Highlights of the Literature
The emerging themes from the literature review are listed in [Table 1]. They covered physiology and nutrition, risk stratification, education and lifestyle,
antidiabetic medications, diabetes technology, fasting with diabetes in special circumstances,
RF in the COVID-19 pandemic, and, finally, cultural, professional, and advocacy. The
contents of these articles will be presented briefly in the following sections.
Table 1
The themes covered in the research on diabetes and Ramadan in 2023
|
Physiological and nutritional changes during Ramadan fasting
|
|
Validation and utilization of the IDF-DaR risk stratification scale
|
|
The role of Ramadan-focused education and lifestyle modification
|
|
Newer data on pharmacological therapy during Ramadan (insulins, SGLT2 inhibitors,
etc.)
|
|
The impact of diabetes technology on enabling safe fasting with reduced complications
|
|
Ramadan fasting and diabetes in special groups: diabetes in pregnancy, adolescents, and older adults
|
|
Complications: diabetic ketoacidosis and hypoglycemia, renal disease, cardiovascular disease, and
mental health
|
|
The interplay between diabetes, Ramadan, and COVID-19 infection
|
|
Some cultural, professional, and advocacy perspectives
|
|
IDF-Dar: International diabetes Federation-Diabetes and Ramadan international Alliance
|
Physiology and Nutrition
Several factors, including health status, and diet, influence fasting blood glucose
(FBG). Some studies have reported a beneficial effect of RF on PWD. However, clinical
observations have shown that glycemic deterioration can be exacerbated in some patients.
In 2023, three studies addressed glucose homeostasis; one investigated lipid metabolism,
and the other evaluated changes in osmolality.
A cross-sectional study investigated the influence of RF on FBG levels by identifying
factors associated with variations in FBG levels during RF among PWD. They monitored
the FBG levels of 181 patients with type 2 diabetes (T2D) over 2 months, representing
the Islamic lunar months of Shaban (8th month) and Ramadan (9th month).[9] Based on their findings, PWD was classified into three groups depending on the influence
of RF on FBG levels: the positively affected group (44%) with lowering in average
FBG levels; the neutral group (24%) with no change in the average FBG levels; and
the negatively affected group (32%), whose average FBG levels increased during Ramadan
compared to the previous month. Furthermore, they found that the positive effect of
RF was more frequent among patients with obesity, nongeriatric, and male patients
with diabetes. In contrast, the negative effect of RF was more frequent among patients
who were not adhering to their medications. They concluded that RF affects FBG levels
differently among PWDs. More studies are needed to identify the factors associated
with interindividual variation in the response to RF and those who are suitable candidates
for RF. In a different study, the effect of RF on interstitial glucose control and
variability before, during, and after Ramadan in T2D patients receiving insulin therapy
was investigated.[10] Participants received a flash glucose monitoring (FGM) system 1 week before Ramadan
that was removed on the sixth or seventh day of Ramadan (pre- and early Ramadan periods)
and a second FGM system 1 week before the end of Ramadan that was removed 1 week after
the end of Ramadan (late and post-Ramadan periods). Fasting blood samples were collected
during the pre-, early, and late Ramadan study visits and tested for glycosylated
hemoglobin (HbA1c), serum creatinine, and plasma glucose levels. Thirty-four patients
were prospectively included. The standard deviation and coefficient of variation of
glucose concentrations were higher in the early Ramadan period than in the pre-Ramadan
period. Still, they were similar in the late or post-Ramadan periods. Changes in the
early Ramadan period were restricted to males and patients younger than 55 years.
No significant changes were observed in the average glucose level, glucose management
indicator, time in range (TIR), time in hyperglycemia, or time in hypoglycemia at
any time. RF in patients with insulin-treated T2D was associated with an initial increase
in glucose variability that quickly returned to pre-Ramadan levels. RF was not associated
with any significant changes in glycemic control measures. Sibarani[11] aimed to ascertain how serum lipid parameters were affected by RF. The study prospectively
evaluated 19 patients with T2D during Ramadan who were not on statin therapy and had
an average age of 57.2 years. At the end of RF, apolipoprotein B levels increased,
and both small, dense low-density lipoprotein (LDL) size and mean body weight (BW)
decreased. However, no changes were noted in the serum LDL cholesterol, high-density
lipoprotein (HDL) cholesterol, and triglyceride levels. Keskinler et al[12] studied the changes in osmolarity levels due to fasting in Ramadan among 52 T2D
patients (22 females and 30 males), including fasting and nonfasting patients. The
mean levels of morning serum osmolality were not different between the fasting and
nonfasting groups. There was no difference in the nonfasting group between the morning
and evening levels, whereas with fasting, evening serum osmolality was significantly
lower than morning serum osmolality. Use of sodium-glucose cotransporter 2 (SGLT2)
inhibitors was not associated with any biochemical signs of dehydration during fasting,
and there was no significant difference between morning and evening serum osmolality.
Furthermore, Elmajnoun et al[13] performed a systematic review and meta-analysis to investigate the impact of RF
on glycemic control in patients with T2D in relevant studies (January 2000–December
2021). Observational studies that examined the changes in BW and glucose parameters
(HbA1c and FBG) before and after RF among different age groups with T2D were included
in the systemic review and meta-analysis. Effect sizes for the tested outcomes were
calculated as weighted mean difference (WMD). Quality assessment was examined using
the National Heart, Lung, and Blood Institute (NHLBI) tool. Of the 1,592 identified
records, 12 studies conducted in the Middle Eastern and Asian countries were eligible
and included in the quantitative analyses. The quality of the retrieved studies was
evaluated and found to range between fair (83%) and good (17%). These 12 studies included
5,554 participants, of whom 54% were males and 46% were females. Their pooled analysis
demonstrated that the HbA1c and FBG levels significantly decreased after RF when compared
to the prefasting levels. However, the difference in BW in fasting patients after
RF versus the prefasting stage was nonsignificant. Although young patients with T2D
were enrolled in the 12 selected studies, the investigators did not find any studies
that solely focused on this group. The impact of RF on adults with T2D was associated
with favorable outcomes. However, future studies should evaluate data from young adults
separately. In addition, it is essential to identify the effects of the number of
fasting days (level of exposure), diet, level of physical activity, and sleeping patterns
on optimal glycemic control. Medical professionals could utilize this information
as a nonpharmacological therapeutic method for managing diabetes in patients willing
to practice fasting during Ramadan and other months of the year.
Risk Stratification
Several studies in 2023 evaluated the potential challenges and values of using the
2021 IDF-DAR (International Diabetes Federation-Diabetes and Ramadan Alliance) risk
stratification tool ([Table 2]).[14]
[15]
[16]
[17]
[18]
Table 2
Summary of the recent studies on IDF-DaR risk stratification scoring system
|
Study
|
Population
|
Study design
|
Outcome measures
|
Conclusions
|
|
Mohammed et al[14]
|
659 patients who intended to fast in Ramadan; 98.2% participated; 91.5% with T2D and
8.5% with T1D
|
A prospective, study before and after RF (2021)
|
To explore the ability of the new IDF-DaR risk stratification tool
|
The tool reliably predicts the ability to fast during Ramadan and the likelihood of
hypoglycemia or hyperglycemia
|
|
Afandi et al[15] (multicountry)
|
Established physician with experience in managing diabetes in RF
|
A survey with 26 clinical scenarios
|
Physicians' variation in risk stratification.
|
A wide variation in evaluating patients' risk, particularly in moderate-risk cases
|
|
Noor et al[16] (Sudan)
|
300 individuals with diabetes (79% have T2D) from diabetes centers in Sudan
|
A cross-sectional hospital-based study
|
Risk score and its relationship with sex, type, and duration of diabetes
|
Most patients have a high risk of fasting during Ramadan. An IDF-DAR risk score is
significant in assessing individuals with diabetes for RF
|
|
Kamrul-Hasan et al[17] (Bangladesh)
|
1,328 adults with T2D
|
A prospective study in the peri-Ramadan period of 2022
|
Categorization by IDF-DAR risk stratification tool, risk-based counseling, patient
practice, and outcomes
|
The new IDF-DAR risk scoring system seems conservative in the risk categorization
of T2D patients in predicting complications
|
|
Shaltout et al[18] (Egypt)
|
Not applicable
|
Consensus development
|
Risk assessment scoring
|
The risk is based on several factors (DM type, presence, severity of complications,
fasting hours, socioeconomic factors)
|
Abbreviations: AHCL, advanced hybrid closed-loop; DM, diabetes mellitus; IDF-DaR,
International Diabetes Federation-Diabetes and Ramadan International Alliance; RF,
Ramadan fasting; SGLT2i, sodium-glucose cotransporter 2 inhibitor;; T1D, type 1 diabetes;
T2D, type 2 diabetes.
The original creators of the tool investigated its validity using two different approaches.
In the first study, they performed a prospective, survey-based study before and after
Ramadan (2021) to explore the ability of the new IDF-DAR risk stratification tool
to predict the probability of fasting and complications risk.[14] A total of 659 participants had a pre-Ramadan assessment; 647 (98.2%) answered the
post-Ramadan follow-up questionnaire. The mean age was 53.5 years and 47.9% were females.
Six hundred and three patients (91.5%) had T2D, while 56 patients (8.5%) had type
1 diabetes (T1D). Using the IDF-DAR risk tool pre-Ramadan, 51.4% were categorized
as low risk, 26.3% as moderate risk, and 22.3% as high risk. The percentage of patients
who fasted the full 30 days constituted 94.3, 81.1, and 76.9% in the low-, moderate-,
and high-risk groups, respectively (p < 0.0001). Any hypoglycemia was reported in the low-, moderate-, and high-risk groups,
and severe hypoglycemia was reported by 2.1% patients in the high-risk group, 3 (1.8%)
patients in the moderate-risk group, and none (0%) in the low-risk group. Hyperglycemia
(>250 mg/dL) was reported in the low-, moderate-, and high-risk groups by 2.7, 13.0,
and 23.8% patients, respectively. The investigators concluded that the IDF-DAR risk
assessment tool reliably predicted both the ability to fast during Ramadan and the
likelihood of hypoglycemia or hyperglycemia. A second approach to determining the
validity of the risk score examined the variability among physicians in risk stratification
for PWD during RF.[15] A twenty-six clinical scenario questionnaire was developed. Cases were prescored
using the proposed risk calculator. The survey was sent to 350 practicing physicians
with expertise in managing patients with diabetes. The survey sought expert opinions
on patients' risk classification during RF. The responses of 312 participants were
analyzed. A wide variation in evaluating patients' risk was evident, particularly
in moderate-risk cases. Overall, responses to case scenarios were classified correctly,
with a 33 to 85% variation in the correct response. Geographical and interspecialty
differences were noted.
Two other groups from Sudan and Bangladesh evaluated the risk scale independently.[16]
[17] The first group assessed the scale using a cross-sectional hospital-based study
that recruited 300 individuals with diabetes (79% have T2D) from diabetes centers
in Sudan.[16] Risk scores were distributed as low risk (13.7%), moderate risk (24%), and high
risk (62.3%). There was a significant difference in the mean risk score by sex, duration,
and type of diabetes. One-way analysis of variance (ANOVA) revealed a significant
difference in the risk score by age group. Logistic regression revealed that the odds
of being in the 41- to 60-year age group had a lower probability of being categorized
in the moderate-risk group of fasting rather than in the low-risk group by 4.3 times
than being in the group of patients older than 60 years (p = 0.008). The odds of being in the age group of 41 to 60 years lower the probability
of being categorized in the high risk of fasting rather than low risk by eight times
more than being in the age group more than 60 years. The second group performed a
prospective study in the peri-Ramadan period in 2022, evaluating adults with T2D and
categorizing them using the IDF-DAR 2021 risk stratification tool.[17] Counseling on fasting according to the risk categories was made, and their intention
to fast was recorded. Among 1,328 participants (age: 51.1 years; females: 61.1%),
only 29.6% had a pre-Ramadan HbA1c level less than 7.5%. According to the IDF-DAR
risk category, the frequencies of participants in the low-risk group (should be able
to fast), moderate-risk group (not to fast), and high-risk group (should not fast)
were 44.2, 45.7, and 10.1%, respectively. Most (95.5%) patients intended to fast,
and 71% fasted the full 30 days of Ramadan. The overall frequencies of hypoglycemia
(3.5%) and hyperglycemia (2.0%) were low. Hypoglycemia and hyperglycemia risks were
3.74- and 3.86-fold higher in the high-risk group than in the low-risk group. The
first study noted that most patients had a high risk of RF and that the IDF-DAR risk
score was significant in assessing individuals with diabetes for RF. However, the
second study included a small percentage of high-risk patients and concluded that
the new IDF-DAR risk scoring system was conservative in risk categorization of T2D
patients in predicting complications as it found fasting to be safe for patients in
the high-risk group.
Furthermore, another diabetes group based in Egypt released a consensus statement
to provide further insights into risk stratification in PWD intending to fast during
Ramadan based on the three-step modified Delphi method.[18] The panel comprised senior adult and pediatric endocrinologists and other experts
in relevant specialties affiliated with academic institutions in Egypt. The group
developed a new risk assessment tool based on several factors, including the type,
presence, and severity of complications, the number of fasting hours, and certain
socioeconomic factors. Patients were classified into four categories (high, high,
moderate, and low risk) according to their risk factors. The tool contained some items
included in the IDF-DAR tool but did not depend on a scoring system. Further research
is needed to validate this new risk assessment tool.
Education and Lifestyle Modification
A previous study analyzed the impact of applying recommendations from the American
Diabetes Association and the European Association for the Study of Diabetes (ADA/EASD)
on management of T2D during Ramadan.[19] A multinational, randomized controlled trial (RCT) was conducted in five Muslim-majority
countries. Six hundred and sixty participants were approached. However, nearly a quarter
of them declined to participate later for various reasons. In total, 506 participants
were enrolled and were randomized to receive Ramadan-focused education with diabetes
treatment adjusted per the 2020 ADA/EASD recommendations or the control group that
involved usual care. At the end of the study, data for 231 participants in the intervention
group and 221 participants from the control group were available. The total number
of hypoglycemic episodes in the intervention group was less than that in the control
group. The intervention group also had a significantly lower severe hypoglycemia than
the controls, with an odds ratio of 0.2. In both groups, the HbA1c levels were significantly
reduced compared to baseline, but the improvements were significantly greater in the
intervention group. While BW reduced and HDL cholesterol increased with the intervention,
these changes were not significantly different from usual care. The authors affirmed
that a pre-Ramadan assessment of people with T2D coupled with pre-Ramadan education
and an adjustment of glucose-lowering treatment can prevent acute complications by
reducing the risk of hypoglycemia, improve metabolic outcomes, and allow safer fast
for these patients.
Access to and engagement with diabetes education is variable and its digitization
may provide high-quality education at a low cost. Two Ramadan-focused massive open
online courses (MOOCs) were developed and delivered for Ramadan 2023: one for health
care professionals (HCPs) in English and another for PWD in English, Arabic, and Malay.[20] A user-centered iterative design process was adopted. The MOOCs featured interactive
elements, videos, patient stories, and live multilingual question-and-answer sessions.
Promotion occurred through diabetes organizations and health authorities. The evaluation
included platform usage analysis and mixed-methods evaluation of user surveys. In
total, 1,531 users registered for the platform from more than 50 countries; 809 (549
HCPs and 260 patients) started a course, and 387 completed a course. HCPs worked in
mostly (60%) nondiabetes specialist roles; 55% identified as Muslim, and most self-reported
high baseline levels of diabetes and Ramadan awareness. Users found the course to
be informative and useful. In the HCP MOOC, users reported improved post-MOOC Ramadan
awareness, associated diabetes knowledge, and ability to manage diabetes during Ramadan.
A model used in developing an educational booklet consists of four stages: define,
design, develop, and disseminate.[21] The feasibility of growing media was analyzed by the content validity index (CVI)
using the item-level content validity index (I-CVI) and the scale content validity
index (S-CVI) to assess whether an item was relevant or not relevant to the index
(CVI > 0.80). The patients' CVI was assessed using the I-CV and S-CVI. The average
value of I-CV was 0.875, and the average value of S-CVI was 0.875, meaning that all
parts of the content were relevant in providing information about healthy eating for
diabetes during RF. The investigators proposed that the booklet can be used as an
educational medium for pre-Ramadan education.
Pharmacological Therapy
Seven studies investigated various pharmacological agents, including insulin (2),
DDP-4 inhibitors (1), and SGLT2 inhibitors (4; [Table 3]).[22]
[23]
[24]
[25]
[26]
[27]
[28] A Cochrane review was also published on the effects of various interventions during
RF.[29] They will be discussed briefly below.
Table 3
Summary of the studies on various pharmacological therapies for diabetes during Ramadan
|
Study
|
Population
|
Medications
|
Outcome measures
|
Conclusions
|
|
Hassanein et al[23]
|
A prospective, observational study of 140 patients with T2D in four countries
|
Glargine U-300 (Gla-300)
|
HBA1c, FPG, symptomatic documented, and severe hypoglycemia
|
Gla-300 maintained the glycemic control of T2D during RF with less insulin dose and
no increasing hypoglycemic risk
|
|
Hassanein et al[22] (SoliRam study)
|
A multinational, prospective, single-arm, real-world observational study of 409 patients
with T2D
|
iGlarLixi
|
>1 episode of severe and/or symptomatic documented hypoglycemia (<70 mg/dL)
|
iGlarLixi is effective and well tolerated for people with T2D who intend to fast during
Ramadan
|
|
Elbarbary and Ismail[24]
|
50 adolescents and young adults with T1D
|
Vildagliptin 50 mg add-on to insulin via MiniMed 780G AHCL
|
Efficacy and safety on glucose excursions of iftar
|
Adjunctive vildagliptin-mitigated postprandial hyperglycemia. Vildagliptin significantly
increased TIR and reduced glycemic variability
|
|
Samkari et al[25]
|
220 adult patients with T2D (89 on empagliflozin vs. 131 control group)
|
Empagliflozin
|
Safety and tolerability
|
Empagliflozin produced less hypoglycemia during Ramadan; better eGFR after Ramadan
|
|
Sheikh et al[26]
|
89 adult patients with T2D
|
Empagliflozin, dapagliflozin
|
Safety and tolerability
|
Significant drop in eGFR, symptomatic dehydration with no hospitalization. No severe
hypoglycemia
|
|
Goh et al[27]
|
98 adults with T2D single-center observational study
|
Empagliflozin
|
Risk of dehydration, ketosis, or hypoglycemia
|
Empagliflozin is safe and not associated with increased risk
|
|
Ghazi[28]
|
100 older people with T2D, aged ≥60 y
|
Empagliflozin vs. vildagliptin on top of metformin
|
Days broken, eGFR, hypoglycemia
|
No difference observed. SGLT2i is deemed safe in older adults
|
Abbreviations: AHCL, advanced hybrid closed-loop; eGFR, estimated glomerular filtration
rate; FPG, fasting plasma glucose; RF, Ramadan fasting; SGLT2i, sodium-glucose cotransporter
2 inhibitor; T1D, type 1 diabetes; T2D, type 2 diabetes.
A prospective, observational, noncomparative, multicenter study investigated the safety
and clinical outcomes of patients with T2D treated with Glargine U-300 during Ramadan.[22] The study included patients from four countries who had T2D and were currently treated
with Glargine U-300 who planned to fast during Ramadan. The mean HbA1c decreased during
the study period from 7.9% pre-Ramadan to 6.9% post-Ramadan. The overall HBA1c target
value was 6.9%, achieved by 29 patients (21.9%). The mean FBG decreased from baseline
post-Ramadan by 0.09 mmol/L. Only five patients had symptomatic documented hypoglycemia
during Ramadan, and none were considered to have severe hypoglycemia. The study showed
that insulin Glargine U-300 maintained the glycemic control of T2D patients who decided
to fast during Ramadan with less insulin dose required and without increasing the
risk of hypoglycemia. The same group also evaluated the safety and effectiveness of
the combination of insulin glargine/lixisenatide (iGlarLixi) in adults with T2D fasting
during Ramadan in a multinational, prospective, single-arm, real-world observational
study.[23] Among the 409 eligible participants who were followed during Ramadan, the vast majority
fasted for ≥25 days, and 92.4% did not break fasting during Ramadan. Only four participants
broke their fast due to hypoglycemia. Minimal adjustments were seen in antihyperglycemic
therapies from before to during Ramadan. The investigators concluded that iGlarLixi
is an effective and well-tolerated therapy for people with T2D who fasted during Ramadan.
It was associated with a low risk of hypoglycemia, and improvement in diabetes was
observed both during and after Ramadan.
The efficacy and safety of vildagliptin as an add-on therapy on glucose excursions
of iftar Ramadan meals was investigated among adolescents and young adults with T1D
using the advanced hybrid closed-loop (AHCL) treatment.[24] Fifty T1D patients receiving basal/meal insulin therapy and using MiniMed 780G AHCL
were randomly assigned to receive vildagliptin (50 mg) with an iftar meal during Ramadan
or no therapy. All participants received premeal insulin bolus based on the insulin-to-carbohydrate
ratio (ICR) for each meal constitution. Vildagliptin was shown to blunt postmeal glucose
surges together with concomitant exceptional euglycemia, with TIR significantly increased
at the end of Ramadan in the intervention group from 77.8 to 84.7% (p = 0.016), and time above range (180–250 mg/dL) decreased from 13.6 to 9.7% (p = 0.003) without increasing hypoglycemia. A significant reduction was observed in
automated daily correction boluses and total bolus dose with less aggressive ICR settings
within the intervention group at the end of Ramadan. No severe hypoglycemia or diabetic
ketoacidosis (DKA) were reported. Thus, adjunctive vildagliptin treatment seemed to
mitigate postprandial hyperglycemia compared with premeal bolus alone and significantly
improve TIR while reducing glycemic variability without compromising safety.
Four studies examined their use during RF.[25]
[26]
[27]
[28] Samkari et al assessed the safety and tolerability of empagliflozin in T2D patients
during Ramadan in a prospective cohort study conducted for adult Muslim T2D patients.[25] Patients were categorized into two subcohorts (control vs. empagliflozin). The primary
outcomes were the incidence of hypoglycemia symptoms and confirmed hypoglycemia. A
propensity score (PS) matching and risk ratio (RR) were used to report the outcomes.
Among the 1,104 patients with T2D screening, 220 patients were included, and empagliflozin
was given to 89 patients as an add-on to oral hypoglycemic medications (OHDs). The
two groups were comparable after matching with PS (1:1 ratio). Other oral glucose-lowering
medications, such as sulfonylurea (SU), DPP-4 inhibitors (DPP-4Is), and biguanides,
were not statistically different between the two groups. The risk of hypoglycemia
symptoms during Ramadan was lower in patients who received empagliflozin than in the
control group (p = 0.02). Additionally, the risk of confirmed hypoglycemia was significantly different
between the two groups. Sheikh et al[26] reported an observational study of the use of empagliflozin during Ramadan in patients
with T2D in a Pakistani population at a university hospital. Participants were older
21 years and on stable SGLT2 inhibitor doses starting at least 2 months before Ramadan.
Endpoint assessments were done 1 month before and within 6 weeks after Ramadan. Of
the 102 participants enrolled, 82 completed the study with an average duration of
T2D of 11.2 years. In all, 63% were on empagliflozin, whereas dapagliflozin was used
by 37% of patients. Documented symptoms of hypoglycemia were reported in 7.3% of patients,
and no severe hypoglycemia, hyperglycemia, dehydration, DKA, hospitalization, or discontinuation
of SGLT inhibitors were reported. A reduction in HbA1c was noted alongside a reduction
in the weight with an improvement in eGFR. Also, Goh et al[27] investigated the effects of empagliflozin in fasting T2D patients. This was a prospective
cohort study in a single diabetes center in Malaysia. The empagliflozin group was
on the study drug for at least 3 months. For the control group, patients not receiving
SGLT2 inhibitors were recruited. Follow-up visits were performed before and during
RF. During visits, anthropometric measurements, blood pressure, renal profile, and
blood ketone were recorded. Symptoms of hypoglycemia were assessed via the hypoglycemia
symptom rating questionnaire (HypoSRQ). The investigators recruited a total of 98
participants. Baseline anthropometry, blood pressure, and renal parameters were similar
in the two groups. No significant changes in blood pressure, weight, urea, creatinine,
eGFR, or hemoglobin levels during Ramadan were found in both groups. Likewise, no
difference was detected in blood ketone levels or hypoglycemia indices. These studies
suggested that the use of SGLT2 inhibitors during RF is associated with a lower risk
of hypoglycemia symptoms and higher tolerability, seems safe, and is not associated
with an increased risk of dehydration, ketosis, or hypoglycemia. Similarly reassuring
data were found in older adults as will be discussed below.[28]
Lee et al assessed the effects of interventions for people with T2D fasting during
Ramadan by conducting a meta-analysis that included 17 RCTs with 5,359 participants,
with a 4-week study duration and at least 4 weeks of follow-up.[29] At least one high-risk domain in the risk of bias assessment was present. Four trials
compared DPP-4Is with SUs. DPP-4Is may reduce hypoglycemia compared to SUs. Serious
hypoglycemia was similar between groups. The evidence about the effects of DPP-4Is
on adverse events other than hypoglycemia and HbA1c changes was very uncertain. Two
trials compared meglitinides and SU; the evidence is very uncertain about the effect
on hypoglycemia and HbA1c changes. One trial compared SGLT2 inhibitors with SU. SGLT2
inhibitors may reduce hypoglycemia compared to SU. The evidence was very uncertain
for serious hypoglycemia and adverse events other than hypoglycemia—SGLT2 inhibitors
result in little or no difference in HbA1c. Three trials compared GLP-1 analogs with
SUs. GLP-1 analogs may reduce hypoglycemia compared to SUs. The evidence for serious
hypoglycemia was very uncertain. Evidence suggests that GLP-1 analogs result in little
to no difference in adverse events other than hypoglycemia, treatment satisfaction,
or change in HbA1c. Two trials compared insulin analogs with biphasic insulin—the
evidence about the effects of insulin analogs on hypoglycemia and serious hypoglycemia.
The evidence for the effect of insulin analogs on adverse effects other than hypoglycemia,
all-cause mortality, and HbA1c changes was very uncertain. Two trials compared telemedicine
with usual care. The evidence regarding the effect of telemedicine on hypoglycemia
was very uncertain compared with usual care, health-related quality of life (HRQoL),
and HbA1c change. Two trials compared Ramadan-focused patient education and usual
care. The evidence needed to be more certain about the effect of Ramadan-focused patient
education on hypoglycemia and HbA1c change.
Diabetes Technology
The latest data on diabetes and technology during Ramadan in 2023 are presented in
[Table 4].[24]
[30]
[31]
[32]
[33]
[34]
[35] These are briefly summarized here. AlGhatam et al in a randomized pilot study investigated
the effects of different insulin pump settings on TIR.[30] Patients classified as having low to moderate risk for fasting were assigned to
either a control group to receive basal insulin adjustments only or an intervention
group to use the temporary basal rate and extended bolus features in addition to the
basal insulin modifications. The percentage of time spent at different glucose ranges
was measured by continuous glucose monitoring (CGM). The percentage of time spent
within the target increased significantly in the intervention group from 63 to 76%
(mean difference, 27% points; p < 0.001). The percentage of time spent in hyperglycemia levels 1 and 2 met the criterion
of significance, indicating that the intervention group spent less time in hyperglycemia.
However, there was no significant difference in the percentage of time spent in hypoglycemia
ranges. The investigators concluded that incorporating technological approaches to
insulin pump therapy in clinical practice guidelines could improve glycemic control
during Ramadan. Messaoudi et al assessed the efficacy, safety, and patient satisfaction
of the MiniMed 780G AHCL system in managing glycemic control in two individuals with
T1D throughout RF.[31] The glycemic target was established at 110 mg/dL, with the potential implementation
of a temporary objective if blood glucose levels fell below 100 mg/dL. The glycemic
parameters of CGM, including TIR, time above range, and time below range, were comparable
in both patients before and during RF. In addition, there was a high level of satisfaction
among the patients with the technology. These preliminary findings are encouraging
and require further research involving more patients. Wannes et al assessed the efficacy
and safety of a hybrid closed-loop (HCL) system during RF in a pediatric cohort with
T1D.[32] Glucose control outcomes in older children and adolescents aged 8 to 16 years with
automated insulin delivery for T1D were analyzed during Ramadan and 1 month before
Ramadan. Participants on MiniMed standard HCL (670G) or advanced HCL (780G) systems
of Medtronic were categorized as fasting or nonfasting. The average age of the 19
participants (8 and 11 on standard and advanced HCL systems, respectively) was 11.4
years. Eleven patients fasted during Ramadan. Pump setup and sensor statistics were
the same during Ramadan and the month before; no difference was found between the
two groups in terms of insulin and glucose control metrics, with practically the same
coefficient of variation, TIR, and time spent in hypoglycemia, maintained within the
international recommended targets. Total daily doses were paradoxically higher in
patients who fasted during Ramadan (p = 0.01) without repercussions on glucose control metrics. The investigators concluded
that standard and advanced HCL use during Ramadan was safe and was associated with
a maintained TIR greater than 70% and no significant hypoglycemia in adolescents and
older children with T1D. Al Ozairi et al compared glucose responses in remotely supervised
exercise performed before or after breaking the fast in people with T1D in a randomized
crossover design study in Kuwait.[33] Thirty-two participants were recruited for the study (mean age: 34 years; body mass
index [BMI]: 26 kg/m2). Glucose levels were measured using CGM during a baseline week of normal activity.
Remotely supervised exercise was performed thrice weekly, either before or after breaking
the fast. The exercise involved resistance and aerobic exercise and was supervised
during a video call. The authors demonstrated that remotely supervised exercise performed
during Ramadan can safely reduce glucose levels and may be of greater benefit when
performed in the evening. Al-Sofiani et al[34] reported on the effectiveness and safety of the MiniMed 780G automated insulin delivery
system in real-world users during Ramadan. CareLink Personal data were extracted from
MiniMed 780G system users from the Gulf region. Users were included if they had ≥10 days
of sensor glucose data during the month of Ramadan 2022 and in the month before and
after. For the main analysis, CGM endpoints were aggregated monthly and reported by
time of day (daytime and nighttime). Additional analyses were performed to study the
pace at which the algorithm adapts. Glycemic control was well kept in the 449 included
users (mean sensor glucose = 153 mg/dL; glucose management indicator = 7.0%; TIR = 70.7%;
time below 70 mg/dL = 2.3%). Although some metrics differed from the month before,
absolute differences were small and were considered clinically irrelevant. During
Ramadan, there was no increased risk of hypoglycemia during daytime, TIR was highest
during daytime (80.0% vs. 60.4% during nighttime), while time above 180 mg/dL was
highest during nighttime. The algorithm adapted immediately upon lifestyle change.
The investigators concluded that the MiniMed 780G automated insulin delivery system
is effective, safe, and fast in adapting to the substantial changes in the lifestyle
of people with T1D during Ramadan. In the investigation of the efficacy and safety
of vildagliptin as an add-on therapy on glucose excursions of iftar Ramadan meals
among adolescents and young adults with T1D described by Elbarbary and Ismail, 50
T1D patients employed the MiniMed 780G AHCL system, as discussed earlier.[24] Also, Wannes et al described insulin pump therapy and glucose control during RF
in a child with T1D.[35] This illustrates progressing from an open-loop sensor-augmented pump therapy with
predictive low-glucose management to an AHCL system. The child fasted for two successive
Ramadan seasons under two innovative insulin administration technologies regarding
diabetes management. He had an 8-year history of diabetes, and his case exemplifies
the progression from a conventional regimen to an AHCL system over the past decade
in terms of diabetes management and treatment and the testing of multiple daily injections
(MDIs) and continuous subcutaneous insulin infusion (CSII) therapy. The authors argued
that the AHCL system, with automatic adjustments of basal insulin delivery and automated
bolus correction in response to CGM readings and a flexible, temporary target feature,
allows improved glycemic outcomes and reduced hypoglycemia during fasting periods
of more than 14 hours per day during the month of Ramadan, which could not be reached
using the advanced CSII with the suspend before low system. Further study on a larger
scale should be performed to confirm their findings.
Table 4
Summary of the use of diabetes technology during Ramadan fasting
|
Study
|
Population
|
Technology
|
Outcome measures
|
Conclusions
|
|
AlGhatam et al[30]
|
30 T1D patients
|
Insulin pump settings
|
Time in range (TIR)
|
Pump therapy could improve glycemic control
|
|
Messaoudi et al[31]
|
Two T1D patients (illustrative case report)
|
MiniMed 780G AHCL system
|
Efficacy, safety, and patient satisfaction
|
Demonstrable reliability and efficacy
|
|
Wannes et al[32]
|
19 adolescents and older children with T1D (8–16 y)
|
MiniMed standard HCL (670G) or AHCL (780G) systems
|
Coefficient of variation, TIR, and time in hypoglycemia
|
RF was associated with a maintained optimum TIR and no significant hypoglycemia
|
|
Al Ozairi et al[33]
|
32 T1D in a randomized crossover study
|
CGM during a baseline week of normal activity and resistance and aerobic exercise
|
Interstitial glucose responses during remotely supervised exercise
|
RF can safely reduce glucose levels and may be of greater benefit when performed in
the evening
|
|
Al-Sofiani et al[34]
|
449 T1D patients
|
CareLink Personal data; MiniMed 780G system
|
Effectiveness and safety in real-world users
|
The system is effective, safe, and fast in adapting to the lifestyle changes
|
|
Elbarbary and Ismail[24]
|
50 adolescent and young adults with T1D
|
AHCL treatment by MiniMed 780G
|
Post-iftar glucose excursions
|
Less glucose excursions at iftar by vildagliptin add-on therapy
|
|
Wannes et al[35]
|
An 11-year-old adolescent with T1D
|
Open-loop sensor-augmented pump therapy with predictive low glucose, AHCL system
|
Glucose control metrics, quality of life
|
Illustrative case report of the impact of using progress in diabetes technology on
diabetes control and quality of life
|
Abbreviations: AHCL, advanced hybrid closed-loop; CGM, continuous glucose monitoring;
HCL, hybrid closed-loop; T1D, type 1 diabetes; T2D, type 2 diabetes; RF, Ramadan fasting.
Furthermore, Litvinova et al attempted to systematize the global patenting trends
of digital sensors for CGM and analyze their effectiveness in controlling the treatment
of patients with diabetes of different ages and risk groups.[36] The LENS database was used to build the patent landscape of sensors for CGM. A retrospective
analysis showed that the patenting of sensors for CGM had a positive trend over the
analyzed period (2000–2022). Several leading development companies are involved. Since
2006, a new approach has emerged where digital sensors are used for CGM, and smartphones
act as receivers for the data. Additionally, telemedicine communication is employed
to facilitate this process. This opens up new opportunities for assessing the glycemic
profile (glycemic curve information, quantitative assessment of the duration and amplitude
of glucose fluctuations, and so on), which may contribute to improved diabetes management.
Several digital sensors for minimally invasive glucose monitoring are patented, have
received Food and Drug Administration (FDA) approval, and have been on the market
for over 10 years. Their effectiveness in the clinic has been proven, and the advantages
and disadvantages have been clarified. Digital sensors offer a noninvasive option
for monitoring blood glucose levels, providing an alternative to traditional invasive
methods. This is particularly useful for patients with diabetes who require frequent
monitoring, including before and after meals, during and after exercise, and in other
scenarios where glucose levels can fluctuate. However, noninvasive glucose measurements
can also benefit patients without diabetes, such as those following a dietary treatment
plan, pregnant women, and individuals during fasting periods like Ramadan. The availability
of noninvasive monitoring is especially valuable for patients in high-risk groups
and across different age ranges. New world trends have been identified in patenting
digital sensors for noninvasive glucose monitoring in interstitial skin fluid, saliva,
sweat, tear fluid, and exhaled air. Several noninvasive devices have received the
CE mark approval, which confirms that the items meet the European health, safety,
and environmental protection standards. The sensors mentioned earlier have characteristics
that make them popular in treating diabetes: they do not require implantation, do
not cause an organism reaction to a foreign body, and are convenient to use. The development
of systems, which include digital sensors for CGM, mobile applications, and web platforms
for professional analysis of glycemic control and implementation of unified glycemic
assessment principles in mobile health care, represents promising approaches to controlling
glycemia in patients.
Ramadan Fasting and Diabetes in Special Groups
Diabetes in Pregnancy
In 2023, two studies addressed glucose control during pregnancy,[37]
[38] and one focused on the outcome.[39] Alsulami and Ghamri determined the fasting and postprandial blood glucose levels.[37] They predicted hypoglycemia risk factors through a prospective cohort study at a
single tertiary hospital in 53 pregnant women with gestational diabetes mellitus (GDM)
and 17 pregnant women with T2D in their second and third trimesters during RF. The
FBG and PPBG levels during Ramadan were compared to those of the previous month, and
hypoglycemia was defined as blood glucose less than 60 mg/dL. The GDM and T2D groups
were similar in age, parity, number of fasting days, and daily fasting hours. Only
26.9% of the women permitted to fast were given special instructions for RF. Dietary
intervention was more common in the GDM group, whereas insulin and metformin treatment
was more common in the T2D group. Fasting glucose FBG levels decreased significantly
after RF in both groups. However, there was a significantly higher number of hypoglycemia
events in the T2D group. Alamoudi et al conducted a prospective observational study
in Jeddah to compare the risk of hypoglycemia, glucose patterns, and fasting tolerance
in pregnant women with GDM versus women without GDM during Ramadan.[38] Pregnant women with and without GDM managed by diet or metformin who were planning
on fasting during Ramadan and were dedicated to applying an FGM device for 2 weeks
were recruited. Women with GDM received standard-of-care diabetes education regarding
fasting during Ramadan. Thirty women with gestational age ≥24 weeks completed the
study: 8 without GDM (group 1), 16 with GDM on diet (group 2), and 6 with GDM on metformin
(group 3). Mean age, body mass index, and prior pregnancies were not different. Breaking
RF was reported in 43% of all participants because of hypoglycemia, hyperglycemia,
and other reasons, including fatigue and acute illness. On the other hand, Abdullah
et al[39] compared maternal and perinatal outcomes of RF during pregnancy in women with and
without GDM in a prospective case-control study conducted in Karachi, Pakistan. Normoglycemic
pregnant women and those identified as GDM (n = 52) on oral glucose tolerance tests who fasted during Ramadan were included. Women
with GDM were categorized into those on diet control and those on diet plus metformin.
The study questionnaire included demographic details, days of fasting, and self-reported
hypoglycemic episodes. Maternal outcomes included preterm birth and pregnancy-induced
hypertension. The perinatal outcome included hyperbilirubinemia, hypoglycemia, weight
of the placenta, and Apgar score. Fifty-seven women with GDM and 25 women with normoglycemia
were included in the study. Average days of fasting were 16 days (range: 5–30 days).
Women with GDM were older; had raised levels of HbA1c, mean FBS, and mean RBS; and
had higher BMI at delivery. The HbA1c level and the head circumference of the baby
were found to be lower in those who fasted for more than 20 days among normoglycemic
pregnant women. No other maternal and neonatal outcomes were found to be significantly
affected by RF among pregnant women with/without GDM.
These studies suggest that pregnant women with non-insulin-treated GDM, compared to
those without GDM, experienced similar difficulties in tolerating RF and increased
risk of hypoglycemia.[38] RF may improve fasting glucose control in pregnancy and T2D was identified as a
risk factor for hypoglycemia.[38] Also, GDM does not affect maternal and perinatal outcomes among pregnant women during
RF. However, the studies are limited by the small sample size and observational design.[39]
Older Adults
The safety and tolerability of SGLT inhibitors among older adults with T2D fasting
during Ramadan were evaluated in 100 patients aged ≥60 years.[28] In group 1, 50 patients were on vildagliptin and metformin, and in group 2, 50 patients
were on empagliflozin and metformin. HbA1c and estimated glomerular filtration rate
(eGFR) were measured before and 2 months after Ramadan. Episodes suggesting hypoglycemia
and volume depletion were estimated. Days to break fasting were also compared. The
mean age and HbA1c of the two groups were not different. No difference was observed
in episodes suggesting hypoglycemia and volume depletion, nor days to break fasting,
suggesting that SGLT2 inhibitors may be used safely as they were well tolerated among
older adults with T2D fasting during Ramadan, provided patients were well prepared
and educated.
Young Adults
The behavior and attitudes of a population with T1D during and outside of Ramadan
were examined in a descriptive study in two health establishments in Constantine,
Algeria.[40] The study involved 63 patients with T1D from both sexes with a mean age of 21.2
years. The average duration of diabetes was 6.6 years. HbA1c averaged 8.1%. Less than
a third (28.6%) of the patients practiced RF, averaging 13.8 days. Only 31.7% consulted
their doctors before observing RF, and 77.8% monitored their blood sugar mainly before
breaking the fast. COVID-19 affected 15.9% patients, and hyperglycemia was the most
recorded diabetes-related complication. Therefore, despite health risks, if patients
with T1D insist on fasting, early consultation and diabetes monitoring before RF are
recommended.
Complications
Diabetic Ketoacidosis and Hypoglycemia
Ata et al examined the differences in the number of DKA episodes during Ramadan compared
to the rest of the year in patients with T1D and T2D in Qatar with view to examine
the seasonality of DKA between 2015 and 2021.[41] Of 922 patients, 52% had T1D and 48% had T2D. The median age was 35 years. There
were 94 DKA admissions in six collective Ramadans, whereas the DKA admissions ranged
from 61 to 88 episodes in other months (p = 0.3). The highest DKA admissions were observed in autumn (N = 236) and the lowest in spring (N = 226; p = NS). Also, Ruqaib et al evaluated the factors associated with the increased risk
of DKA during Ramadan among patients on SGLT2 inhibitors and assessed DKA risk during
RF in a retrospective study in 99 patients with T2D treated with empagliflozin.[42] Most patients (n = 61) had a 6- to 10-year history of diabetes. About 93% of the patients were used
to RF, whereas only 5 patients did not fast previously during Ramadan. The patients
had known complications, such as hypertension, dyslipidemia, cardiovascular disease,
and other associated diseases. None of the participants had DKA during RF. Thirty-one
of the fasting patients broke fasting during Ramadan for 1 to 5 days, and only 2 did
so for more than 6 days. On the other hand, Tan et al explored driving experiences
and coping strategies to ensure safe driving among people with T2D who fasted during
Ramadan in an exploratory qualitative study.[43] They purposefully selected people with T2D who drove and fasted during Ramadan.
Two major themes were identified: (1) knowing oneself and (2) voluntary self-restriction.
Participants described the importance of understanding how RF affected them and their
level of alertness. Participants often adjusted their daily activities and tested
their blood glucose levels to prevent experiencing hypoglycemia. Other coping strategies
reported were adjusting their medications and driving restrictions or driving in the
mornings when they are more alert.
In conclusion, these studies lend support to the notion that DKA occurrence does not
increase during Ramadan, with no evidence of seasonal variations in the rates of DKA.
Also, because of the risks and effects of hypoglycemia among those who fast, there
is a need to provide appropriate and focused patient education during Ramadan to people
with T2D to ensure safe performance of complex activities such as driving. SGLT2 inhibitors
are effective antidiabetic agents that can be safely used in PWD during RF. Finally,
understanding the experiences and coping mechanisms of PWD while driving during Ramadan
should help in the management of diabetes during RF.
Renal Disease
Mohammad et al studied the effect of RF on diabetic nephropathy in patients with T2D.
They included 90 patients, aged between 40 and 60 years, wishing to fast the whole
of Ramadan.[44] There was a highly statistically significant increase in serum creatinine and serum
urea after Ramadan in all the studied groups. The change in GFR was higher in macroalbuminuria.
The percentage change in the urine albumin-to-creatinine ratio (UACR) in the micro-
and macroalbuminuria groups was significantly lower than that in the normoalbuminuria
and macroalbuminuria groups. No significant differences were found regarding the BMI,
systolic blood pressure, diastolic blood pressure, FBG, postprandial blood glucose,
and HbA1c before and after Ramadan. The authors concluded that RF had no harmful impact
on albuminuria among patients with T2D. However, fasting led to a significant decline
in renal function parameters among PWD and albuminuria. This decline is more prominent
in patients with macroalbuminuria than in those with microalbuminuria. Thus, fasting
should be avoided in patients with a severe renal impairment. Adequate hydration and
dietary modification should be stressed during pre-Ramadan health care education.
On the other hand, no negative impacts on glycemic control and other metabolic parameters
were observed. Nevertheless, further trials to assess the role of fasting in at-risk
patients are still needed.
Cardiovascular Disease
Tahapary et al aimed to determine intercellular adhesion molecule-1 (ICAM-1) changes
in T2D and non-DM patients during RF.[45] A retrospective cohort study was performed on 26 patients with T2D and 21 persons
without DM. Measurements were taken 4 weeks before (T0) and 14 days after RF (T1).
The median ICAM-1 level in T2D patients was 340.9 ng/mL at T0 and 312.3 ng/mL at T1,
while the ICAM-1 level in nondiabetic patients was 482 at T0 and 398.4 ng/mL at T1.
There was no significant difference in the ICAM-1 level between the study groups at
both T0 and T1 (p > 0.05). Both T2D and non-DM patients had lower ICAM-1 levels following RF. However,
only non-DM persons had a significantly lower post-Ramadan ICAM-1 (p = 0.008). The investigators concluded that there was a significant decrease in the
ICAM-1 level in T2D and non-DM patients after RF.
Mental Health
Akkuş and Kiliç studied the feelings, difficulties, attitudes, and spiritual coping
status of Turkish patients with T2D toward RF.[46] The sample of this descriptive qualitative study consists of 14 patients diagnosed
with T2D. They determined two main themes and relevant subthemes. The first was “the
feelings and difficulties experienced due to diabetes mellitus” with the subthemes
of “negative emotions” and “difficulties in fasting.” The second theme was identified
as “religious and spiritual coping,” with the subthemes of “believing the disease
comes from God,” “having difficulty in adhering to disease-specific practices while
fasting,” and “feeling that fasting facilitates coping and provides relief.” The authors
concluded that PWD continued to fast despite difficulties and facilitated coping and
relaxation.
COVID-19
Different aspects of the impact of COVID-19 infection on diabetes for people observing
RF were assessed by a few investigators.[47]
[48]
[49]
[50]
[51]
The DaR Global survey was conducted in 13 countries to assess the impact of the COVID-19
pandemic on the intentions to fast and the outcomes of fasting in PWD with chronic
kidney disease (CKD).[47] The study included 6,736 PWD, of which 10.5% had CKD. There were 16.7% patients
with T1D and 83.3% with T2D, and 65.2% patients with T1D and 76.1% with T2D had CKD.
Episodes of hypoglycemia and hyperglycemia were more frequent among people with T1D
compared to those with T2D (64.5 and 43.5% vs. 25.2 and 22.3%, respectively). Visits
to the emergency department and hospitalization were more frequent among people with
CKD, but no significant difference was found between people with T1D and T2D. Therefore,
the COVID-19 pandemic seemed to have only a minor effect on the intention to fast
during Ramadan in PWD and people with CKD, and hypoglycemia, hyperglycemia, emergency
visits, and hospital admissions were more frequent among people with diabetic kidney
disease.
Alamoudi et al[48] compared patients in Saudi Arabia with other countries regarding patient attitudes
toward RF and complications related to fasting during the COVID-19 pandemic. Data
were collected from Saudi Arabia and 12 other Muslim-majority countries via physician-administered
questionnaires within post-Ramadan 2020. A total of 1,485 T1D patients were analyzed;
47.5% were Saudis. In total, 1,056 (71.1%) participants fasted during Ramadan, of
which 636 (90.2%) were Saudi patients. The COVID-19 pandemic did not affect the decision
to fast in Saudi patients with T1D, while it significantly influenced the decision
in other countries (1.4 vs. 9.9%, p < 0.001). More Saudis needed to break the fast due to a diabetes-related complication
compared to others (67.4 vs. 46.8%, p ≤ 0.001). The mean number of fasting days in Saudi Arabia and other countries was
24 and 23, respectively. Hypoglycemic events were more common among Saudis during
Ramadan compared to other countries. There was a significant difference in timing;
the largest peak for Saudi patients was after dawn, while it was presunset for patients
from the other countries. Daytime hyperglycemia was also more common among Saudi patients.
However, it was a less likely cause to break the fast. The investigators noted that
observing RF is extremely common among Saudi T1D patients compared to other Muslim
countries. It was not affected by the COVID-19 pandemic and was associated with a
higher frequency of hypoglycemic and hyperglycemic episodes.
Babiker et al[49] reported a cross-sectional study that assessed the effect of the lockdown during
the COVID-19 pandemic on the lifestyle and quality of life (QoL) on fasting children
living with T1D during Ramadan in the Middle East and North Africa (2020–2021). They
compared the child (self) and parent (proxy) reports using PEDQoL v3.0 disease-specific
questionnaires during the lockdown and nonlockdown periods. They also assessed the
correlations with lifestyle changes using regression and gap analyses. A total of
998 reports from 499 children with T1D aged 8 to 18 years (study = 276 children; control = 223
children) and their parents during RF in lockdown and nonockdown periods. Fathers
were more involved in their children's care during lockdown. Patients had better compliance
with treatment, a reversed sleep pattern, increased food intake, and less exercise.
Children and parents perceived better QoL during lockdown. Self-reports and proxy
reports differed in all domains during the nonlockdown period. In gap analysis in
the study, the gap was approximated between children's and parents' perceptions in
all domains during lockdown, but that was not statistically significant.
Cultural, Professional, and Advocacy Perspectives
Alabbood et al[50] investigated the approaches adopted by Iraqi physicians to manage diabetes during
Ramadan through a cross-sectional online survey. The participants were specialist
Iraqi doctors from different regions involved in managing PWD. In total, 140 responses
were collected in this study. Most participants were family physicians, followed by
internal medicine physicians and endocrinologists. Among the respondents, 94.3% advised
their patients regarding RF; 84.3% of this advice was based on several factors. Over
half (53%) do not follow a specific guideline and depend on their experience (70.2%
of them were family physicians). Pre-Ramadan education was provided by 75% of participants.
A minority (14.3%) allowed patients with T1D to fast, and 32.1% allowed those with
T2D on insulin to fast. Recent DKA and severe hypoglycemia were the main reasons for
not allowing people to fast.
Regarding treatment modification during fasting, 56.4% of physicians changed the frequency
of administration. Finally, 67.8% scored 7/10 or above in the questions to test physicians'
familiarity with the established international guidelines. This survey underscores
the importance of medical education for doctors, particularly family physicians.
Hillier et al[51] evaluated the HCPs' knowledge, attitudes, practices, and perspectives in providing
care to Muslims in Western countries who fast during Ramadan, intending to identify
research gaps and opportunities for improving health care services for Muslims during
Ramadan. Their scoping review found that HCPs' knowledge of RF practices varies, with
many needing more adequate knowledge. While HCPs recognize potential health complications,
adjustments to medications for fasting patients, especially those with diabetes, are
often neglected. Challenges in care included language barriers, limited cultural training,
and resource awareness. Strategies identified to address barriers include reducing
language barriers, providing resources in relevant languages, and enhancing cultural
competence training. Further research is required on HCPs' knowledge of providing
care to Muslims during Ramadan, the impact of cultural competency training, and diverse
health care interventions for fasting Muslims. Addressing these gaps may enhance culturally
safe care and improve patient outcomes.
Haque et al[52] shared their approach to optimizing care for Bangladeshi patients with diabetes
in the United States, with particular attention to culturally sensitive care and nutrition
counseling. Culturally sensitive care is an approach to health care that considers
a patient's cultural background, beliefs, and values when providing medical care.
The authors concluded that health care providers should be aware of and respect cultural
differences, involve family members in caring for Bangladeshi patients, provide language-concordant
care, and incorporate traditional Bangladeshi foods and religious practices into the
nutrition counseling plan. They also noted that by providing culturally sensitive
care and nutrition counseling, health care providers can improve diabetes management
and ultimately improve the QoL not only for Bangladeshi patients with diabetes but
also for those from other cultural backgrounds.
