Key-words:
Diabetes - ethnicity - fasting - hyperglycemia - hypoglycemia - Muslims - Ramadan
- safety
Introduction
Fasting is prescribed on adult Muslims during this month from just before dawn to
just after sunset.[[1]] This daytime fasting forbids the consumption of food and drink as well as oral
and injected medications in addition to smoking and sexual intercourse. Depending
on the season and geographic location, each period of fasting may last for up to 20
h. Although fasting is obligatory for all Muslim adults, certain groups are exempted.
The relevant aspect of medical practice is that “being ill” is one of the justifications
for people not to abide by observing the fast.[[1]] This may include some individuals with diabetes. Estimates suggest that there are
148 million Muslims living with diabetes worldwide. Good quality research and evidence-based
approach have been repeatedly called for.[[2]],[[3]]
The Diabetes and Ramadan International Alliance
Diabetes and Ramadan (DaR) International Alliance was formed in January 2013. DaR
engages stakeholders of known professional groups to raise awareness of managing diabetes
during Ramadan.[[4]] This led to collaborations with other interested organizations in particular IDF
Africa Region and Europe Diabetes UK. DaR International Alliance works with many of
those involved with the management of diabetes during Ramadan fasting to make it a
safe and enjoyable month for those who observe it. Perhaps the most prominent activities
were its annual meeting and the recent guidelines.[[5]]
DaR aims to enhance understanding of how best to manage diabetes during the month
of Ramadan by uniting healthcare professionals, patient associations, Muslim societies,
public and private stakeholders in education, and research. In addition to several
local and national conferences, since its inception, DaR held 7 international conferences.
The 8th DaR International Alliance Annual Conference was held over 2 days on of January
24th and 25th in Dubai, United Arab Emirates. It was attended by 643 delegates and
involved 43 speakers and moderators.
Conference Highlights
The state of the art lectures
Three states of the art lectures were delivered during the conference. Mohamed Hassanein,
host of the meeting, presented an overview of the current knowledge on insulin therapy
during Ramadan. The use of newer agents with lower risk of hypoglycemia was recommended
whenever possible. He also alluded to yet unpublished data from the ORION trial, an
observational study of the use of insulin Glargine U300 during Ramadan. A multicenter,
multinational, prospective, single-arm, observational study to describe the clinical
outcomes in patients with type 2 diabetes (T2D), treated with insulin glargine 300
U/mL (insulin glargine U300) before, during and after the period of Ramadan. Its primary
objective was the percentage of patients experiencing at least one episode of severe
and/or symptomatic documented hypoglycemia with plasma glucose ≤70 mg/dL (3.9 mmol/L)
during the pre-Ramadan, Ramadan, and post-Ramadan periods. Reportedly, the risk of
hypoglycemia was low, and patients using this insulin were able to experience safer
fasting. Its full report is eagerly awaited. The journey of diabetes and Ramadan research
was revisited from EPIDIAR to CREED and ending by DAR-MENA-T2DM[[6]],[[7]],[[8]] was revisited by Abdul Jabbar who has participated in this from 1989 onward and
underscored the most important landmarks. The three major epidemiological studies
of DaR found that most people with diabetes would wish to observe the fast despite
their illness. Feasibility and management of fasting after bariatric surgery were
reviewed by Ebaa Al-Ozairi based on their recent studies from Dasman Diabetes Center
in Kuwait. A prospective analysis of nutritional intake, hunger and satiety and adaptive
behaviors during fasting was undertaken.[[9]] Fasting was well tolerated in persons who had undergone sleeve gastrectomy. However,
the speaker emphasized that it is advisable to raise awareness about dietary protein
intake and managing medications appropriately during fasting.
Impact fasting Ramadan on physical and mental wellbeing
Mo'ez Al-Islam Faris started the 1st day by reviewing the metabolic impacts of diurnal
intermittent fasting during Ramadan in healthy Muslims. Ramadan fasting (RDIF) may
incur a small protection against inflammation and oxidative stress, and improvements
in glucometabolic markers and body anthropometrics in healthy controls. Benefits of
fasting Ramadan in diabetes physical and mental well-being-Yakoob Ahmedani (Pakistan)
enumerated the benefits of Ramadan fasting to promote weight loss, reduce insulin
resistance, improves lipid profile, reduces blood pressure, reduces anxiety and depression,
prevent cancer, and improve NAFLD. Ebaa AlOzairi presented data from Dasman Diabetes
Center on the positive impact of fasting during Ramadan in diabetic individuals and
depression. This is contradicts some of the older recommendations that such patients
should not fast at all.
Safety of newer antidiabetic medications in Ramadan
The use of SGLT2 inhibitors during Ramadan was discussed by Al Amin bdelGhadir (UAE).
He reviewed the available data from the five studies that included both low risk and
high-risk patients. He also alluded to the physicians' opinions and practices on the
subject made by an early online survey. He specifically addressed the fact that hypoglycemia
is mostly increased when this class is used together with insulin. He also question
the undue caution in the use of SGLT2 inhibitors in people on diuretics on the basis
that benefit was obtained in the recent heart failure studies despite being treated
with diuretics.
The host of the meeting, Mohamed Hassanein, addressed the frequently asked question
of whether the risk of hypoglycemia during Ramadan fasting is the same for all members
of the SU class. He used data from an unpublished observational study of effectiveness
and tolerability of Gliclazide MR 60 mg in diabetic patients fasting during Ramadan
(DIA-RAMADAN; ClinicalTrials.govIdentifier: NCT04132934). Patients taking Gliclazide
MR had low rates of confirmed or any hypoglycemia with no severe hypoglycemia while
maintaining good glycemic control.
Rakesh Sahay reviewed the two Ramadan-specific studies, namely Lira-Ramadan and Lixi-Ramadan.
Lira-Ramadan was a randomized trial of the efficacy and safety of liraglutide compared
to sulfonylurea during Ramadan in patients with T2D.[[10]],[[11]] The study compared the effects of liraglutide 1.8 mg and sulfonylurea, both combined
with metformin, on glycemic control in patients with T2D fasting during Ramadan. Despite
lower fructosamine levels and body weight at the beginning of Ramadan, the use of
liraglutide showed similar glycemic improvements, fewer hypoglycemic episodes, and
greater bodyweight reduction compared with sulfonylurea.[[10]] Despite the proportion of subjects reporting adverse effects was similar between
the groups, the event rate was higher with liraglutide compared with sulfonylurea
group. Moreover, as it was expected were gastrointestinal adverse effect related to
GLP1 mode of action. LIRA-Ramadan provides evidence for liraglutide being safe and
efficacious for the management of T2D during Ramadan fasting.[[9]] Lixi-Ram study adding lixisenatide to basal insulin (BI) instead of sulfonylurea
(SU), versus continuing SU + BI was assessed in people with T2D who intended to fast
during Ramadan (2017). He reported that compared with SU + BI, lixisenatide + BI provided
lower rates of any hypoglycemia in people with T2D during Ramadan fasting. And surprisingly,
none of the hypoglycemia events in the lixisenetide + BI group occurred during nonfasting
hours compared with SU + BI group, where most of the event happened during the fasting
period, which clearly propose that Lixisenatide + BI therapy may be a suitable treatment
option during fasting. Therefore, he concluded that GLP1-RA therapy is a suitable
option for use in people with diabetes who elect to fast during Ramadan supported
by the decreased risk for hypoglycemia.[[11]]
Medication adherence in Ramadan
Shehla Sheikh (India) discussed the issue of adherence to antidiabetes and related
medication and considered the potential impact of having to observe the Ramadan fast
on these practices. Tamer El Sherbiny (Egypt) presented the results of a study on
thyroxine replacement therapy during Ramadan. Of 250 patients, preferences of the
timing of intake of their thyroxine replacement therapy clustered around three methods.
In addition, adherence to thyroxine in Ramadan predicted the adequacy of replacement
therapy. Adherence was associated with a higher rate of euthyroidism after Ramadan
(74%), vice versa, nonadherence resulted in dysthyroidism after Ramadan in previously
euthyroid patients (35%).
Cardiovascular and renal safety in diabetics during Ramadan
Ines Khochtali gave a concise summary of the contributions of her Ramadan Research
Group in (Monstair, Tunisia) effects of fasting in high-risk cardiovascular disease
(CVD) patients. Their study included effects of Ramadan fasting on platelet reactivity
in diabetic patients treated with clopidogrel, metabolic effects of Ramadan fasting
in patients at high risk of cardiovascular diseases and impact of lipid profile on
thrombin generation during Ramadan fasting in patients with cardiovascular risks.[[12]],[[13]],[[14]] It was noted a significant and discrete rise in blood glucose level, triglycerides,
cholesterol creatinine, and HOMA-IR during Ramadan. Ramadan fasting significantly
decreased platelet sensitivity to clopidogrel in DM patients during and after Ramadan.
The effect is possibly related to an increase of glycemia and serum lipids levels
induced by fasting. In addition, it was found that Ramadan is associated with an increase
of Aspirin resistance only in patients with diabetes. It is noteworthy that the Tunisian
groups have recently been very productive in Ramadan research and a special issue
of their national journal (La Tunisie Medicale) was dedicated for Ramadan and health.
On the other hand, on increase in the risk of stroke during Ramadan fasting could
be detected by the group from Alexandria as reported by Arafa Elshabrawy and without
increased frequency of hospitalization of stroke as a whole. Coronary artery disease
and heart failure emergencies during Ramadan fasting were discussed by Dr Abdul Basit,
from Pakistan. He concluded that patients with stable cardiac disease may fast during
the month of Ramadan since most studies show no significant adverse effects of fasting
on these patients. Moreover, the safety of fasting in chronic kidney disease (CKD)
patients with native or transplanted kidneys was discussed Dr Alaa Bashir from Dubai.
He looked at and compared patients with diabetes and moderate CKD to patients with
diabetes and moderate CKD who did not fast. There was no significant deterioration
in renal function, no increase in mild or moderate hypoglycemia, and no increase in
cardiovascular events or hospital admissions.
Bridging the gap between science and religion in Ramadan
Mohamed Sandid gave an excellent presentation on the Lebanese experiencing of jointly
working with the Imams and the community. Bachar Afandi (Al Ain, UAE) sounded the
Alarms for the increased risk of patients fasting against medical advice despite a
well-structured educational and fairly supportive and sensitive advocacy services.
“Ask the imam” was a fully interactive live question and answer session. Several questions
were presented regarding fast breaking-qualifying travel, definitions of fasting-imposing
features of puberty on bases of age or appearance of solid versus soft physical features
of puberty in males and females. The uniform age of 15 years is established for both
genders. However, the invited imam made a distinction of wet dreams for boys and menstruation
for girls as hard markers for puberty on one side and lanugo hair (contrast to thick
black hair) in the axillary and pubic regions and the early changes of voice for boys
as soft signs that are taken to indicate puberty on their own. Discussions included
rulings for the terminally ill, the elderly, specific rulings for various medications
taken per nose, per rectum, and as injections.
Type 1 diabetes and fasting
Nancy Albarabary presented the recent management recommendations for adolescents and
children with T1D who wish to observe the fasting. Esphie G Fojas described management
and outcomes of T1D fasting among older children and adolescents attending a fully
resourced center such as the Imperial College London Diabetes Center in Abu Dhabi,
UAE. Whereas, Mohamed Suliman used the experience he had from Sudan to illustrate
the management of adults T1D during Ramadan in resource-restricted settings. Under
both circumstances, education, support, and individualization remain the key elements
of good management. However, adaptations may be needed for one to survive within his
means. For instance, whereas possible flexibility to allow T1D patient to fast with
full access to modern insulins and real-time monitoring, recourse to the Farwa that
all T1D patients should be full exempted from fasting when cost of adequate motoring
is not available or unduly prohibitively expensive. Finally, Mohamed Hassanein attempted
to address the question of can and how technology minimize risks to people with diabetes
fasting during Ramadan fasting. He considered the improved profiles of various modern
medications, insulin pump therapy and real-time/noninvasive monitoring. Again, support
remains a crucial element to make the best use of these advances. Examples of T1D
patients, high-risk groups, and pregnant women were utilized for these arguments.
Attitude, weight and nutrition management during Ramadan
The last two sessions were dedicated to sharing experiences on attitude of patients
and physicians and also on weight and nutrition management during Ramadan. Reem Alamoudy
(Saudi Arabia) described the experience with the attitudes and habits of patients
with T1D during fasting Ramadan.[[15]] The study comprised a prospective cohort of patients with T1D who were on insulin
pump (n = 61) or multiple daily insulin injections (n = 95) regimen. The patient questionnaires
captured the frequency of self-monitoring of blood glucose, the need to make changes
in insulin regimen by patients, timings of insulin administration, performing carbohydrate
counting, and levels of physical activity. They found that fasting Ramadan is associated
with significant and variable changes in the attitudes and behaviors of patients with
T1D with no difference in glucose control between patients on insulin pump or MDI
regimen. Siham Bouchareb shared experience from the Netherlands on the development
and implementation of local guidelines. Rachid Malek described the DaR organized global
program for training health-care professionals and patients. He described the overall
program and used the Algerian experience as an example of its implementation. Finally,
a couple of basic studies were presented. Early exploratory experiments on the thermic
effect of food and during Ramadan fasting were described by Tomader Ali from ICLDC-Abu
Dhabi group and on aspects of nutritional education nutritional during Ramadan were
presented by Barakatun Nisak from Malaysia. The meeting closed by Professor Ahmed
Hassoun of Dubai Medical College and Dubai Diabetes Center giving a commentary and
some final closing remarks.
Conclusions
The 8th DaR edition has provided an update on the current challenges and future ambition
on optimization of the management of diabetes and allied conditions during Ramadan.
The presentations included a mixture of overviews, perspectives, and recently published
or completely unpublished work. The admixture of these types of presentations kept
both researchers and practicing clinicians interested throughout the 2 days. Although
many of the themes are old, focus on newer antidiabetic agents made some difference.
It was nice for the newcomers to the Ramadan research to hear the journey of diabetes
from EPIDIAR to CREED and ending by DAR-MENA-T2DM and recognizing many of the people,
places, and themes that evolved over the years. Despite its lack of its formal incorporation
as an independent body, the activities of RaD Alliance seem to develop progressively
in variety and quality of content and also reaching the audience far afield. However,
formal incorporation should give DaR the opportunity to move to newer roles such as
raising and sharing resources from rich parts to less well-off regions of the world.
This should advance its role to a higher-level professional and advocacy over and
above its current work of education and production and guidelines.
Authors' contributions
All authors contributed equally to the drafting, development and finalization of the
manuscript.
Compliance with ethical principles
Not applicable.
Reviewers:
Not Applicable (commissioned)
Editors:
Elmahdi A Elkhammas (Columbus, OH, USA)
