled with excessive reduction in hypoglycaemic therapy.

Diabetic Ketoacidosis: It is estimated to be particularly increased in people with type 1 diabetes but can occur in people with type 2 diabetes as well – especially those with poor glycaemic control prior to fasting.

Dehydration & Thrombosis: This is particular risk is well recognised if Fasting is observed in hot weather with longer hours of fasting associated with physically demanding out door work.

Categories of risks in patients with type 1 or type 2 diabetes who fast during Ramadan (Recommendation of ADA in 2005)

 

 

 

Very High Risk

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Severe hypoglycaemia within the last 3 months prior to Ramadan

 

 

 

 

 

 

 

 

 

 

 

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Patients with a history of recurrent hypoglycaemia

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Patients with hypoglycaemia unawareness

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Patients with sustained poor glycaemic control

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Ketoacidosis within the last 3 months prior to Ramadan

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Type 1 diabetes

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Acute illness

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Hyperosmolar hyperglycaemic coma (HONK) within the previous 3 months

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Patients who perform intense physical labour

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Pregnancy

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Patients on chronic dialysis

High Risk
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Patients with moderate hyperglycaemia (average blood glucose 15-17mmol/L HbA1c 58-75 mmol/mol)

 
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Patients with renal insufficiency

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Patients with advanced macro vascular complications

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People living alone that are treated with insulin or sulphonylureas

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Patients living alone

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Patients with co morbid conditions that present additional risk factors

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Old age with ill health

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Drugs that may affect mentation

Moderate Risk
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Well-controlled patients treated with short-acting insulin secretagogues such as repaglinide or nateglinide

 
Low Risk

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Well-controlled patients treated with diet alone, metformin, or a thiazolidinedione (glitazones) who are otherwise healthy

 
   

Reference: Recommendations for Management of Diabetes During Ramadan. Diabetes Care Vol 28 No 9 Sept 05.

 
   

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Principles of Management of Diabetes during Fasting

There are diverse cultural and ethnic variations in diet that further vary during the month of Ramadan.

Typically diet is rich in Carbohydrate & Fat.

There is also increased prayer-related physical activities and increased socialisation (Iftar parties) that also contribute to clinically significant glycaemic fluctuation hence following recommendations -

 

Individual Plan of Care is essential. This should be agreed with patient well in advance as a part of Pre-Ramadan Medical Assessment. Each agreed plan should address following key factors

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Previous glycaemic control

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Duration of diabetes and its short & long-term complications

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Other medical conditions & co-morbidities

 

Frequent glucose monitoring: This is critical in people taking hypoglycaemic medications particularly Insulin therapy.

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Best time to check routine capillary blood glucose levels are 2-3 hours before breakfast - ie Iftar and at bed time to capture lowest and highest glucose levels that should help to adjust the dose of hypoglycaemic therapy.

 

Glycaemic Targets: Safety of patients is paramount.

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Capillary Blood Glucose (CBG) levels between 5-6 mmol/L within couple of hours prior to breaking Fast (Iftar) and CBG at bedtime or within 2 hours of meals between 10-15mmol/L are pretty satisfactory.

 

Ketone Testing: Patients with type 1 diabetes should be advised to test urine for ketones if CBG levels are higher than 17mmol/L.

 

Nutrition: Principles of balanced diet are essentially same as prior to Ramadan.

 

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Weight fluctuation of >3% should be avoided during Ramadan.

 

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Avoid food rich in carbohydrates (high in sugar) and fat especially at sunset meal (Iftar). Recommend limits on the consumption of snacks (samosa, pakoras & paratha etc ) and avoidance of sweets (ladoo, jelabi, burfi etc).

 

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Encourage complex carbohydrates particularly at pre-dawn meal (Sehari).

 

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Encourage the consumption of salads and whole fresh fruits

 

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Encourage frequent fluid intake (at least 3 litres) between sunset & dawn (Iftar & Sehari)

 

Exercise: Avoid physically demanding activities in particular between the period of mid-day & sunset

 

Advice on “non scheduled breaking of the fast”: Patients should be advised to break the fast immediately if CBGs at any time during the fasting period falls outside 3.5 to 17 mmol/L.

 

Discourage Pregnant and Breast Feeding women from fasting due risk to mother & babies.

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Guidance for Modifications of Hypoglycaemic Therapy

Need for changes in modification in the dose or type of hypoglycaemic therapy should be made as a part of Pre-Ramadan Medical Assessment.

Following guidance is based on the assumption that glycaemic control is satisfactory i.e

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HbA1c < 58 mmol/mo prior to Ramadan

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Absence of moderate to marked fluctuation of CBGs.

Principles are the same for both type 1 & type 2 diabetes (Many patients with type 1 diabetes also take Metformin)

Long acting hypoglycaemic agents such as Glibenclemide be changed to short acting agents such as Repaglinide or alternative agents such as DPP4 inhibitors during the pre-Ramadan assessment.

As a rule, all hypoglycaemic agents if used in TDS frequency should be reduced to BD frequency by omitting usual lunch dose. However part (1/3 or ½) of this can be taken at supper time in individuals who continue to run CBGs higher than 15 mmo/L after few days of fasting.

Following advice can only be effective if CBGs are monitored more frequently for the first few fasting days of Fasting so the dosages of hypoglycaemic therapy can be safely re-adjusted.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Usual Medication AM (Sehari)   PM (Iftar)  
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Metformin bd

Omit if usual morning/lunch dose is 500mg
Reduce to 500mg if usual dose >500mg

 

Usual evening dose after Iftar (max. 1000mg)

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Metformin tds

Omit if usual morning dose is 500mg
Redu
ce up to 50% if dose >500mg daily.

 

Usual lunch & evening dose be taken after Iftar (max. 1000mg)

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Glucophage SR either
once or twice daily

Nil

 

Reduce usual dose by  500mg taken after Iftar (max.1500mg)

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Repaglinide
or Nateglinide

Reduce usual morning dose to 50% or Nil if food in take less than usual breakfast

 

Full usual evening dose soon after Iftar.
Additional ½ of usual evening  dose at bed time CBG >12.

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Pioglitazone

 

 

Take full dose after Iftar

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Gliclazide bd

Reduce usual morning dose by ½

 

Usual evening after Iftar.
Additional ½ of evening dose at bed time if CBG > 12

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Gliclazide MR* or Glimepiride*

Nil

 

½ of usual dose after Iftar.

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GLP1 agonist or DPP4 inhibitors

Usual dose

 

Usual dose after Iftar

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Basal Insulin OD

2/3 of total daily dose (if part of OD regime taken in the morning)

 

2/3 of total daily dose (if part of OD regime taken in the evening/night)

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Glibenclamide^

Replace with Repaglinide or DPP4 inhibitors preferably at Pre-Ramadan Assessment

 

Replace with Repaglinide during Pre-Ramadan assessment)

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Basal insulin BD

½ of morning dose   ½ of evening dose

Biphasic Mixtures
Novo Mix 30
Humalog Mix 25
Humalog Mix 50
Insuman Comb 15, 25 or 50

Ό of morning dose

 

½ of evening dose

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Basal Bolus Regime

If CHO counting give insulin according to CHO intake. If fixed dose see right 

 

½ of usual morning dose of bolus quick acting  insulin

 

 

1) Normal basal (long acting) insulin for Type 1. For Type 2 use ½ normal basal dose.

2) Usual bolus insulin (quick acting) evening dose after Iftar
Additional ½ of Iftar bolus insulin dose at bed time if CBG > 15

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* Replace with Repaglinide or DPP4 inhibittors if marked fluctuation, high post-parandial >15 mmol/L & < 4 pre meals

^ High risk of severe hypoglycaemia hence replace with Repaglinide

Repaglinide 4mg is equal to 5mg of Glibenclemide, 1mg Glemepiride or 30mg Diamicron MR

 

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Useful External Links & Resources

PDF File

Medication Guidance for Ramadan

 
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