1
Diabetes & Ramadan
Dr. Nizar Albache
Head of Diabetes Research Unit, Aleppo UniversityPresident of Syrian Endocrine Society
Carlton citadel Hotel , Aleppo, July 20th
Diabetes & Ramadan
Why Muslims should fast ?
When Muslims should fast ?
What are the metabolic changes during fasting and their consequences on diabetes control ?
Who should not fast ( exempted) ? Religious recommendations Medical recommendations
What are the diet advices ?
What are the therapeutic changes or recommendations ?
2
3
Diabetic Patients in the Muslim Countries
Muslims: 1.1-1.5 Billion around the world
The prevalence of type 2 diabetes in the Muslim World is very high ( 10-20 %)
What percentage of diabetic patients actually fast ?
20 %
4
TimeNo
diabetesPre-
diabetesType 2
Diabetes
T2 Diabetes:Insulin resistance + insulinopenia
Glycemia
Insulin secretion
Insulin resistance
5
Decline of ß-cells function determinesthe progressive nature of T2DM
-12 -10 -8 -6 -4 -2 0 2 4 6
0
20
40
60
80
100
Time of diagnostic
Time (years)
ß-c
ell f
unct
ion
(%of
nor
mal
by
HO
MA
) ?
HOMA=homeostasis model assessment.UKPDS Group. Diabetes 1995;44:1249-58.Adapted from Holman RR. Diabetes Res Clin Pract 1998;40(suppl 1):S21-5.
Pancreatic function = 50% of normal
6
ADA/EASD Consensus Guidelines Treatment Algorithm, 2006
Additional medications: insulin, sulfonylureas or TZDs, on the top of metformin
Diagnosis
Lifestyle intervention+ Metformin
HbA1c 7%
Add basal insulin
(Most effective)
Add sulfonylurea
(Least expensive)
Add glitazone
(No hypoglycemia)
Step 1
Step 2
Nathan DM, et al. Diabetes Care 2006;29:8.
7
ADA/EASD guidelines recommend use of basal insulin as early as the second step in type 2 diabetes management
At diagnosis:Lifestyle + Metformin
Lifestyle + Metforminplus
Basal insulin
Lifestyle + Metforminplus
Sulfonylureaa
Lifestyle + Metforminplus
Intensive insulin
Tier 1: well-validated core therapies
STEP 1 STEP 2 STEP 3
Tier 2: Less well validated therapies
Lifestyle + Metforminplus
PioglitazoneNo hypoglycaemia
Oedema/CHFBone loss
Lifestyle + metforminplus
GLP-1 agonistb
No hypoglycaemiaWeight loss
Nausea/vomiting
Lifestyle + Metforminplus Pioglitazoneplus Sulfonylureaa
Lifestyle + Metforminplus Basal insulin
a. Sulfonylureas other thanGlybenclamide or chlorpropamide
b. Insufficient clinical safety data; CHF,congestive heart failure
Nathan DM, et al. Diabetes Care 2008;31:1-12.
Check HbA1C every
3 months until <7%. Change
treatment if HbA1C is ≥7%
8
Types 2 Diabetes
Recommendations in case of oral bitherapy failure:
Diet and lifestyle recommendations
Target not reached at 6 monthsHbA1c >7%
Treatment
Met + SUMet + GlitazonesSU + Glitazones
Oral triple therapyMet+SU + GIitazones
Insulin therapy
HbA1c >8%
New IDF guidelines 2011 in type 2 diabetes:
Two key changes : A change in the HbA1c target to 7.0% (previously 6.5%) Algorithm TT :effectiveness, harm, cost and global availability
Each step of the algorithm recommends a preferred therapy and also alternative therapies:
1. Metformin as first line therapy(unless contraindicated)2. Sulfonylureas are the recommended second line 3. Third line therapy is either a third oral agent or insulin (basal or
premixed)4. Finally insulin should be used if the choice has been to use an
oral agent as the third step, or intensification of insulin therapy if insulin had been chosen in the previous step.
Stephen Colagiuri, Boden Institute, University of Sydney, Australia; MGSD CASABLANCHA 2011
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10
Considerations for Fasting During Ramadan
Religious Considerations: imposition, obligation
Exemption of the sick
البقرة
=183 � �وا آم�ن �ذ�ين� ال �ه�ا ي� أ �ا �ام� ي الص#ي �م� �ك �ي ع�ل �ب� �ت �م�ا ك ك
�ق�ون� �ت ت �م� �ك �ع�ل ل �م� �ك �ل ق�ب م�ن �ذ�ين� ال ع�ل�ى �ب� �ت ك
=184 م�نك�م �ان� ك ف�م�ن م�ع�د�ود�ات5 �ام:ا �ي و� م�ر�يض:اأ� أ
�ذ�ين� ال و�ع�ل�ى �خ�ر� أ 5 �ام �ي أ م#ن� ف�ع�د�ة< ف�ر5 س� ع�ل�ىف�ه�و� ا �ر: ي خ� �ط�و�ع� ت ف�م�ن ك�ين5 م�س� ط�ع�ام� �ة< ف�د�ي �ه� �ط�يق�ون ي
�م�ون� �ع�ل ت �م� �نت ك �ن إ �م� �ك ل �ر< ي خ� � �ص�وم�وا ت �ن و�أ �ه� ل �ر< ي خ�
=185 ه�د:ى آن� �ق�ر� ال ف�يه� �نز�ل� أ �ذ�ي� ال م�ض�ان� ر� ه�ر� ش�ه�د� ش� ف�م�ن ق�ان� �ف�ر� و�ال �ه�د�ى ال م#ن� �ات5 #ن �ي و�ب �اس� #لن لع�ل�ى و�
� أ م�ر�يض:ا �ان� ك و�م�ن �ص�م�ه� �ي ف�ل ه�ر� الش� �م� م�نك�ر�يد� ي �خ�ر� أ 5 �ام �ي أ م#ن� ف�ع�د�ة< ف�ر5 � س� و�ال ر� �س� �ي ال �م� �ك ب �ه� الل
ر� �ع�س� ال �م� �ك ب �ر�يد� ع�ل�ى ي �ه� الل � وا #ر� �ب �ك �ت و�ل �ع�د�ة� ال � �وا �م�ل �ك �ت و�لون� �ر� ك �ش� ت �م� �ك �ع�ل و�ل �م� ه�د�اك م�ا
الدولي اإلسالمي الفقه مجمع 2010فتوى : فئات اربع إلى بالسكري المصابين تصنيف تم
: األولى الفئةذوو بالسكري جدا المصابين الكبيرة االحتماالت
مؤكدة بصورة الخطيرة :للمضاعفات
الفقدان • أو المتكرر أو الشديد السكر هبوط حدوثتسبق ) التي الثالثة األشهر خالل السكر بنقص الحس
رمضان(السكرية• الغيبوبة فرط ( حدوث أو الكيتوني الحماض
رمضان( تسبق التي الثالثة الشهور خالل التناضحللسكري• المرافقة االخرى الحادة األمراضشاقة• بدنية أعماال مضطرين يمارسون
كلى• غسيل لهم يجري
الحمل • اثناء
: الثانية الفئةالصيام نتيجة مضاعفات لحدوث كبير احتمال
وقوعها والتي األطباء ظن على :يغلب بـ وتتمثل
السكر )• ( 300-180ارتفاع السكري/ الخضاب و دسل <ملغ10%
كلوي• قصور
الكبيرة• والشرايين القلب اعتالل
عليهم• إضافية oأخطارا تضيف أخرى أمراض
بمفردهم• يسكنون الذين
أخرى• بأمراض المصابون السن كبار
العقل• على تؤثر عالجات يتلقون
الدولي اإلسالمي الفقه مجمع 2010فتوى
: والثانية األولى الفئتين حكم•
الصيام له يجوز وال يفطر ان المريض على oشرعا o فيتعين درءا ، ) ( : vةwكxل yهzالت vلwى إ yمxيكvدyيw بvأ y وا xقyلxت wالwو تعالى لقوله نفسه، عن للضرر
البقرة
عليهم، • الصيام خطورة لهم يبين ان المعالج الطبيب على يتعين كماغالب - في تكون قد بمضاعفات إلصابتهم الكبيرة واالحتماالت
حياتهم- أو صحتهم على خطيرة الظن
الدولي اإلسالمي الفقه مجمع 2010فتوى
: الثالثة الفئةالصيام نتيجة للمضاعفات للتعرض المتوسطة االحتماالت ذوو
المستقرة الحاالت ذوي بالسكري المصابين ذلك ويشملبالـ عليها .S.Uوالمسيطر
: الرابعة الفئةالصيام نتيجة للمضاعفات للتعرض المنخفضة االحتماالت ذوو
المستقرة الحاالت ذوي بالسكري المصابين ذلك ويشملالعالجات بتناول أو الحمية بمجرد عليها .METFوالمسيطر
: والرابعة الثالثة الفئتين حكم
ال الطبية المعطيات الن اإلفطار، الفئتين هاتين لمرضى يجوز الالكثير ان بل وحياتهم بصحتهم ضارة مضاعفات احتمال إلى تشير
. الصيام من يستفيد قد الحكم منهم بهذا االلتزام الطبيب وعلى. حدة على حالة لكل المناسب العالج يقدر وان
الدولي اإلسالمي الفقه مجمع 2010فتوى
Duration of Fast
• There is variation in the number of days:
Depends on the moon sighting.
• There is variation in the number Fasting hours:
Depends on the season.
• There is variation in the Temperature:
• Effect on total body fluid.
17
Hours of fast during the month of Ramadan Globally
18
Day hours 24
22
20
18
16
14
12
10
8
6
4
2
0
Winter in the lower pale and in the summer upper pale for the year
رمضان :2011حلب3.55إمساك 19.44إفطار
ساعة 15صيام=
الحرارة 44درجة
Change in blood glucose profile
19
0
5
10
15
20
12 6 12 6 12
Daily glucose profile during the month of Shawal
Patients were asked to test their blood sugar every two hours with a glucometer for one day during the month of Shawal as part of diet change study regardless of their diabetes management. There are three peaks for serum blood glucose following meals. The highest been following lunch and the lowest following breakfast with a mean daily glucose at 10.2 mmol/L.
Change in blood glucose with meal timing
20
Daily glucose profile during the month of Ramadan
Change in blood glucose with meal timing
21
Risk of hypoglycemia
– The change in meal time will affect the glucose level through the day.– There will be a prolonged period of fasting with risk of hypoglycemia.– Sever hyperglycemia occur following the main meal ( ie: Eftar ).
Ramadan Diabetes Study ( unpublished data )
Daily glucose profile for both months
Biochemistry of Fasting
Carbohydrate metabolism
In normal subjects fasting will:
• Decrease in serum glucose to 3.3 - 3.9 mmol ( 60-70 mg/dl ).
• Gluconeogenesis by liver will stop further drop of blood glucose.
• Insulin secretion will decrease but glucagon will increase.
• In diabetic subjects fasting will:
• Blood glucose fell within physiological limits if properly controled.
• Drug induced hypoglycemia is the commonest complications.22
Dietary Change
23
28002950
2500
2600
2700
2800
2900
3000
SHABAN RAMADAN
Calorie ChangeTotal daily calorie intake before and
during
24
25
EPI.DIA.REPI.DIA.R EPIEPIdemiologydemiology ofof DIAbetesDIAbetes
Ramadan 1422/2001Ramadan 1422/2001
Salti IS et al Diabetes Care 27: 2306-2311, 2004
26
Number of patients by country )N = 12,914(
994
889
981
871
827
1,066
837
927
1,089
1,000
1,370
1,007
1,056
0 200 400 600 800 1000 1200 1400 1600
Turkey
Tunisia
Saudi Arabia
Pakistan
Morocco
Malaysia
Lebanon
Jordan
Indonesia
India
Egypt
Bangladesh
Algeria
Overallpatientswith DM
Salti IS et al Diabetes Care 27: 2306-2311, 2004
27
Repartition by type of DM
27
13
15
10
10
8
8
7
6
4
4
2
1
2
10
5
8
7
7
5
4
3
71
78
80
83
83
81
86
88
91
92
94
97
93
11
1
6
2
0 20 40 60 80 100
Saudi Arabia
Morocco
Egypt
Jordan
Tunisia
Algeria
Pakistan
Lebanon
Turkey
Malaysia
India
Bangladesh
Indonesia
type 1 DM
DMunclassifiable
type 2 DM
)%(type 1 DM = 1,070 patients )8.3%(
type 2 DM = 11,173 patients )86.5%(DM unclassifiable = 671 patients )5.2%(
Salti IS et al Diabetes Care 27: 2306-2311, 2004
28
Fasting during Ramadan )1( )% of patients who fast > 1 day(
49
24
77
55
12
92
52
45
70
58
6152
80
0 20 40 60 80 100
Turkey
Tunisia
Saudi Arabia
Pakistan
Morocco
Malaysia
Lebanon
Jordan
Indonesia
India
Egypt
Bangladesh
Algeria
73
73
89
77
83
95
78
88
83
91
9592
91
0 20 40 60 80 100
Turkey
TunisiaSaudi Arabia
Pakistan
MoroccoMalaysia
Lebanon
JordanIndonesia
India
EgyptBangladesh
Algeria
DM type 1 DM type 2
)%(
DM type 1 = 54% DM type 2 = 86%Overall population
29
Results
Hyperglycemia 3-fold increase in T1D 5-fold in T2D (from 1 to 5 events/100pts/month)
Excessive reduction in insulin doses (1/3-1/4 of patients change their insulin dose or OHAs)
Increase in food intake (sugar)
Severe Hypoglycemia 4-fold increase in type 1 diabetes 7-fold increase in type 2 diabetes
Salti IS et al Diabetes Care 27: 2306-2311, 2004
30
The need for guidelines for physicians and patients
The Diabetes and Ramadan Advisory Board
(supported by Aventis Intercontinental)
Chairmen:
Ibrahim SALTI, Lebanon; Abdul JABBAR, Pakistan
Members:
Kamel Ajlouni, Jordan; Khalid AL-RUBEAAN, Saudi Arabia;
Fahmy AMARA, Egypt; Mohamed BELHADJ, Algeria; Jamalleddine BELKHADIR, Morocco;
Aissa BOUDIBA, Algeria; Said Nouou DIOP, Senegal; Ugur GORPE, Turkey;
Farid HAKKOU, Morocco; Ak.Azad KHAN, Bangladesh;
Adrien Lohourignon LOKROU, Ivory Coast; Jean-claude MBANYA, Cameroon;
NAGATI, Tunisia; Nadim RAIS, India;
Pradana SOEWONDO, Indonesia; W.Mohamed WAN BEBAKER, Malysia
31
RECOMMENDATIONS OF THE ADVISORY GROUP
In principle, all patients with type 1 should not fast.
However, if a patient insists against medical advice, please consider the following:
Absolute Contra-indications:
Brittle DM (as defined by the American Diabetes Association)
Patients on insulin pump Patients on multiple insulin injections per day Ketoacidosis or severe hypoglycemia in the last 3 months
before Ramadan People living alone Advanced micro- or macro-vascular complications Pregnancy and lactation
Salti IS et al for the Diabetes and Ramadan Advisory Board. International Medical Recommendations for Muslim Subjects with Diabetes Mellitus Who Fast During the Month of Ramadan. Clinical Diabetes- Middle East, 3:143-145, 2004
32
RECOMMENDED RAMADAN GUIDELINES FOR PATIENTS WITH DIABETES MELLITUS Type 2:Continued
Patients with one or more of the following are advised not to fast:
Physiological conditions: Lactation
Co-existing major medical conditions such as:
Acute peptic ulcer Pulmonary Tuberculosis and uncontrolled infections Severe bronchial asthma People prone to urinary stones formation with frequent
Urinary Tract Infections Cancer Overt cardiovascular diseases (recent MI, unstable
angina) Severe psychiatric conditions Hepatic dysfunction (liver enzymes > 2 x ULN)
Salti IS et al for the Diabetes and Ramadan Advisory Board. International Medical Recommendations for Muslim Subjects with Diabetes Mellitus Who Fast During the Month of Ramadan. Clinical Diabetes- Middle East, 3:143-145, 2004
33
RECOMMENDATIONS OF THE Advisory Group-2
Relative Contra-indications (fast with risk):
Well controlled type1 DM patients No diabetes keto-acidosis (DKA) No recent hypoglycemia Not more than 2 insulin injections per day
Salti IS et al for the Diabetes and Ramadan Advisory Board. International Medical Recommendations for Muslim Subjects with Diabetes Mellitus Who Fast During the Month of Ramadan. Clinical Diabetes- Middle East, 3:143-145, 2004
34
RECOMMENDED RAMADAN GUIDELINES FOR PATIENTS WITH DIABETES MELLITUS Type 2:
Patients with one or more of the following are advised not to fast:
Conditions related to diabetes:
Nephropathy with serum creatinine more than 1.5 mg/dL
Severe retinopathy
Autonomic neuropathy: gastroparesis, postural hypotension
Hypoglycemia unawareness
Major macrovascular complications: coronary and cerebrovascular
Poorly controlled diabetes (Mean Random BG > 300) Multiple insulin injections per day
Salti IS et al for the Diabetes and Ramadan Advisory Board. International Medical Recommendations for Muslim Subjects with Diabetes Mellitus Who Fast During the Month of Ramadan. Clinical Diabetes- Middle East, 3:143-145, 2004
I. General considerations
II. Pre-Ramadan medical assessment and educational
counseling
III. Management of patients with type 1 diabetes
IV. Management of patients with type 2 diabetes:
Diet-controlled patients
Insulin therapy +OHAs
Insulin alone
V. Pregnancy and fasting during Ramadan
VI. Management of hypertension and dyslipidemia 35
Monira Al-Arouj,, Samir Assaad-Khalil,, John Buse, MDDiabetes Care August 2010 vol. 33 no. 8 1895-1902
II. Pre-Ramadan medical assessment and educational counseling
Medical assessment
Educational counseling
36
I. General considerations: Nutrition
The diet during Ramadan should not differ significantly from a healthy and balanced diet
It should aim at maintaining a constant body mass : 50–60% maintain their BMI 20–25% gain or lose weight (>3 kg)
Avoid the ingesting of large amounts of foods rich in carbohydrate and fat
Advise the ingestion of foods containing “complex” carbohydrates at the predawn meal
Advise Simple carbohydrates at the sunset meal
Fluid intake be increased during non fasting hours
37
Monira Al-Arouj,, Samir Assaad-Khalil,, John Buse, MDDiabetes Care August 2010 vol. 33 no. 8 1895-1902
I. General considerations: Exercise:
Normal levels of physical activity may be maintained
Excessive physical activity may lead to higher risk of hypoglycemia and should be avoided particularly before the sunset meal
Tarawaih prayer should be considered a part of the daily exercise program
In some patients with poorly controlled type 1 diabetes, exercise may lead to extreme hyperglycemia.
38
I. General considerations; Breaking the fast
If hypoglycemia (blood glucose of <60 mg/dl)
If blood glucose reaches <70 mg/dl (3.9 mmol/l) in the first few hours after the start of the fast especially if insulin, sulfonylurea drugs, or meglitinide are taken at predawn fast
if blood glucose exceeds 300 mg/dl
Typical or atypical symptoms of hypoglycemia ?39
III. Management of patients with type 1 DM
INSULIN THERAPYIt is unlikely that one injection of intermediate- or long-acting insulin administered before the evening meal would provide adequate insulin coverage for 24 h:
Less flexible ( fixe dose) Hypoglycemic risk Timing during Ramadan
Another option could be to use: one daily injection of the long-acting insulin analog Glargine or twice-daily injections of the insulin analog Detemir with premeal
rapid-acting insulin analogs
40
IV. Management of patients with type 2 DM
DIET-CONTROLLED PATIENTS:the risk associated with fasting is quite low
there is still a potential risk for occurrence of postprandial hyperglycemia after the predawn and sunset meals
combine this with a regular daily exercise program 2 h after the sunset ∼meal (Tarawih)
older age-group, often with hypertension and dyslipidemia, fluid restriction and dehydration may increase the risk of thrombotic
41
IV. Management of patients with type 2 DM
PATIENTS TREATED WITH ORAL AGENTS:
Metformin: two thirds of the total daily dose be administered immediately before the sunset meal
Glitazones no change
Sulfonylureas unsuitable for use during fasting because of the inherent risk of hypoglycemia utilized with caution Use of chlorpropamide is absolutely contraindicated(gliclazide MR or glimepiride) have been shown to be effective
Sulfonylureas Short-acting insulin secretagogues: repaglinide might be safer than use of
42
PATIENTS TREATED WITH INSULIN
(similar to those with type 1 diabetes)
Use of intermediate- or long-acting insulin preparations plus a short-acting, or premixed insulin administered before meals hypoglycemia is still a risk
Using one injection of a long-acting insulin analog, such as insulin Glargine
or two injections of NPH, Lente, Detemir insulin
The dosage of each injection should appropriately individualized
Very elderly patients may be at high risk
43
IV. Management of patients with type 2 DM
44
"Basal" Insulins:intermediate or long-acting insulins
Reproduce the basal insulin secretion
Inhibition of hepatic glucose production
Control of FBG
45
LANMET: Insulin glargine or NPH insulin with metformin
9-month, comparative study of insulin glargine + metformin versus NPH + metformin in 110 patients with T2DM
4
8
12
16
Beforebreakfast
Afterbreakfast
Beforelunch
Afterlunch
Beforedinner
Afterdinner
22:00 04:00
Insulin glargine + metformin
NPH + metformin
Baseline
Weeks 25 - 36
Blo
od g
luco
se (
mm
ol/L
)
p=0.0003
p=0.0047p=0.07
Yki-Järvinen H, et al. Diabetologia 2006;49:442-51.
46
Insulin glargine + OHAs achieves glycaemic control with low risk of hypoglycaemia
Treat-to-Target is a pivotal landmark trial: Randomized comparison of OHAs + insulin glargine or NPH titrated
for 24 weeks in 756 overweight insulin-naïve patients with T2DM
5
6
7
8
9
Baseline Study end
5
10
15
20
25
Symptomatichypoglycaemia
Confirmedhypoglycaemia*
* Confirmed events of ≤4mmol/L (72 mg/dL)Riddle M, et al. Diabetes Care 2003;26:3080-6.
Hb
A1
c )
%(
Eve
nts
per
pat
ien
t-ye
ar
8.56 8.61
6.96 6.97
17.7
13.912.9
9.2
NPH
Insulin glargine
p<0.02
p<0.005
47
Percentage of patients with HbA1c <7 % without nocturnal hypoglycaemia
Better response (HbA1c <7% without nocturnal hypoglycaemia) in the insulin glargine group vs. NPH
NPHLANTUS®
33%
27%
% patients p<0.05
V. Pregnancy and fasting during Ramadan
controversy :
pregnant Muslim women are exempt from fasting
some with known diabetes (type 1, type 2, or gestational) insist on fasting during Ramadan
These women constitute a high-risk group, and their management requires intensive care
Women with pregestational or gestational diabetes should be strongly advised to not fast during Ramadan
if they insist on fasting: special attention should be given to their care
Pre-Ramadan evaluation of their medical condition is essential
48
VI. Management of hypertension and dyslipidemia
Dehydration, volume depletion
A tendency toward hypotension may occur with fasting
medications antihypertensive perspiration may need to be adjusted to prevent hypotension
Dyslipidemia should be checked during Ramadan
49
50
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