Diabetes and Ramadan Practical Guidelines 2021 International Diabetes Federation (IDF), in collaboration with the Diabetes and Ramadan (DAR) International Alliance DISCLOSURE All members of the guidelines working group declared dualities of interest in respect of commercial enterprises, governments and non-governmental organisations. No fees were paid to the authors in connection with the development of this document or the guidelines described herein. PUBLISHER: International Diabetes Federation and DAR International Alliance ISBN: 978-2-930229-99-7 PUBLICATION DATE: January 2021 SUPPORT: The preparation of this document was made possible through an educational grant from © International Diabetes Federation and DAR International Alliance All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means without the written prior permission of the IDF. Requests to reproduce or translate IDF publications should be addressed to [email protected] Please cite this report as: International Diabetes Federation and DAR International Alliance. Diabetes and Ramadan: Practical Guidelines, Brussels, Belgium: International Diabetes Federation, 2021. www.idf.org/guidelines/diabetes-in-ramadan and www.daralliance.org IDF-DAR PRACTICAL GUIDELINES EDITOR Mohamed Hassanein (Dubai Hospital, Dubai Health Authority, Dubai, UAE) CHAPTER LEADS Bachar Afandi (Tawam Hospital, Al Ain UAE) Muhammad Yakoob Ahmedani (Baqai Institute of Diabetology & Endocrinology, Baqai Medical University, Karachi, Pakistan) Reem Mohammad Alamoudi (King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia) Fatheya Alawadi (Dubai Hospital, Dubai Health Authority, Dubai, UAE) Harpreet S. Bajaj (LMC, Diabetes and Endocrinology, Ontario, Canada) Abdul Basit (Baqai Institute of Diabetology & Endocrinology, Baqai Medical University, Karachi, Pakistan) Abdullah Bennakhi (Dasman Diabetes Institute, Kuwait City, Kuwait) Adel A. El Sayed (Sohag Faculty of Medicine - Sohag Univerisity - Egypt) Osama Hamdy (Joslin Diabetes Center, Harvard University, Boston, MA, USA) Wasim Hanif (University Hospital Birmingham, UK) Abdul Jabbar (Mohamad bin Rashid University, Dubai, UAE) Line Kleinebreil (UNFM (Université Numérique Francophone), Paris, France) Nader Lessan (Imperial College London Diabetes Centre, Abu Dhabi, UAE) Inass Shaltout (Faculty of Medicine, Cairo University, Cairo) Wan Mohamad Wan Bebakar (School of Medical Sciences, Universiti Sains Malaysia, Hospital Universiti Sains Malaysia, Kota Bharu, Malaysia) CHAPTER CO-AUTHORS Elamin Abdelgadir (Dubai Hospital - Dubai Health Authority - UAE) Sarah Abdo (Bankstown – Lidcombe Hospital, Sydney, Australia) Ebaa Al Ozairi (Dasman Diabetes Institute, Kuwait City, Kuwait) Yousef Al Saleh (College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, KSA) Monira Alarouj (Dasman Diabetes Institute, Kuwait City, Kuwait) Tomader Ali (Imperial College London Diabetes Centre, Abu Dhabi, UAE) Abdulrazzaq Ali Almadani (Al Borj Medical Centre, Dubai, UAE) Samir Helmy Assaad-Khalil (Alexandria University, Alexandria, Egypt) Alaaeldin Mohammed K. Bashier (Dubai Hospital, Dubai Health Authority, Dubai, UAE) Salem Arifi Beshyah (United Arab Emirates and Mediclinic Airport Road Hospital, Abu Dhabi, UAE) Mehmet Akif Buyukbese (Medistate Kavacık Hospital, Istanbul, Turkey) Tahseen Ahmad Chowdhury (Royal London Hospital, London, UK) Said Norou Diop (Department of Medicine, Universite Cheikh Anta Diop De Dakar, Senegal) Nancy Samir Elbarbary (Faculty of Medicine , Ain Shams University, Cairo, Egypt) Tarik A. Elhadd (Hamad Medical Corporation, Doha, Qatar) Fatimah Eliana (Yarsi University, Jakarta, Indonesia) MoezAlIslam Ezzat Faris (College of Health sciences, University of Sharjah, Sharjah, UAE) Khadija Hafidh (Dubai Health Authority, Dubai, UAE) Zanariah Hussein (Department of Medicine, Hospital Putrajaya, Putrajaya, Malaysia) Hinde Iraqi (Endocrinologie et Maladies Métaboliques, CHU de Rabat, Maroc) Walid Kaplan (Tawam Hospital, Abu Dhabi, UAE) Tayyab S. Khan (Western University, London, ON, Canada) Kamlesh Khunti (University of Leicester, Leicester General Hospital, Leicester, UK) Salma Maher (Diabetes UK, Meethi Zindagi Pakistan, Baqai Institute Pakistan, MywayDiabetes UK, Digibete UK) Rachid Malek (Department of internal Medicine. Setif hospital University. Algeria) Rayaz Ahmed Malik (Weill Cornell Medicine-Qatar) Mafauzy Mohamed (Universiti Sains Malaysia) Mesbah Sayed Kamel Mohamed (Internal Medicine and Diabetes, Minia University, Minya, Egypt) Nazeer Ahmed Mohamed (Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, South Africa) Fauzia Rashid (Dubai Hospital, Dubai Health Authority, Dubai, UAE) Rakesh K. Sahay (Osmania Medical College & Hospital, Hyderabad, India) Bashir Taha Salih (Corniche Hospital, Abu Dhabi, UAE) Mohamad A. Sandid (Labib Meical Center, Medical General Security, Lebonon) Shehla Shaikh (Saifee Hospital, Mumbai, India) Ines Slim (Multidisciplinary Private Clinic “Les Oliviers”, Sousse, Tunisia) Khaled Tayeb (Sheffaa Charity Society, Mecca, Saudi Arabia) Barakatun-Nisak Mohd Yusof (Universiti Putra Malaysia, Selangor, Malaysia) Sueziani Binte Zainudin (Sengkang General Hospital, Singapore) *Author names listed alphabetically by surname ACKNOWLEDGEMENTS Project management and coordination support was provided by Sameer Pathan, Medical and Digital Health Initiatives Manager, IDF, Brussels, Belgium Medical writing and editorial services were provided by Aman Malhi (Amrinder), London, United Kingdom Design services were provided by Brandstudio (www.brandstudio.pt), Portugal IDF EXECUTIVE OFFICE – BELGIUM Delphine Sartiaux, Phil Riley, Xangô Bimont, Lorenzo Piemonte, Margaux Ysebaert, Adilson Randi. FOREWORD | FOREWORD The holy month of Ramadan falls on the ninth month of the lunar calendar. It is one of the five pillars of Islam. Ramadan involves fasting every day for one month, between dawn and sunset. Fasting is an important component of Ramadan and allows Muslims to devote themselves to their faith. Fasting is not recommended for everyone. People who are ill or live with a medical condition, including some people with diabetes, can be exempted. However, a majority of people living with diabetes choose to fast and sometimes choose to do so in contrary to medical advice. According to the latest estimates from the International Diabetes Federation (IDF), 463 million people are living with diabetes worldwide, a figure that is set to reach 700 million by 20451. This dramatic rise will be highest in regions with large Muslim populations such as Africa, Middle-East and North Africa and South-East Asia1. As a large number of people with diabetes fast during Ramadan, there is an urgent need for coherent, evidence-based, practical guidance to help them and the health professionals who support them to ensure a safe and healthy fast. IDF and the Diabetes and Ramadan (DAR) International Alliance have come together to deliver a comprehensive set of guidelines to meet this need. This update of the IDF-DAR Practical Guidelines, first published in 2016, features new guidance based on a greater and more recent body of evidence. This includes an updated set of criteria for risk stratification; information on the impact of fasting on physical and mental well-being; specific guidance on the management of type 1 and type 2 diabetes in special populations such as pregnant women and the elderly; and information on changes to the risk of comorbidities such as cardiovascular disease, stroke and renal impairment. These guidelines are intended to provide real-world recommendations to health professionals and the people with diabetes who choose to fast. It is our hope these guidelines will contribute to supporting people with diabetes to safely and successfully participate in Ramadan and enjoy the personal and spiritual benefits this can bring. Professor Andrew Boulton President, International Diabetes Federation Professor Mohamed Hassanein Chair, Diabetes and Ramadan International Alliance [1] International Diabetes Federation., IDF Diabetes Atlas. 2019. Brussels, Belgium. 5 l 330 INDEX CHAPTER 1 | Introduction to the IDF-DAR Practical Guidelines 9 CHAPTER 2 | Epidemiology of diabetes and fasting during Ramadan 21 CHAPTER 3 | What happens to the body? Physiology of fasting during Ramadan 35 CHAPTER 4 | The effects of fasting during Ramadan on physical and mental wellbeing 67 CHAPTER 5 | Risk stratification of people with diabetes before Ramadan 87 CHAPTER 6 | Diabetes and Ramadan: A medico-religious perspective 99 CHAPTER 7 | Pre-Ramadan Assessment and Education 117 CHAPTER 8 | The Ramadan Nutrition Plan (RNP) for people with diabetes 143 CHAPTER 9 | Management of Type 1 diabetes when fasting during Ramadan 159 CHAPTER 10 | Management of Type 2 diabetes when fasting during Ramadan 199 CHAPTER 11 | Management of hyperglycaemia in pregnancy when fasting during Ramadan 245 CHAPTER 12 | Management of diabetes among the elderly when fasting during Ramadan 257 CHAPTER 13 | Risks of fasting during Ramadan: Cardiovascular, Cerebrovascular and Renal complications 271 CHAPTER 14 | Identifying and overcoming barriers to guideline implementation 295 CHAPTER 15 | Grading of evidence & areas of future research in diabetes and fasting during Ramadan 311 | GLOSSARY 325 7 l 330 CHAPTER 1 Introduction to the IDF-DAR Practical Guidelines Chapter lead: Abdullah Bennakhi Authors: Mehmet Akif Buyukbese Yousef Al Saleh Abdulrazzaq Ali Almadani Fatimah Eliana