1. Dr, I have Diabetes, Can I fast?
Dr Majedah AbdulRasoul
Assistant Professor
Pediatric Department Faculty of Medicine
Kuwait University

2. 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

3. 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.

4. Ramadan
“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”
Surrah AlBaqara 2: 183

5. 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.

6. 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

7. Exception from fasting
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

8. 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

9. Back to Basics: CHO Carbohydrate metabolism in healthy persons:
Most of the studies show slight decrease in serum glucose to 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 gluconeogenesis
Decrease glycogenesis
DeGroot and Jameason 2004
Am J Med 200; 199: 341

11. 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: 351
Saudi Med J 1986; 7: Eur J Clin Nutr 2000; 54:508

12. What happens in Diabetics

14. 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: Ann Saudi Med 1994; 14:139
*BMJ,2010; 340: BMJ 1993; 307: 292

15. So, Can patients with Diabetes Fast?

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

17. Type 1 Diabetes?
No Fasting

18. Your views?

19. 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?

20. 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

21. 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

22. 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

23. Risks associated with fasting in T1DM
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.**
*Diabetes Care 2004; 27:2306
** Abusrewil et al 2003 Jamahiriya Med J; 2:99

24. 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

25. 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

26. Risk Categories for Fasting Ramadan In Diabetics: High Risk
Moderate hyperglycemia: Average BG , 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

27. 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.

28. 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?

29. 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.

30. 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

31. 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

32. 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 &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

33. 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

34. AlKhawari etal 2010; Pediatr Diabetes

35. AlKhawari etal 2010; Pediatr Diabetes

36. AlKhawari etal 2010; Pediatr Diabetes

37. AlKhawari etal 2010; Pediatr Diabetes

38. 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

39. Fasting in T1DM on MDI
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

40. 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
Kadiri et al 2010

41. 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

42. 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?

43. Your recommendations:
No fasting for patients with type 1 diabetes.
But:
On CSII
On CGMS
Excellent glycemic control
I may allow her to fast

44. What does the literature say?
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
Benbaraka et al 2010; Diabetes Technol Ther 12(4)

45. Results: Days fasting: 50% decreased their basal by 5-50%
61.2% fasted the whole month with no problems
18.4% fasted 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 =0.007
Benbaraka et al 2010; Diabetes Technol Ther 12(4)

46. 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)

47. What does the literature say?
(2)
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
Khalil et al 2012; Diabetes Technol Ther 14(9)

48. 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)

49. 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)

50. 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.

51. Conclusions & Recommendations (2)
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

52. Conclusions & Recommendations (3)
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.

53. Conclusions & Recommendations (4)
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