Presentation on theme: "Ramadan Fasting and Diabetes Mellitus"— Presentation transcript:
1Ramadan Fasting and Diabetes Mellitus Dr. Tofail Ahmed,Associate Prof. of Endocrinology, BIRDEM
2Ramadan Fasting and Diabetes Mellitus Fasting during daytime in the month of Ramadan is an obligatory duty of all healthy adult Muslims.
3Ramadan Fasting and Diabetes Mellitus Ramadan is a lunar-based month, and its duration varies between 29 to 30 days. It’s timing changes with respect to season.Depending on the geographical location and season, duration of daily fast may range from a few to more than 20 hours.
4Ramadan Fasting and Diabetes Mellitus Some 40 – 50 million people with diabetes worldwide fast during Ramadan.
5Ramadan Fasting and Diabetes Mellitus During fasting a Muslim must abstain fromeating,drinking,use of oral medications andsmokingfrom predawn (Suhur/ shehre) to after sunset (Ifter) andhowever there is no restrictions on food or fluid from Ifter to shehre.
6Ramadan Fasting and Diabetes Mellitus The Koran specifically exempts the sick from the duty of fasting (Holy Koran, Al-Bakara, 183 –185), especially if fasting may lead to harmful consequences for the individual.
7Ramadan Fasting and Diabetes Mellitus Diabetic patients are at risk of harmful consequences due to the changes in pattern and amount of food and fluid intake during Ramadan.The harmful consequences associated with fasting areHypoglycemia,Hyperglycemia,Ketoacidosis,Dehydration and thrombosis …. but..
8Ramadan Fasting and Diabetes Mellitus Severity of the risk in an individual i.e. categorization depends on many factors such as status of diabetic control, treatment regimen, co-existing disease etc.ADA workgroup has categories risk in patients with diabetes who fast during Ramadan intoVery high risk,High risk,Moderate risk andLow risk group.
9Ramadan Fasting and Diabetes Mellitus Management guidelines are available to perform fasting by the diabetics with low and moderate risk groups.But cases with very high-risk categories need to enjoy exemption of duty of fasting.Because this exemption represents more than a simple permission not to fast; the Prophet Mohammad said, “ Allah likes his permission to be full led, as he like his will to be executed.”
10Ramadan Fasting and Diabetes Mellitus Management of diabetes during fasting should consist of Pre-Ramadan medical assessment and educational counseling.Cases eligible for fasting needs appropriate modification in diet and drugs and perform monitoring on regular basis.
11CONTINUOUS LOW LEVEL SECRETION BETWEEN MEALS & THROUGH NIGHT ( Called BASAL secretion . Rate is approximately 1 iu per hour, so in total 24 iu of insulin is secreted as basal )STIMULATED INSULIN SECRETION FOLLOWING MEALS ( PRANDIAL secretion and rate & total amount secretion is influenced by amount and composition of meals. )
12Glucose Homeostasis after food intake InsulinPancreas1KidneyFats34LiverGlucose2MuscleGlucose of gut
13Glucose Homeostasis during fasting state Glycogen from liver (kidney also) breakdown and pour into blood ‘Hepatic Glucose Output’ (HGU) (2).Insulin14Glucose25Blood glucose is consumed mainly by vital organs like brain cells, RBC, renal & gut epitheliums. These cells are not insulin dependent cells(5).
16ADA workgroup has categories risk in patients with diabetes who fast during Ramadan as follows Very high risk groupSevere hypoglycemia within the last 3 months prior to RamadanPatient with history of recurrent hypoglycemiaPatient with hypoglycemia unawarenessPatient with sustained poor glycemic controlKetosis within the last 3 months prior to RamadanType 1 DMAcute illnessHyperosmolar hyperglycemic coma within the last 3 months.Patients who performs intense physical labour.Pregnancy.Patient on dialysis.
17ADA workgroup has categories risk in patients with diabetes who fast during Ramadan as follows High risk groupPatient with moderate hyperglycemia (average blood glucose between 150 and 300 mg/dl. HbA1c 7.5 – 9.0%)Patients with renal insufficiencyPatients with advanced macrovascular complicationsPeople living alone that are treated with insulin or sulfonylureasPatients with co morbid conditions that presents additional risk factors.Old age with ill health.Drugs that may affect mentation
18ADA workgroup has categories risk in patients with diabetes who fast during Ramadan as follows Moderate risk groupWell controlled patients treated with short acting secretagogues such as repaglinide or nataglinide Low risk groupWell-controlled patients treated with diet alone, metformin or a thiazolidinedione who are otherwise healthy
19Management of diabetes during Ramadan General considerationsPre-Ramadan medical assessment and educationManagement of DM (drug therapy)
20Management of diabetes during Ramadan General considerationsSeveral individual issues deserve special attentionIndividualization: Each specific patient require his/her specific management plan. They should take Seheri (morning meal ) close to insak ( subuh) time.Frequent monitoring of glycemic status ( multiple times daily – esp. patients on insulin: 2 to 4 hours after sheheri and 1 hour prior to ifter).
21Management of diabetes during Ramadan General considerationsNutrition: In terms of calori and composition diet should remain same healthy and balanced as before Ramadan.Ingestion of large amount of foods rich in carbohydrate and fats during ifter should be avoided.A complex carbohydrate that delays in digestion and absorption is good choice for sheri and while food with more simple carbohydrate may be taken during ifter.
22Management of diabetes during Ramadan General considerationsExercise: Normal level of activity. Excessive physical activities may lead to hypoglycemia. Tarawaih prayer can be considered part of daily exercise programme.Breaking the fasting: If blood sugar goes < 3.3 mmol/L (60mg /dl) or > 16.7 mmol/L (300mg /dl). Sick days.
23Management of diabetes during Ramadan Patient on diet: No change in total calorie intake. Ensure three at least meals and adequate fluid intake .Patient on metformin: Start with single dose at meal after.Patient on glitazone: No change.Patient on sulfonylurea: Use glimiperide at ifter or rapaglinide/ netiglinide.Patient on insulin: Use prmixed or combination of analogs
24Total daily insulin (U) During Ramadan morning dose at ifter and half the evening dose at seheri ADA recommended guidelineTotal daily insulin (U)Ifter doseSeheri doseTotal201331621141722151823419242526527282930
25ConclusionFasting during Ramadan for patients with diabetes carries a risk of an assortment of complications.But a careful, individualized management plan with close follow-up can reduce the risk.There is need of population based epidemiology of diabetes and Ramadan.