Diabetes Management In Ramadan By :SHOROUK MOUSSA Lecturer of Internal medicine and Endocrinology Cairo University A large number of Muslim patients with diabetes fast during Ramadan Global Muslim population1 1.6 billion 2.2 billion (2010) (2030) > 50 million people with diabetes are estimated to fast during Ramadan worldwide2,3 • The global prevalence of diabetes is projected to increase in emerging economies, including those with large Muslim populations4,5 • The pattern of daytime fasting and night-time meals and use of anti-diabetic treatment increases the risk of complications, including hypoglycaemia in patients with diabetes2,3 • Although the consensus from religious and medical leaders is that Muslims with diabetes are generally not obliged to fast6 many choose to do so2,3 3 1The Pew Forum on Religion & Public Life. http://www.pewforum.org/The-Future-of-the-Global-Muslim-Population.aspx (Accessed March 2013); 2Al-Arouj M et al. Diabetes Care 2010;33:1895–902; 3Salti I et al. Diabetes Care 2004;27:2306–11; 4IDF Diabetes Atlas 5th edition. www.idf.org/diabetesatlas/5e/the-global-burden (Accessed March 2013); 5Whiting DR et al. Diabetes Res Clin Pract 2011; 94: 311–21; 6Beshyah SA. Ibnosina J Med Biomed Sci 2009;1:58–60 Frequently asked questions • Can a diabetic patient fast Ramadan, SAFELY??? • What are the risks?? • What about diet and exercise?? • How to adjust medications?? Many patients with diabetes insist on fasting during ramadan creating medical challenge for themselves and their physicians Risks associated with FASTING in patients with diabetes . EPI.DIA.R trial (EPIdemilogy DIAbetes in Ramadan) . Multi-country epidemiological study (Algeria, Bangladesh, Egypt, India, Indonesia, Jordan, Lebanon, Malaysia, Morocco, Pakistan, Saudi Arabia, Tunisia & Turkey) . 12,273 Muslim patients with diabetes fasting during Ramadan. Individuals who fast during Ramadan showed a high rate of acute complications Diabetes Care, volume 28, NUMBER 9, September 2005 HYPOGLYCEMIA 11,173 patients with T2DM; 78.7% chose to fast for at least 15 days during It has been estimated that 1 Ramadan hypoglycemia accounts for 2-4%of mortality in Higher risk of severe hypoglycaemic events† in overall population during Ramadan‡1,2 patients with T1DM much lesser with T2DM P<0.0001 4 3 3 7.5-fold increase* EPIDIAR study showed that 2 fasting during Ramadan patients/month) increased the risk of severe Incidence 100 1 0.4 hypoglycemia (7.5 fold in T2DM and 4.7 foldin 0 (events/ patients with type T1DM Pre-Ramadan During Ramadan 11 †Events requiring hospitalization in overall population with T2DM; ‡compared with previous months * There was a 7.5 fold difference of hypoglycaemia in overall population fasting during Ramadan. For patients who fasted for > 15 days difference was, 6.7 fold EPIDIAR = EPIdemiology of DIAbetes and Ramadan; T2DM = type 2 diabetes mellitus 1Salti I, et al. Diabetes Care 2004;27:2306–11; 2Al-Arouj M, et al. Diabetes Care 2010;33:1895–902 HYPERGLYCEMIA EPIDIAR study: 5 fold increase in the incidence of Higher risk of severe hyperglycaemic events† severe hyperglycemia in patients in overall population during Ramadan‡1,2 with type 2 DM. 3fold increase in the incidence of severe hyperglyemia with or 5-fold increase P<0.0001 6 without ketoacidosis in patients 5 with type 1 DM 5 4 3 2 1 1 0 Pre-Ramadan During Ramadan Hyperglycaemia May be due to excessive reduction of medication dosages to prevent hypoglycaemia. Increase in food and/or sugar intake during Nonfasting hours Diabetic ketoacidosis • Patients with diabetes, especially those with type I DM, who fast during Ramadan are at increased risk for development of diabetic ketoacidosis, particularly if they grossly hyperglycaemic before Ramadan Dehydration and Thrombosis • Hypercoagulable states in diabetes might be exacerbated, due to an increasing in clotting factors, decrease in endogenous anticoagulants and impaired fibrinolysis enhancing the risk of thrombosis and stroke • Increased blood viscosity secondary to dehydration may enhance the risk of thrombosis • Increased incidence of retinal vein occlusion Conditions associated with “Very High”, “High”, “Moderate” & “Low” risk for adverse events in diabetic patients deciding to fast RAMADAN Fasting is NOT recommended May choose Not to fast May choose to fast with caution May choose to fast Pre-Ramadan medical assessment Medical Assessment: • 1-2 months before RAMADAN • Approach should be individualized Specific attention to the: Physical well-being assessment of the patient Glycemic control BP control Lipids control Diabetes-related complications Diabetes-unrelated comorbidities • Specific medical advice for those who wish to fast against medical Diabetes recommendationsCare, volume 28, NUMBER 9, September 2005 • Dose and timing of anti-hypertensive medications may need to be adjusted to prevent hypotension. • Diuretics should be used with caution to avoid volume depletion. • Lipid lowering medications: should be continued without the need for dose adjustment, as it is common practice to have higher intake of foods rich in carbohydrates and saturated fats during Ramadan. Structured Diabetes Education Patients who received diabetes education and fewer episodes of hypoglycemia Key areas in Ramadan focused Education BG monitoring & When to stop fasting Meal planning and dietary advice Physical activity timing and intensity Recognize and Management of acute complications •( Signs & symptoms of hypoglycemia, hyperglycemia and dehdration) Self monitoring • Confirm that blood glucose testing doesn’t constitute breaking fast. • Teaching patients who fast how to test their blood sugar • Encouraging people with diabetes to test their blood sugar especially if they feel any symptoms related to hypoglycemia or hyperglycemia Timing and frequency of SMBG based on treatment • Insulin therapy Diabetic patients who are in the moderate to high risk categories are advised to monitor their blood glucose: • Pre-meal and 2-hour post pre-dawn meal (sahur) • Mid-day • Pre-meal and 2-hour post sunset meal (iftar) Bedtime Timing of SMBG could reflect adequacy of insulin dose Oral anti-diabetic (OAD) therapy To monitor when symptomatic BREAK THE FAST IF NECESSARY BLOOD GLUCOSE ≤ 60 mg/dl BLOOD GLUCOSE < 70 mg/dl early in the day Stop fasting even if hypoglycemia occurs to close to the time of Iftar Blood glucose > 300 esp type I DM Check ketoned in blood or urine Sick days or unusual symptoms ( vomiting, SOB… Nutrition in Ramadan • DO I need to go on a special diet during Ramadan ???? • If you are already following a balanced diet, then there is a big chance that you do not have to change the ingredients of your diet. • In fact, you should eat as you normally do, with the only difference being the time you eat your meals, rather than quantity or type of food consumed. Nutrition in Ramadan • Aim at maintain a constant body weight • Divide food into to 2-3 meals : iftar, dinner and suhur • Healthy and balanced diet • Limit amount of sweet food taken at iftar Limit food high in saturated fat & fried food • Encourage High fibre foods (whole grain cereals/brown rice/beans/fruits/vegetables/salads) • Choose sugar free type of drinks • Drink plenty of water during non fasting hours: (Drink 8-10 cups of water between Iftar and Sahour meals.) Suhur meal: Should be taken as late as possible before the fasting time starts, and including foods that are rich in complex carbohydrates, such as whole grain bread or vegetables Complex carbohydrates take more time to digest, absorb and ingest, keeping the body fueled for more hours throughout the fasting day. Brown rice, wholemeal bread, brown rice vermicelli and oats are examples of complex carbohydrates Ramadan Nutritional Facts and Tips Some interesting information to note: There are 250 calories in one piece of fried samboosa and 125 calories in a baked samboosa. • Try baking samboosa instead of frying and consume one to two pieces maximum. Also, try to use light fillings, like low fat cheese. • Try to eat/drink low fat soup options, like vegetable and lentil soups. If you plan to have a cream soup, replace the cream with skimmed milk. • Cheese or walnut katayef can range from 200 to 400 calories a piece. Avoiding these foods is recommended; however, if you choose to eat them once in a while, bake them instead of frying and choose low fat fillings and reduce the density of the sugar syrup. Exercise in Ramadan It is very hot during Ramadan and fasting is very tiring, so I can’t exercise” • Normal physical activity may be maintained • Excessive Physical activity should be reduced during day time (higher risk of hypoglycemia) • Tarawaeeh praying should be considered a part of the of the daily excercise program. • It is good to do some moderate exercise just before you break your fast at Iftar, and again just before going to bed, as well as right before Suhoor. Management Of Type I DM Fasting at Ramadan carries a very high risk for type I diabetic patients The risk is particularly exacerbated in: Poorly controlled patients. Those with limited access to medical care. Hypoglycemic unawareness , unstable glycemic control, or recurrent hospitalizations. Unwilling or unable to monitor their blood glucose levels several times daily. If The Patient Insists On Fasting: Basal-bolus regimen is the preferred protocol of management tend to be safer, with fewer episodes of hyper and hypoglycemia. A frequently used option is once or twice daily injections of intermediate or long acting insulin along with premeal rapid acting