بسم اهلل الرمحن الرحيم فمن شهد منكم الشهر فليصمه
Najat Buzaid
Introduction
Ramadan is a lunar-based month, and its duration varies between 29 and 30 days.
The fasting hours vary from 10 hours in a temperature climate to 20 hours in hot climates, depending on the geographical location and time of Ramadan in the seasonal cycle.
There are about 1.9 billion Muslims worldwide. The prevalence of diabetes in middle east adult population is 7.7%.
Although diabetics may be exempted from fasting; many of them prefer not to accept the exemption
First international congress held in Casablanca, Morocco in January 1994, concluded that there is No major change in the baseline health during Ramadan.
The population-based Epidemiology of Diabetes and Ramadan (EPIDIAR) study 2001 demonstrated among 12,243 people with diabetes from 13 Islamic countries that 43% of patients with type 1 diabetes and 79% of patients with type 2 diabetes fast during Ramadan a minimum of 15 days (> 50 million people with diabetes fast during Ramadan).
In a study of 493 diabetic patients at Benghazi Diabetes and Endocrine Center; 70% of diabetic patients completed the 30 days of Ramadan fasting (Elmehdawi R 2oo8)
PATHOPHYSIOLOGY OF FASTING
Counter regulatory hormones
As fasting becomes protracted for more than several hours, glycogen stores become depleted, and the low levels of circulating insulin allow increased fatty acid release from adipocytes.
Oxidation of fatty acids generates ketones that can be used as fuel by skeletal and cardiac muscle, liver, kidney, and adipose tissue, thus sparing glucose for continued utilization by brain and erythrocytes.
The transition from a fed to a fasted state devided into three stages: 1) the postabsorptive phase, 6 24 h after beginning fasting 2) the gluconeogenic phase, (2 10 d) 3) the protein conservation phase, beyond 10 days of fasting. (Felig)
Effect of diabetes on fasting
In patients with type 1 diabetes, glucagon secretion may fail to increase appropriately in response to hypoglycemia. Epinephrine secretion is also defective in some patients with type 1 diabetes because of a combination of autonomic neuropathy and defects associated with recurrent hypoglycemia.
In patients with severe insulin deficiency, a prolonged fast in the absence of adequate insulin can lead to excessive glycogen breakdown and increased gluconeogenesis and ketogenesis, leading to hyperglycemia and ketoacidosis
Patients with type 2 diabetes may suffer similar perturbations in response to a prolonged fast; however, ketoacidosis is uncommon, and the severity of hyperglycemia depends on the extent of insulin resistance and/or deficiency.
In patients with diabetes, glucose homeostasis is influenced often by pharmacological agents designed to enhance or supplement insulin secretion
Insulin therapy augments fasting hypoglycemia, and counter regulatory response might be curtailed in the advanced disease leading to profound hypoglycemia
Risks associated with fasting in patients with diabetes
Hypoglycemia Hyperglycemia Diabetic ketoacidosis Dehydration and thrombosis
Dehydration and thrombosis Limitation of fluid intake during the fast, especially if prolonged, is a cause of dehydration. The dehydration may become severe as a result of excessive perspiration in hot and humid climates and among individuals who perform hard physical labor.
In addition, contraction of the intravascular space can further exacerbate the hypercoagulable state that is well demonstrated in diabetes. Increased blood viscosity secondary to dehydration may enhance the risk of thrombosis and stroke.
Categories of risk in patients with type 1 or type 2 diabetes who fast during Ramadan*
Very high risk Severe hypoglycemia within the 3 months prior to Ramadan A history of recurrent hypoglycemia Hypoglycemia unawareness Sustained poor glycemic control Ketoacidosis within the 3 months prior to Ramadan Acute illness Hyperosmolar hyperglycemic coma within the previous 3 m Performing intense physical labor Pregnancy Chronic dialysis
High risk Moderate hyperglycemia (average blood glucose 150 300 mg/dl or A1C (7.5 9.0%) Renal insufficiency Advanced macrovascular complications Living alone and treated with insulin or sulfonylureas Patients with comorbid conditions. Old age with ill health Treatment with drugs that may affect mentation
Moderate risk Well-controlled diabetes treated with short-acting insulin secretagogues Low risk Well-controlled diabetes treated with lifestyle therapy, metformin, acarbose, thiazolidinediones, and/or incretin based therapies in otherwise healthy patient
Studies on diabetes and Ramadan Most papers on Ramadan and diabetes report survey data and only few controlled clinical assays were carried out on this subject. Results showed discrepancies that could be explained in terms of protocol differences.
Uysal A et al (1998) conducted a study on 41 type 2 diabetic patients (30 women, 11 men, mean age 55 years) to observe the clinical and metabolic effects of fasting. DIABETES CARE, VOLUME 21, NUMBER 11, NOVEMBER 1998
None of the patients experienced severe hypoglycemia or neuro glycopenic symptoms. No statistically significant change was observed in mean body weight, BMI, total cholesterol level, or LDL cholesterol level. DIABETES CARE, VOLUME 21, NUMBER 11, NOVEMBER 1998
The mean HDL cholesterol level increased significantly during Ramadan, and it was still significantly higher 3 weeks after Ramadan than that before Ramadan. The mean triglyceride level was significantly lower during the 4th week of Ramadan than it was before Ramadan DIABETES CARE, VOLUME 21, NUMBER 11, NOVEMBER 1998.#
The population-based Epidemiology of Diabetes and Ramadan Study 13 Countries, 12,243 people with diabetes Type 2 DM: (86.5%) mean age: 54 years Duration: 7.6 years Type 1 DM:(8.3%) mean age: 31 years Duration: 10 years D.M unclassified: (5.2%) Diabetes Care, October 2004 The EPIDIAR study
The incidence of severe hyperglycemia with or without ketoacidosis in patients with type 1 diabetes (from 5 to 17 events/100 people/ month). The incidence of severe hyperglycemia (requiring hospitalization) during Ramadan in patients with type 2 diabetes (from 1 to 5 events / 100 people /month). Diabetes Care, October 2004
fasting during Ramadan increased the risk of severe hypoglycemia (defined as hospitalization due to hypoglycemia) in patients with type 1 diabetes (from 3 to 14 events/100 people/month) and In patients with type 2 diabetes (from 0.4 to 3 events /100 people/month). Diabetes Care, October 2004
The incidence of severe hypoglycemia was probably underestimated in this study because events not requiring hospitalization were not included. DIABETES CARE, VOLUME 33, NUMBER 8, AUGUST 2010
Benghazi Diabetes and Endocrinology centre BDEC study, 2008 (n= 493) Population 493 patients 95% T2 Dm The incidence of hypoglycemia during Ramadan was 31 episodes/100 patients/ month Libyan J Med 2010
The incidence of sever hyperglycemia was 17 episodes/ 100 patients / month. Those who experienced sever hyperglycemia had a significantly high baseline HBA1C Libyan J Med 2010
Aquestionnaire survey conducted in Pakistan (n= 453) 2004 found that (72.5%) fasted during the month of Ramadan. (96.3%) of those who fasted were type II diabetics and fasted for an average of 25 days They found a prevalence of hypoglycaemia 21.7% for and hyperglycaemia 19.8%.
Diabetic ketoacidosis Elmehdwi et al, conducted A descriptive retrospective analysis of the records of all patients admitted with diabetic ketoacidosis to all Benghazi hospitals during the lunar year 1428 Hijri (2007-2008). They found that 15 episodes occurred during Ramadan compared to a mean of 19.5 episodes/month during the other lunar months (p<0.001), and there was no significant difference in the mean age,mortality rate or in the length of hospitalization during Ramadan.
Body weight during Ramadan fasting In normal subjects: Weight losses of 1.7-3.8 kg have been reported in normal weight individuals after they have fasted for the month of Ramadan.
In diabetics: A review of literature shows controversy about weight changes in diabetics during Ramadan.
In women with type 2 diabetes and a high body mass index (34.63 ± 3.29 kg/m2), fasting during Ramadan resulted in significant weight loss ( 3.12 kg; p < 0.01).
Blood glucose variations during Ramadan fasting in diabetics Most patients show no significant change in their glucose control. In some patients, serum glucose concentration may fall or rise.
In general, HbAIC values show no change or even improvement during Ramadan. The amount of fructosamine, insulin, C- peptide also has been reported to have no significant change before and during Ramadan fasting.
Serum lipid variables during Ramadan fasting in diabetics Most patients with diabetes show no change or a slight decrease in concentrations of total cholesterol and triglyceride.
Few studies have reported increases in high-density-lipoprotein (HDL) cholesterol in diabetics during Ramadan.#
Effects of fasting on cardiovascular endpoints A large population-based study conducted in Qatar, where 95% of the adult population fast for Ramadan, has shown no significant difference in hospital admissions for acute coronary syndrome between Ramadan and non fasting months. Heart 2004
Effects of fasting on cardiovascular endpoints A 13-year review of a stroke database also showed no significant difference in the number of hospitalizations for stroke during the fasting month of Ramadan as compared to other months. Singapore Med J. 2006
Summary and recommendations The large proportion of diabetic subjects who fast during Ramadan represent a challenge to provide more intensive education before fasting and to disseminate guidelines.
Summary and recommendations Serum glucose variations during Ramadan may be due to the amount or type of food consumed, changes in body weight and exercise habits, regularity of taking medications.
Newer pharmacological agents and insulin pump therapy may have specific advantages during Ramadan.
Ramadan focused education.
بسم اهلل الرمحن الرحيم وأن تصوموا خري لكم إن كنتم تعلمون