Authors: Fauzia Mohsin  ( Department of Paediatrics, BIRDEM General Hospital and Ibrahim Medical College, Dhaka, Bangladesh. )
Kishwar Azad  ( Department of Paediatrics, BIRDEM General Hospital and Ibrahim Medical College, Dhaka, Bangladesh. )
Bedowra Zabeen  ( Changing Diabetes in Children (CDiC), BIRDEM General Hospital, Dhaka, Bangladesh. )
Samin Tayyeb  ( Changing Diabetes in Children (CDiC), BIRDEM General Hospital, Dhaka, Bangladesh. )
Abdul Baki  ( Department of Paediatrics, BIRDEM General Hospital and Ibrahim Medical College, Dhaka, Bangladesh. )
Nazmun Nahar  ( Department of Paediatrics, BIRDEM General Hospital and Ibrahim Medical College, Dhaka, Bangladesh. )

Fasting during the holy month of Ramadan is obligatory for all healthy adult and adolescent Muslims from the age of 12 years. This involves abstaining from eating or drinking from early dawn (Suhur/Sehri) till sunset (Iftar).Fasting is not meant to create excessive hardships or impart any adverse effect to the Muslim individual. As such, Islam has exempted certain categories of people from fasting including young children, travelers, the sick, the elderly,and pregnant and lactating women. According to expert opinion, people with type 1 diabetes who fast during Ramadan are at very high risk of metabolic deterioration. However, some recent studies have demonstrated that individuals with type 1 diabetes who are otherwise healthy and stable, can fast during Ramadan provided they comply with the Ramadan focused management plan and are under close professional supervision. This article discusses how to assess, counsel, monitor and manage people with type 1 diabetes who wish to fast during Ramadan.
Keywords: Ramadan, fasting, Type 1diabetes.


Introduction

Fasting during the holy month of Ramadan, one of the five pillars of Islam, is obligatory for all healthy adult and adolescent Muslims from the age of 12 years. The month has huge spiritual implications and is an opportunity to purify ourselves. Along with refraining from all sorts of sins and misdeeds, one has to abstain from eating or drinking from early dawn (Suhur/Sehri) till sunset (Iftar) each day-approximately 11-20 hours, depending on the geographic location and season for 28-30 days. The large population based EPIDIAR (Epidemiology of Diabetes and Ramadan) study conducted among 12,243 people with diabetes from 13 Islamic countries reported that, 42.8% of type 1 and 78.7% of type 2 diabetics fasted for at least 15 days during the month of Ramadan.¹ Fasting is not meant to create excessive hardship or impart any adverse affect to the Muslim individual and as such Islam has exempted certain categories of people from fasting, including young children, travelers, the sick, the elderly, pregnant and lactating women. Many patients with diabetes, specially many of the type 1 diabetics might fall into these categories. Nevertheless, many patients with type 1 diabetes (T1DM) insist on fasting during Ramadan, thereby creating a challenge for themselves and their health care providers. This article discusses how to assess, counsel, monitor and manage people with type 1 diabetes who wish to fast during Ramadan.
Risks associated with fasting in patients with diabetes
The extensive EPIDIAR study showed 4.7-fold increased risk of severe hypoglycaemia and an approximate 3 fold increase in the incidence of severe hyperglycaemia with or without ketoacidosis in patients with type 1diabetes during the month of Ramadan.¹ Table-1 shows major risks associated with fasting in patients with diabetes.


Table-1: Major risks associated with fasting in patients with diabetes.

Hypoglycaemia
Hyperglycaemia
Diabetic Ketoacidosis
Dehydration and thrombosis

Risk stratification

Physicians working in Muslim countries commonly face difficulty in advising people with diabetes on the safety of fasting. According to expert guideline following are the patients who are in very high risk group and high risk group who fast during Ramadan:^2,3

Very high risk group:

Severe hypoglycaemia within the three months prior to Ramadan
A history of recurrent hypoglycaemia
Hypoglycaemia unawareness
Sustained poor glycaemic control
Ketoacidosis within the 3 months prior to Ramadan
Type 1 diabetes mellitus
Acute illness
Hyperosmolar hyperglycaemic coma within the previous 3 months
Performing intense physical labour
Pregnancy
Chronic dialysis

High risk group:

Moderate hyperglycaemia
Renal insufficiency
Advanced macrovascular complications
Patient living alone and treated with insulin

Aged people with ill health

Patients receiving treatment with drugs that may affect mentation
Fasting is a spiritual issue for which patients make their own decision after receiving appropriate advice from religious teachings and from health care providers but it has been emphasized that all brittle type 1 diabetic patients should be strongly advised not to fast. Fasting at Ramadan carries a very high risk of adverse effect for people with type 1 diabetes. This is further exacerbated if they have any of the above mentioned risk factors. In addition, the risk is also very high in patients who have limited access to medical supervision and those who do not comply with medical advice.

Can people with type 1 diabetes fast during Ramadan?

Many people with type 1 diabetes wish to observe fasts in Ramadan. The potential risks and the risk stratification in diabetic patients who fast during Ramadan have already been described. During the past few decades, there have been studies on Ramadan fasting in patients with type 1 diabetes. Some recent studies have demonstrated that with proper education, appropriate adjustment of insulin, diet and daily activities, type 1 diabetes patients, including adolescents with type 1 diabetes, can fast during Ramadan, provided they do regular self-monitoring and are under close professional supervision.^4-10 This is only applicable to patients who are otherwise healthy and stable. In most of those studies, there were no significant short term parameter changes (eg. body weight, HbA1c, fasting lipid profile) and major complications like severe hypoglycaemia, DKA. The Clinical trials of Ramadan fasting in patients with type 1 diabetes are described in brief in Table-2.


Table-3 provides pragmatic guidance as to how risk stratification can be done in people with type 1 diabetes.
Type 1 diabetics who wish to fast during Ramadan and do not have the aforementioned criteria, who are otherwise healthy and stable, comply well with medical advice and under close medical supervision can be allowed to fast.

Recommendations

Health care providers commonly face the difficulty in advising patients with diabetes on dietary, drug regimens and overall care during the month of Ramadan.
Following recommendations are made for type 1 diabetics who wish to fast during Ramadan:^2,11

A. Organizational issues:

The management of diabetes during Ramadan fasting should be considered well in advance of the holy month. Diabetes care providers should have comprehensive strategy as well as clear understanding of the religious ruling on fasting to give their advice with confidence. Leaflets, posters, booklets etc containing information and advice about Ramadan fasting should be available for patients well before the start of Ramadan.

B. Individualization:

Management plan must be individualized for each patient according to need.

C. Pre-Ramadan Medical Assessment:

This should be undertaken 1-2 months before the fasting month starts.
1. Physical status, weight, blood pressure, glycaemic and lipid control should be assessed.
3. Patient should be assessed for acute and chronic complications, and individual risk stratification should be done.

D. Ramadan focused Patient Education:

Patients with type 1 diabetes who are fit for fasting and wish to fast should receive education regarding the following:
1. Self monitoring of blood glucose at home.
2. Focus on the causation, early recognition and emergency management of hypoglycaemia, hyperglycaemia, dehydration and impending DKA.
3. Meal planning and dietary advice.
4. Timing and intensity of physical activity.
5. Adherence to therapy.

E. Diet and nutrition:

1. People should maintain a healthy and balanced diet during Ramadan. Ingestion of large amount of foods rich in carbohydrate and fat, specially during Iftar should be avoided.
2. Meal at Suhur should contain complex carbohydrate (eg. rice, chapati) that delays digestion and absorption which should be taken as late as possible.
3. Inclusion of fruits, vegetables, lentils, yogurt, whole cereal made food items.
4. Fluid intake (sugar free) should be increased at Iftar and during nonfasting hours.

F. Exercise and physical activity:

1. Normal level of physical activity should be maintained.
2. Rigorous exercise during fasting hours should be avoided.
3. Tarawih prayer can be considered as part of daily exercise programme.

G. Checking glycaemic status:

1. Checking blood glucose through finger prick does not invalidate fasting state. Frequent home blood glucose monitoring should be performed to adjust the insulin dose and prevent any hypoglycaemia and postprandial hyperglycaemia.
2. Urine should be checked for ketones if blood glucose is high (>270 mg/dl).

H. Breaking the fasting:

1. Patient should break the fast if blood sugar level is low (300 mg/dl.
2. Patient should avoid fasting on sick days.

I. Insulin regimens for Type 1 diabetic patients:

It is fundamental to adjust the insulin regimen for good glycaemic control during Ramadan fasting. Use of insulin lispro instead of soluble insulin as the short-acting component has shown to reduce hypoglycaemia and improve postprandial glycaemic excursions.⁹ Insulin aspart can also be recommended for this purpose. Use of long-acting synthetic analogue (e.g. insulin glargine or insulin detemir), in basal-bolus regimen has been recommended as they are less likely to cause hypoglycaemia.² Fasting at Ramadan may also be successfully accomplished in people with Type1 diabetes if they are fully educated and familiar with the use of insulin pump and are otherwise metabolically stable and free from any acute illness. Most will need to reduce their basal infusion rate while increasing the bolus doses to cover the predawn and sunset meals.² Following insulin therapy methods have been studied successfully (Table-4):



Novel Insulin Therapy

Insulin degludec has recently been introduced in many Islamic countries, including Bangladesh and India. It is an ultra long acting basal insulin used in adults with type1 or type 2 diabetes and has shown to reduce nocturnal hypoglycaemia in adult type 1 diabetics.¹³ To know whether Insulin degludec and insulin deglutec aspart are potentially safe options for use in adult type 1 diabetics who wish to observe Ramadan fast needs further studies.

Conclusion

It is crucial that a patient\'s decision to fast be made after thorough consultation and assessment by the physician concerning the risks involved. According to expert opinion, type 1 diabetics who fast during Ramadan are at very high risk of metabolic deterioration. However, some recent studies have demonstrated that type 1 diabetics who are otherwise healthy and stable, can fast during Ramadan provided they comply with the Ramadan focused management plan and are under close professional supervision. The strategies to ensure safety of type1diabetics who are planning to fast include: Ramadan focused medical education, pre-Ramadan medical assessment, following a healthy diet and physical activity pattern, modification in insulin regimen and blood glucose monitoring as advised by the physician.


References

1. Salti I, Benard E, Detourney B, Bianchi-Biscay M, Le Brigand C, Voinet C, et al. A population based study of diabetes and its characteristics during the fasting month of Ramadan in 13 countries: results of epidemiology of diabetes and Ramadan. 1422/2001 (EPIDAR) study. Diabetes Care 2004; 27: 2306-2311.
2. Al-Arouj M, Assaad-Khalil S, Buse J, Fahdil I, Fahmy M, Hafez S. et al. Recommendations for management of diabetes during Ramadan, Update 2010,Diabetes Care 2010; 33: 1895-1902.
3. Hassanein MM. Diabetes and Ramadan-how to achieve a safer fast for Muslims with diabetes.Br J Diabetes Vasc Dis 2010; 10: 246-50.
4. Zabeen B, Tayyeb S, Benargee B, Baki A, Nahar J, Mohsin F, et al. Fasting during Ramadan in adolescents with diabetes. Indian J Endocrinol Metab 2014; 18: 44-47.
5. Al-Khawari M, Al-Ruwayeh A, Al-Doub K, Allgrove J. Adolescents on basal-bolus insulin can fast during Ramadan. Pediatr Diabetes 2010; 11: 96-100.
6. AlAlwan I, Banyan AA. Effects of Ramadan fasting on children with type 1 diabetes. Int J Diabetes Melit 2010; 2: 127-9.
7. Khairulah W, Merheb M,Filti F,Azar S.Ramadan fasting in type-1 diabetics.LMJ 2008; 56: 48.
8. Kassem HS, Zantout MS, Azar ST. Insulin therapy during Ramadan fast for type1 diabetes patients.J Endocrinol Invest 2005;28:802-5.
9. Kadiri A ,Al-Nakhi A, El-Ghazali S, Jabbar A, Al Arouj M, Akram J,et al. Treatment of type 1 diabetes with insulin lispro during Ramadan. Diabetes Metab 2001; 27: 482-6.
10. Salman H, Abdullah M.A, Abanamy M.A, Al Howasi M. Ramadan fasting in diabetic children in Riyadh. Diabet Med 1992; 9: 583-84.
11. Ibrahim MA. Managing diabetes during Ramadan. Diabetes Voice 2007; 52: 19-22.
12. Beshyah SA, Benbarka MM, Sherif IH. Practical management of diabetes during Ramadan fast. Libyan J Med 2007;2:185-9.
13. Mathieu C, Hollander P, Miranda-Palma B, Cooper J, Franek E, Russel-Jones D ,et al. Efficacy and safety of insulin deglutec in a flexible dosing regimen vs insulin glargine in patients with type 1 diabetes (BEGIN: Flex T1): A 26-Week Randomized, Treat-to Target Trial With a 26-Week Extension. J Clin Endocrinol Metab 2013; 98: 1154-62.