Presentation on theme: "Dr, I have Diabetes, Can I fast?"— Presentation transcript:
1Dr, I have Diabetes, Can I fast? Dr Majedah AbdulRasoulAssistant ProfessorPediatric Department Faculty of MedicineKuwait University
2Learning OutcomesUnderstand what happens in diabetics and non- diabetics during fastingImprove knowledge and understand “ safe fast” during RamadanBe able to empower patients to make the right decision to avoid risks associated with fasting during Ramadan
3Muslims 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.
4Ramadan“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
5Ramadan The 9th months of the Islamic calendar Fasting in Ramadan is one of the 5 main pillars of IslamComplete fasting during daylight hours for one full Lunar month (29-30days) , for up to 20 hours depending on the geographical location.
6Exception 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
7Exception from fasting Illness – ChronicDiabetesThose who can not understand the purpose of fasting- mentally challengedFrail elderlyTravelersWomen during menstruation, pregnancy, lactationPre-pubertal children
8Exception from fasting Many patients with diabetes insist on fasting during Ramadan, thereby creating a medical challenge for themselves and their healthcare providersIt is important that medical professionals be aware of potential risks associated with fasting during Ramadan and approaches to decrease those risksA 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
9Back 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 fastingThis may vary depending on:Food habitsDifferences in metabolismDifferences in energy regulationThe fall in glucose cease due to:Serum insulin decrease Increase glycogenlysisSerum glucagon and GH increase Increase gluconeogenesisDecrease glycogenesisDeGroot and Jameason 2004Am J Med 200; 199: 341
11Back to Basics: Lipids Variable results Serum total cholesterol and triglycerides may decrease in the first days of fasting, then rise to pre fasting levelsIncrease in HDL-CEffect 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: Eur J Clin Nutr 2000; 54:508
14Most studies are in Type 2 Blood glucose variation in patients with diabetesIt may fall, nit change, or riseThe variation is due to the amount and type of food consumed and/or decreased physical activityHbA1c 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
19Case 1 18 yrs old teenager Type 1 diabetes since the age of 12yrs On NPH and ActrapidBecause he can not get LantusTesting his blood glucose at home 2-3 times per dayMean 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?
20Your recommendations: No fasting for patients with type 1 diabetes.More so if:Poor controlOn NPHComing close to RamadanHave high risk for hyperglycemia, DKA, and hypoglycemia
21Risks associated with fasting in T1DM Hypoglycemia:2-4% of mortality in patients with T1DMMore with hypoglycemia unawareness, poor glycemic control and recurrent hypoglycemia in the past needing hospitalizationEPIDIAR study:4.7- fold increase in severe hypoglycemia ( needing hospitalization) in patients with T1DM3-14 events /100 people/monthDiabetes Care 2004; 27:2306
22Risks 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 changeEPIDIAR 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
23Risks 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 dehydrationDose reduction in response to acute infectionHowever, it remains non-conclusive1.8% 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
24Risks associated with fasting in T1DM Dehydration and thrombosis:Increased incidence of retinal vein occlusionHowever, coronary artery events or stoke were not increased in RamadanLimitation of fluid intake can lead to dehydrationHot and humid climates increase the riskAlso, hyperglycemia osmotic diuresis fluid and electrolyte imbalance
25Risk Categories for Fasting Ramadan In Diabetics: Very High Risk T1DMSevere Hypos within the last 3 monthsHistory of recurrent hyposHypo unawarenessAcute illnessChronic DialysisSustained poor controlDKA within the last 3 monthsPregnancyHyperosmolar hyperglycemic coma in the last 3 monthsIntensive physical labor
26Risk Categories for Fasting Ramadan In Diabetics: High Risk Moderate hyperglycemia: Average BG , HbA1c 7.5-9%Renal InsufficiencyLiving aloneDrugs affecting mentationAdvanced marcovascular complicationsCo-morbid conditions aggravating the aboveOld age with ill health
27Risk Categories for Fasting Ramadan In Diabetics: Mod / Low Moderate RiskWell controlled treated with short acting insulin, secretagoguesLow RiskWell controlled diabetes treated with lifestyle modification, metformin, acarbose, TZD.
28Case 2 13 yrs old boy Type 1 diabetes since the age of 5 yrs On MDI Glargine and Novorapid 4-5 timesTesting his blood glucose at home 4-6 times per dayMean HbA1c this year improved from 8.5% to 7.1%This year he wanted to fast for the first timeHe came to you in Rajab with his desire to fastWhat will you do?
29Your 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 diagnosisHave younger siblings who fastFriends who fastIf they did not bring the issue of fasting, you should.
30General consideration: Assess physical well beingWeight on the 50th centile – was 25-50th last yrHeight of the 75th centile – same centile for yrsAssessment of metabolic controlHBGM 4-6 per dayFasting 5-8mmol/L, occasional 9mmol/LBed time 10mmol/L1-2 hypos (at school) over the last month, managed by juiceNo admission for DKA since the last 3 yrs
31Your Opinion Now? Your recommendation : No Fasting If despite recommendation he decide to fast:Discuss s/s of low blood sugarReview management of hypoglycemiaCheck if they have glucagonReview diet routine with dieticianCheck blood sugar 4-6 per dayBreak the fast of blood glucose less than 4mmol/LBreak 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 bolusSee after 1 week in Ramadan
32What does the literature say? A study on 20 patients on MDImean age of 12.4 yrs (fasting), 10.5 yr (not fasting)Fasting was for 12.5 hoursChange in weight, HbA1c, lipid profile before anf after RamadanResults:No statistical difference in HbA1c (9,2 &9.4% vs &10%, p=0.9), weight or fasting lipidsNo patient called the helpline and none had intercurrent illness or ketosisAlAlwan etal 2010; Int J Diabetes Mellitus
33What does the literature say? A study on 28 patients ( Amiri Hosp, & Royal London Hospital)Ages: 9-18 yrPoorly 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 DKANo of fasting daysAlKhawari etal 2010; Pediatr Diabetes
38Conclusions and recommendations: Adolescents on basal-Bolus regimen can fast if they wish toThey should receive sufficient education prior to fastingIncrease HBGMCHO countReduce basal by 10-20%, more if had hypoglycemiaIf blood Glucose 15 correction givenBreak fast if:Develop ketonesBG < 4mmolAvoid skipping pre-dawn meal
39Fasting in T1DM on MDIA 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, 2004A 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 hypoglycemiaKadiri et al. Diabetes Metab 2001
40Fasting in T1DM on MDIInsulin 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 slidesKadiri et al 2010
41Can a patient monitor blood sugar while fasting? Patients should monitor their blood glucose during fast to recognize subclinical hypo and hyperglycemiaIslam allows diabetics to have regular blood tests while fasingIf blood glucose drops below 4 mmol/L (some recommend 3.5) the fats must be brokenIf blood glucose goes above 16.5 mmol/L, ketones should be checked, and medical advice sought
42Case 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?
43Your recommendations: No fasting for patients with type 1 diabetes.But:On CSIIOn CGMSExcellent glycemic controlI may allow her to fast
44What does the literature say? 63 patients, aged 22+/-7 yrs, had diabetes for 9.8+/-5.6 yrsOn Medtronic MiniMed 722 for 20+/- 10 monthsOutcome measures:Days fastingHypoglycemiaHyperglycemiaEmergency visits to the ERBenbaraka et al 2010; Diabetes Technol Ther 12(4)
45Results: Days fasting: 50% decreased their basal by 5-50% 61.2% fasted the whole month with no problems18.4% fasted days16.3% fasted 24-25%4.1% fasted 23 days50% decreased their basal by 5-50%27% had hypoglycemia break the fastFasting was broken in 3.8% of potential fasting daysNo severe hypoglycemiaUnusual hyperglycemia in 18.4%, one needed hospital visit12 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)
46Conclusions:Fasting Ramadan is feasible in patients with T1DM on SCII with adequate counselling and supportBenbaraka et al 2010; Diabetes Technol Ther 12(4)
47What 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 weightHbA1cBlood glucoseTotal insulin doseOverriding tendenciesSuspend time during fastHypoglycemiaKhalil et al 2012; Diabetes Technol Ther 14(9)
48Results: Days fasting: Median days 29Basal insulin was decreased by 5-20%, no overall sig.Redistribution of insulin based on daily lifestyle and eating timesNo major hypoglycemiaMild hypoglycemia in 8.4%, managed by basal adjustment or suspension of pumpKhalil et al 2012; Diabetes Technol Ther 14(9)
49Conclusions:The use of CGMS add advantage on CSII in type 1 diabetic patients choosing to fast in RamadanKhalil et al 2012; Diabetes Technol Ther 14(9)
50Conclusions & Recommendations (1) Patients with T1DM are excepted from fasting during RamadanThose who insist on fasting need to be aware of the associated risksThey should adhere to the recommendation of of the healthcare providers to achieve a safe fast.
51Conclusions & Recommendations (2) Patients should maintain their strict diabetes routines, as social functions during Ramadan are frequent and food is plentyAll 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 glucagonDoses of insulin should not be omitted, may be reduced based on CHO counting and amount of food
52Conclusions & Recommendations (3) Gentle physical activity should be encouragedOver-eating after breaking the fast is to be avoided, specially sweat drinksIf hypoglycemia ( <4 mmol if the first few hrs of fasting or <3.3 after that time breaking fast is mandatoryIf Hyperglycemia (> 15 mmol) or ketosis develop, breaking fast is mandatory. Temptation to preserve fasting till the end is to be discouraged.
53Conclusions & 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